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Clin Psychol (New York). Author manuscript; available in PMC 2011 February 28.

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Published in final edited form as:
Clin Psychol (New York). 2008 ; 15(3): 243–253. doi:10.1111/j.1468-2850.2008.00134.x.

The Effect of Telephone-Administered Psychotherapy on
Symptoms of Depression and Attrition: A Meta-Analysis
David C. Mohr,
Northwestern University, Hines Veterans Administration Hospital
Lea Vella,
San Diego State University
Stacey Hart,
Ryerson University
Timothy Heckman, and
Ohio University

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Gregory Simon
Group Health Cooperative

Abstract
Increasingly, the telephone is being used to deliver psychotherapy for depression, in part as a
means to reduce barriers to treatment. Twelve trials of telephone-administered psychotherapies, in
which depressive symptoms were assessed, were included. There was a significant reduction in
depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared
to control conditions (d = 0.26, 95% confidence interval [CI] = 0.14–0.39, p < .0001). There was
also a significant reduction in depressive symptoms in analyses of pretreatment to posttreatment
change (d = 0.81, 95% CI = 0.50–1.13, p < .0001). The mean attrition rate was 7.56% (95% CI =
4.23–10.90). These findings suggest that telephone-administered psychotherapy can produce
significant reductions in depressive symptoms. Attrition rates were considerably lower than rates
reported in face-to-face psychotherapy.

Keywords

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depression; meta-analysis; psychotherapy; telemental health
The telephone was invented by Alexander Graham Bell in 1876. The first report of
telemedicine in a major medical journal, which described the use of the telephone to
diagnose a child's cough, occurred three years later in 1879 (“The Telephone as a Medium
of Consultation and Medical Diagnosis,” 1879). The telephone quickly became a widely
used tool in the practice of primary-care medicine. In contrast, providers of psychotherapy
were slow to adopt the telephone to deliver mental health–related services. To the best of
our knowledge, the first report of the use of the telephone in the administration of
psychotherapy was published in 1949, 70 years after the first telemedicine report (Berger &
Glueck, 1949). In 1996, a report developed by an American Psychological Association task
force found that empirical evidence concerning telephone-administered psychotherapy was

Address correspondence to David C. Mohr, Department of Preventive Medicine, Northwestern University, Feinberg School of
Medicine, 680 North Lakeshore Drive, Suite 1220, Chicago, IL 60611. d-mohr@northwestern.edu.

only 20% of all patients referred for psychotherapy ever enter treatment (Brody et al.5% of all households in the United States (Federal Communications Commission. 2. as evidenced by the finding that approximately two-thirds of depressed patients prefer psychotherapy over antidepressant medication (Bedi et al.. more than two-thirds of psychologists use telephone-administered psychotherapy to some extent in their practice (VandenBos & Williams. many provider organizations.. Mohr et al. Author manuscript. Accordingly. To obtain an estimate of the attrition rate from telephone. 2000. of those who enter. Weddington. 2006. telephone-administered psychotherapy—while slow to be developed and implemented—is now increasingly part of the mental health care landscape. health maintenance organizations. 1999. When analyses revealed significant unexplained variability. Pulier. including telephone-administered psychotherapy (Maheu. 2000. McMenamin. However. 1997. have begun implementing telemental health procedures. VHA Telemental Health Field Work Group.Mohr et al. Gerdes. 1997). NIH-PA Author Manuscript NIH-PA Author Manuscript Most of the work in telephone-administered psychotherapy has focused on treating depressive symptoms. Roberts. the United States Veterans Health Administration. it is time to take a first “snapshot” of this research. In light of these developments. Yuen. this has changed considerably. Page 2 scant to non-existent (Haas. 1996). Priest. Furthermore. 2006). including time constraints. 1996). 2002. Dwight-Johnson. we planned to evaluate the effects of four potential moderators: treatment orientation. found in 95. available in PMC 2011 February 28. & Wells. & Brown-Connolly 2005. To evaluate the efficacy of telephone-administered psychotherapies in reducing symptoms of depression. Roberts. Psychotherapy is an attractive treatment option for many patients. transportation problems. evaluate the magnitude of change in depressive symptoms from pretreatment to posttreatment in telephone-administered psychotherapy. if significant. 1993). & Tylee. Brody Khaliq. & Kobos. Wilhelm. Sherbourne. and therapist level of training. and others. caregiving responsibilities. Vize.. disability. The telephone. Liao. Indeed. Many of these barriers could potentially be mitigated through the use of the telephone in administering psychotherapy. specialization of therapist. we have undertaken a meta-analytic review with the following aims: NIH-PA Author Manuscript 1.. Accordingly. 2003). Depression is common and is a significant cause of disability (Murray & Lopez. 2000). stigma concerns. or living in a rural area that lacks adequate mental health services (Alvidrez & Azocar. Recognizing the potential for outreach. including insurance companies.. a recent study of primary-care patients found that 74% of depressed patients identify one or more barriers that make it very difficult or impossible to attend regularly scheduled psychotherapy sessions (Mohr et al.administered psychotherapy. Clin Psychol (New York). Hollon et al. There have also been a growing number of empirical studies evaluating the utility of telephone-administered psychotherapy. Benedict. nearly onehalf will drop out (Wierzbicki & Pekarik. One reason for this discrepancy between interest and failure to initiate or follow through with psychotherapy is that there are considerable barriers for many patients. In the last decade. 1997. 1983) and. 1996). & Gonzales. is the most widely available telecommunications medium. . treatment format. We planned to evaluate telephone-administered psychotherapy compared with treatment-as-usual (TAU) and. 2003). & Thompson.

5. For analyses comparing telephoneadministered psychotherapy to a control condition. Interventions had reduction in depressive symptoms as a treatment outcome. 3. means and standard deviations were used in this calculation. dropouts/total randomized). Tutty. 2004. Inclusion Criteria A trial was included if it met the following conditions: NIH-PA Author Manuscript 1. study authors were contacted and data were requested. no face-to-face contact between therapist and patient occurred. Tutty. Self-report measures were selected where possible to avoid any potential effects of detection bias. thereby eliminating evaluations of telephone hotlines. Page 3 Methods Identification of Studies NIH-PA Author Manuscript MEDLINE and PsycINFO were searched in March 2006. . All contact between therapists and patients was over the telephone. using key words “telephone” and “psychotherapy or counseling or therapy. the measure that was used most often in other studies was used for this meta-analysis). Requests for unpublished or prepublished data were made through list serves. while all trials. requisite additional data were provided (Simon. Clin Psychol (New York). 2000). & Von Korff. Participants were adults. & Ludman. etc.g. Author manuscript. In two instances. if two measures were used.e.” References from reviewed articles were checked. Heckman et al. 6. 4. Tamburrino. All effect sizes.. Intervention had to include at least four sessions. Attrition analyses used the proportion of participants who dropped out of treatment from the time of randomization to the end of treatment (i. and Nagel (1997) was calculated using the means and t-value as Lynch did not provide standard deviations. and weights were calculated according to methods described by Lipsey and Wilson (2001). a TAU condition and a second control condition that included a minimal intervention (attention control or case management. For all but one study. the standardized mean difference of the posttreatment scores was computed as the effect size of interest. The study was a trial of a telephone-administered form of psychotherapy. A validated measure of depressive symptoms was required. Only randomized controlled trials (RCTs) were included in the analysis of controlled trials. 2. including single arm trials. standard errors. When data were insufficient to calculate an effect size.. Simon. available in PMC 2011 February 28. crisis counseling services. were included in the evaluation of pretreatment versus posttreatment effects. the effect size from Lynch. LV) independently reviewed the identified studies for inclusion and pertinent data. Measures of depressive symptoms were selected on the basis of consistency with other studies in the trial (e. The pre–post analyses of telephone-administered psychotherapy used the standardized mean gain computed from pretreatment and posttreatment depression scores as the effect sizes. Several studies included two control conditions. Operskalski.. Ludman. including the American Psychological Association's Division 12 and Division 38 list serves and the Society for Behavioral Medicine.Mohr et al. 7. Data Extraction NIH-PA Author Manuscript Two investigators (DCM. Treatments had to include a treatment manual or have a clearly identified treatment approach.

26.. 2005). 4 studies did not include four sessions (they only included one or two). therapist specialization. .39. case studies. nine were RCTs (Bailey. These results are displayed in Table 2. the TAU condition was used to improve consistency in control conditions across studies. p < . Belyea. and 4 studies did not provide sufficient data to calculate effect sizes. & Marmar. 2004). Clin Psychol (New York). and the authors were unable to provide the data. Because there was significant heterogeneity. Lynch et al.31). Simon et al. Analyses of telephone-administered psychotherapy versus control condition effect sizes used the standardized mean difference effect size.. p < . Stewart. 10 studies examined interventions that did not target depression (these studies targeted behaviors such as adherence to medical regimens or cancer screening.81. 2006. These results are displayed in Table 2. 2002.0001.14– 0. p < . 2002.. Heckman et al. Sandgren & McCaul. p = . or nondata-driven papers). Napolitano et al. Pretreatment to Posttreatment Effects of Telephone-Administered Psychotherapy There were 12 studies containing pre–post data that could be used in this analysis. 2007. most were rejected for multiple reasons. and anxiety). and one was a single arm outcome study (Mohr.50–1. NIH-PA Author Manuscript Statistical Analyses Mean effect size across the studies for each of the three analyses was calculated using the mean effect size macro written for the statistical software program SPSS and found through Lipsey and Wilson (2001). 2004. and therapist level of training. Sandgren & McCaul. The characteristics of the included studies are provided in Table 1. one was a controlled study but the comparison group was drawn from another study and thus was not randomized (Tutty et al. 2006). Heckman & Carlson. one was an RCT that employed two different types of telephone-administered treatments. Mohr et al. 1997. treatment format.. both of which qualified as bona fide telephoneadministered psychotherapies under the criteria for this meta-analysis (Mohr et al.0001). These analyses included treatment orientation.. 95% confidence interval (CI) = 0. we examined the potential role of the following moderators: treatment orientation.. Page 4 2006. Results NIH-PA Author Manuscript Fifty-one studies were identified and were reviewed in detail. therapist specialization. NIH-PA Author Manuscript Telephone-Administered Psychotherapy versus Control Conditions There were 10 studies that had control conditions that could be included in this analysis. 95% CI = 0. A random effects model was used in both mean effect size analyses and subgroup analyses if the homogeneity analysis (Q-test) was significant. 2004). 5 studies included face-to-face meetings with the therapist. There was no statistically significant evidence of heterogeneity across these studies (Q = 10.Mohr et al. This analysis found a pre–post effect size of d = 0. Of the 39 that were rejected. Pretreatment versus posttreatment analysis effect sizes used the standardized mean gain. 2003. 2003. Of those satisfying inclusion criteria.g.0001. they were surveys. Subgroup analyses for a priori and post hoc hypotheses were performed using Lipsey and Wilson's ANOVA macro in SPSS. 12 studies satisfied the inclusion criteria. Miller & Weissman. In these cases. available in PMC 2011 February 28. The mean effect size was d = 0. & Mohler. 2000.13.5. Mishel. change in health behaviors such as smoking cessation. treatment format.. Simon et al. Of these. The primary reasons for the exclusion of each study were as follows: 12 studies were not clinical trials (e. Author manuscript... Hart. Attrition was calculated using the proportion of participants who dropped out of therapy with the number of subjects randomized to telephone treatment as the denominator. 2000). and therapist level of training. indicating significant heterogeneity between studies.57. There was significant heterogeneity among these studies (Q = 241.

Again. The random effects model.26. indicating that treatment format did not explain the heterogeneity. therefore. while two used nurses (Bailey et al. the mean number of sessions actually completed was not consistently available.. including interpersonal psychotherapy (Miller & Weissman.25).67).Mohr et al.. The treatments administered by mental health professionals produced significantly greater reductions in depressive symptoms compared with other professionals.63–1. The number of sessions by protocol was not related to depressive symptoms (p = . 2003).18. Tutty et al. We note that having only two studies in one comparison group may make these findings unreliable. because there are only two studies using non-mental clinicians.. . supportive emotion-focused therapy (Mohr et al. Number of sessions intended by the protocol was used.06. Attrition There were 12 studies containing attrition data on the telephone-administered psychotherapies that could be used in this analysis. including level of training. considered the number enrolled to be 38 and did Clin Psychol (New York).08). We. p = . 61). For all but two studies. Author manuscript. 2000. two used advanced graduate students in psychology (Mohr et al.. and an uncertainty intervention (Bailey et al. suggesting but not confirming that cognitivebehavioral treatments were more effective (d = 1. Page 5 NIH-PA Author Manuscript Treatment Orientation—Eight studies had orientations that were coded as having a fundamental cognitive-behavioral orientation. indicating that mental health specification is sufficient to account for the heterogeneity in the effect size distribution. 2007). 2003). p = . including treatment format. had a significant Qb (Qb = 4. Napolitano et al. the analyses are presented because they were part of the review's a priori hypotheses.04) and the within-group homogeneity Q value (Qw) was not significant (p = . 2005).62. The random effects model. including treatment orientation. Sandgren & McCaul. 2004)..94 (95% CI = 0.01.0001).45. 2004.52–0. 2002). (2002) noted that 2 of the 40 participants randomized to telephone-administered psychotherapy were removed from the study after randomization but before initiating treatment because they received a medical procedure that excluded their participation. Treatment Format—Ten studies used telephone intervention with individual patients while two applied the telephone intervention in groups (Heckman et al. emotional expression therapy (Sandgren & McCaul..85. reached only a trend level of significance for the between-group homogeneity Q value (Qb = 3. including mental health specialization. 2002). 95% CI = −0. had a nonsignificant Qb (Qb = 0. these findings may be unreliable and appropriate caution should be taken when interpreting these results. Therapists in the mental health professions produced effect sizes of d = 0. p = . 2006.. p < . The model. while four had other orientations. Napolitano et al. two used master's-level therapists (Simon et al. 2004... however. available in PMC 2011 February 28. 2004.. two used nurses (Bailey et al. and two used a mixture of master's-level therapists and PhD-level therapists (Heckman et al. Heckman & Carlson. Sandgren & McCaul. 2006). while treatments provided by non-mental health professionals did not produce statistically significant changes (d = 0. had a nonsignificant Qb (Qb = 2. NIH-PA Author Manuscript Therapist Specialization—Ten studies used mental health specialists.08). p < .11).17.0001) than other treatment orientations (d = 0. p = . 2003). the attrition rate was the number of dropouts from therapy divided by the total number of subjects randomized to the therapy group. p = . Therapist Level of Training—Of the eight studies that did not use only doctoral-level therapists.08.63). p = . NIH-PA Author Manuscript Number of Sessions—Analyses were conducted to examine a post hoc hypothesis that number of sessions might be related to outcomes. The random effects model. 2000).

while those treated by non-mental health professionals had a nonsignificant mean attrition rate of 1. The group format was associated with significantly greater rates of attrition (M = 12. 95% CI = 2.behavioral treatment orientation was associated with significantly greater rates of attrition (M = 7. only two studies used a group format. p = .05). Thus. p = .1%.0001). 95% CI = 0. available in PMC 2011 February 28. rendering these findings as less reliable.14).6.2.57–3. Cognitive.1–18. compared with the individual format (M = 5.23–10.8. NIH-PA Author Manuscript Treatment Format—Treatment format accounted for a significant portion of the variance in attrition (Qb = 4.0001). 84). Miller replaced the three dropouts. because the within-group homogeneity Q value remained significant (Qw = 18. p = .9%.04). p = . Therapist Level of Training—The random effects model showed that level of interventionist training did not explain a significant portion of the variance (Qb = 0. . Studies with therapists in the mental health professions had a mean attrition rate of 7. compared with other orientations (M = 2. p = .90.17.04).08).0001).6% (95% CI = 5.61. p < .0001).0006). Clin Psychol (New York).Mohr et al. Miller & Weissman (2002) reported that 15 subjects were randomized and 3 dropped out. considered the number enrolled to be 18.06. the mean attrition rate above was calculated using random effects estimation. These results are displayed in Table 2. p < . NIH-PA Author Manuscript Number of Sessions—The number of sessions indicated by protocol was not significantly related to attrition (p = . However. These studies had a mean attrition rate of 7.6–10. We examined the ability of the four variables noted above to explain the heterogeneity. p = . p = . p < . Page 6 NIH-PA Author Manuscript not count these two patients as dropouts.0001). This variable also sufficiently accounted for all the excess variability in the effect size distribution.15). p = .4. Therapist Specialization—The random effects model showed that mental health specialization explained a significant portion of the variability in attrition (Qb = 15.58. A significant positive correlation would raise the possibility that larger studies with larger effect sizes were more likely to be published. 95% CI = 5. Author manuscript.28. p = . but this variable did not sufficiently account for all the excess variability in the effect size distribution.9–7.26. p = . while the relationship between sample size and pre–post treatment outcomes was r = .85.2%. therefore.43.83.4–9.07.0002). p < . p = . 0001). Treatment Orientation—Treatment orientation accounted for a significant portion of the variance in attrition (Qb = 14.09–4.56% (95% CI = 4. There was significant heterogeneity in attrition across these studies (Q = 32. because the within-group homogeneity Q value was not significant (Qw = 16. and this variable did sufficiently account for all the excess variability in the effect size distribution. The relationship between sample size and treatment–control condition comparisons was r = −. We. as in the pre–post analysis. 95% CI = 6. because the within-group homogeneity Q value was not significant (Qw = 14.5% (95% CI = −0. Analysis for Publication Bias The potential for publication bias was analyzed by correlating the study sample size with the effect size.4%. there was no evidence that these findings were influenced by publication biases.04.9. However.43.03. p = . 15). p = . As such.

Ward et al. the pre–post finding of d = 0. which put them in frequent contact with medical care providers who may or may not have prescribed medications (Bailey et al.9% (Wierzbicki & Pekarik. Sandgren & McCaul. patients in the TAU condition in Simon's and Tutty's studies (Simon et al.. In addition. 1992.. although this may have been driven by the group treatments. 1994. breast cancer. Stermac. many psychotherapy studies using no-treatment conditions prohibit any psychological or pharmacological intervention outside the study and/or do not include patients with medical conditions that bring them into frequent contact with physicians who could potentially identify and treat the depression. 1997). Elkin et al.. 2003. these could not be controlled for. For example. This figure may be somewhat higher than is found in clinical trials. Unfortunately. 1987. 2006. cognitive–behavioral treatments had higher attrition rates... 2002. Miranda et al. Berman.. Page 7 Discussion NIH-PA Author Manuscript NIH-PA Author Manuscript This meta-analysis found that psychotherapy administered over the telephone was associated with significant reductions in depressive symptoms. Secondary analyses suggested that some of this variability could be accounted for by therapist specialization and that attrition may be higher in group treatments. In contrast. including variability in baseline severity of depressive symptoms and the wide variety of comorbid illnesses across studies. A review of 14 major clinical trials. available in PMC 2011 February 28. Hemmings. Keller et al. Many of the control conditions used in studies included in this meta-analysis provided patients with active treatment conditions. Kalogerakos.. lung cancer. Gordon. & Neimeyer. Tutty et al. AIDS).Mohr et al. However..71–0. 2004). Shapiro et al. 1997.6% across all the studies. Hollon et al. & Breckenridge. DeRubeis et al. as it included a broad range of studies. 1989. Gallagher. Watson.. it is premature to draw any firm conclusions regarding the relative attrition rates between telephone-administered and faceto-face administered psychotherapies. 1992. 1994.26. Williams et al... multiple sclerosis. 1990). 2000. including psychotherapy for depression. 2005. 2000. Thompson. Russell. A meta-analysis of 125 studies reporting dropout from face-to-face psychotherapy found a mean attrition rate of 46.9% to 64. while meeting statistical criteria for significance.... 1993).42 reported in a meta-analysis that compared face-to-face psychotherapy to no-treatment controls (Wampold et al. due to differences in samples used in telephone-administered and face-to-face administered psychotherapy studies. Simon et al. 2000).. over the past 20 years found attrition rates ranging from 13. The secondary analyses accounting for unexplained variance are based on small numbers of analyses and are at best suggestive.. Robinson. Therefore. Scott & Freeman.4% (Blackburn & Moore. Part of this discrepancy may be due to the control conditions used. The variety of Clin Psychol (New York). 2004.g. 2000) were under the care of primary-care physicians who prescribed antidepressant medications. as with the efficacy findings. Gallagher-Thompson & Steffen.82 for telephoneadministered psychotherapy is in line with many findings of meta-analyses of pre–post outcomes for face-to-face therapies in the d = 0. These attrition rates fall outside the 95% CI for attrition from telephone-administered psychotherapy reported in this review. & Steckley 2003. Mohr et al. & Gretter. 1987.. There was significant heterogeneity across the studies for both the pre–post treatment and attrition analyses. Most of the remaining studies were conducted with patients who had some form of severe medical condition (e. Napolitano et al. 2003). Heckman et al. 2005. . these findings support recent observations that telephone administration of psychotherapy may reduce attrition by overcoming barriers to care (Mohr et al. found a mean effect size of d = 0. NIH-PA Author Manuscript The mean attrition rate was 7. which is somewhat less than the d = 0. There are several other potential explanations for the heterogeneity in outcomes.. However. Author manuscript. 2000. The comparison of telephoneadministered psychotherapy with control conditions.73 range (Nietzel. 2004.

or dropout in the initial three to four weeks of treatment (failure to engage). Mohr & Cox. the measures of depression used in this study had a wide range of specificity and sensitivity (Minami. NIH-PA Author Manuscript A potential limitation in the study is that the variability in medical comorbidities may have contributed to the heterogeneity in outcomes in at least two ways. multiple sclerosis. Meyer & Mark. Many of these illnesses produce symptoms that are confounded with symptoms of depression.. and it is possible that some depressive symptoms may result from the pathology or pathogenic processes of the medical disorders (Feinstein et al. & Blumenthal. Unfortunately. Kumpfel. First. Serlin. Thus. heart disease. & Holsboer. Rupprecht. Prevalence of depression in some of these illnesses exceeds prevalence in the general population. and one study targeted chronic depression). while it is possible that medical illness may elevate depressive symptom scores at any single assessment time point. In addition. Trenkwalder. and those for whom telephone intervention may not be appropriate. 1995). any decrease in depressive symptoms over time is most likely due to changes in depressive symptoms and not to the more chronic medical symptoms. Author manuscript. such as fatigue and diminished cognitive capacity. The heterogeneity in the severity of depressive symptoms and in medical comorbidities in the samples also limits generalizability. HIV. 1995). it was not possible to account for these comorbidities statistically. Wampold.Mohr et al. 1998. such as cancer. the various medical illnesses may have had variable effects on depressive symptoms and/or may have had a moderating effect on the efficacy of psychotherapy. because the depression symptom outcomes used in this meta-analysis were self-report instruments. Individual studies suggest specific uses under specific circumstances. available in PMC 2011 February 28. one study identified a variety of chronic illnesses. NIH-PA Author Manuscript We also want to emphasize that it is premature to generalize the results of this meta-analysis broadly. 1999). the generalizability of these findings to clinically diagnosable depressive disorders is limited (Kendall & FlannerySchroeder. it remains unclear if these medical illnesses moderate the effects of psychotherapy. Then Bergh. & Brown. Lett. 2004. Davidson. and others. However. A related potential problem lies in the measurement of depressive symptoms. This was due to the fact that trial reports typically do not distinguish attrition early in treatment from attrition later in treatment. the aggregated effect size estimates for depressive symptom severity should not be used as any sort of benchmark. the populations from which telephone-administered psychotherapy study samples are drawn include a wide variety of primarily medical populations with barriers to treatment. While a growing number of studies indicate that for many medical illnesses. Furthermore. failure to initiate treatment after randomization. 2001. . 2007). Another important limitation of the study is that attrition was not defined with any specificity beyond having dropped out at any point during the study. Kircher. face-toface administered psychotherapies for depression are highly effective (Elliott & Roy-Byrne. Likewise. Clin Psychol (New York). This may mask important differences in the effect that attrition at different stages of treatment may have on outcomes. telephone therapies may provide added benefit compared to care for depressive symptoms by a primary-care physician or to no care at all. three studies focused on medical practices with unspecified medical comorbidities. for example. the level of heterogeneity across studies suggests that we do not yet understand the characteristics of patients for whom such telephone interventions may be effective. thereby eliminating the possibility of covarying the effect of severity. However. For example. the comorbid illnesses targeted by the studies included in this meta-analysis are all chronic or have symptoms that continue longer than the treatment periods. Page 8 NIH-PA Author Manuscript measures for depressive symptoms used made it difficult to reliably rank the baseline depressive symptom scores on severity. Thus. due to the degree of heterogeneity in comorbidities (seven studies focused on five different specific severe illnesses. 2005.

Hollon SD. and perhaps more importantly. Mishel MH. et al. 1999. Author manuscript. injection. Mohr DC. it is not clear whether telephone-administered psychotherapy is equivalent to face-to-face administered psychotherapy in reducing depression and whether telephone-administered psychotherapy can produce lower attrition rates. Patients' perspectives on the management of emotional distress in primary care settings. 62:409–416. Partially randomised preference trial. 2005). Cox D. 1999. available in PMC 2011 February 28. and injury phobia and self-injection anxiety. 2004. British Journal of Psychiatry. Cognitive therapy versus medications in the treatment of moderate to severe depression.Mohr et al. 21:340–347. compared with equivalent face-to-face treatments. 2000. It would be useful if reports of clinical trials differentiated among these different forms of attrition. Trials addressing these questions are urgently needed. It will be important to begin identifying specific populations for whom such treatments are useful. 15:527–534. 1949.. Liao D. Belyea M. Treatment preferences among depressed primary care patients. 177:312–318. Managing difficulties with adherence to injectable medications due to blood. Mohr. 1997. 171:328–334. . Azocar F. 2005. Boudewyn. [PubMed: 11116771] Berger MM. The telephone—its use as a psychiatric adjunct. Assessing effectiveness of treatment of depression in primary care. et al. [PubMed: 9373420] Brody DS. British Journal of Psychiatry. Most centrally. Stewart JL. Duggan C. L. Moore RG. Blackburn IM. Thus. 2000. Salomon RM. Wells KB. the most appropriate conclusion of this meta-analysis is that delivery of psychotherapy for depressive symptoms is promising but requires more research. Psychiatric Quarterly. Sherbourne CD.. Validation of the Cognitive Beliefs Questionnaire for multiple sclerosis. References NIH-PA Author Manuscript Alvidrez J. Boston. Journal of General Internal Medicine. These conclusions can only be drawn from randomized trials directly comparing face-to-face and telephone-administered treatments. General Hospital Psychiatry. Paper presented at the American Psychological Association. 2003. Huang. DA. Acknowledgments NIH-PA Author Manuscript This study was supported by National Institute of Mental Health grant R01 MH59708 to Dr. 12:403–406. Thompson TL. Khaliq AA. Chilvers C. Uncertainty intervention for watchful waiting in prostate cancer. AC. Glueck BCJ. Mohler J. as organizations that provide mental health care have already begun implementing telemental health programs (Maheu et al. Dewey M. Young PR. Churchill R. [PubMed: 15809408] Dwight-Johnson M. [PubMed: 10572775] Bailey DE. 1:215–221. DeRubeis RJ. Amsterdam JD. Distressed women's clinic patients: Preferences for mental health treatments and perceived obstacles. Journal of General Internal Medicine. Mohr. Archives of General Psychiatry. [PubMed: 10940143] Clin Psychol (New York). Shelton RC. A few questions critical to our ability to make broader clinical recommendations remain unanswered. [PubMed: 15525860] Bedi N. [PubMed: 9229277] Cortez. American Journal of Drug Delivery. Cancer Nursing. 23:522–529. 27:339–346. Fielding K.. Telephone administration of psychotherapies may also have deleterious effects. populations for whom telephone-administered psychotherapy is contraindicated. 1997. Page 9 NIH-PA Author Manuscript likely has very different ramifications compared with patients who remain in treatment for many weeks.. Controlled acute and follow-up trial of cognitive therapy and pharmacotherapy in out-patients with recurrent depression. but fail to complete the total number of sessions as specified in the protocol. DC.

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9) Experimental Tx = 33. etc. dysthymia = 6%.1(12. minor depressive disorder = 3% No information Psych Dx and exclusions NIH-PA Author Manuscript Baseline depression mean (SD) Multiple chronic medical conditions Multiple sclerosis Multiple sclerosis No information Family medicine clinic— no information on Dxs HIV/AIDS HIV/AIDS Prostate cancer Comorbid Med Dx 57 48 42 32 49 43 54 75 Mean patient age 100% male 77% female 72% female 100% female 87% female 30% female 32% female 100% male Patient gender NIH-PA Author Manuscript Table 1 Mohr et al. schizophreina or psychosis. current plan and intent to commit suicide.5) for all treatment conditions Experimental Tx = 17.3(8. Author manuscript. Excluded Current MDD = 71%. T-supportive emotionfocused therapy = 28.4. Control Tx = 27.9(12. severe depressive Sx Minor depression No information MDD = 70%.6) Current MDD = 50%.5).4).2).1(7. Experimental Tx = 14. Control Tx = 15. Control Tx = 12.e ent trol ion Clin Psychol (New York).53(2.73(4.1(10. Control Tx = 1.55(5.) No information Inclusion required Hx of depressive disorder.92).3(7. current substance abuse. Excluded Dxs: severe psychopathology (psychosis.8). Control Tx = 5.0(7.34(5. available in PMC 2011 February 28. partial remission of MDD = 21%.1) Experimental Tx = 8. 16 weekly sessions 8 weekly sessions Individual 8 weekly sessions Individual Individual 12 weekly sessions 6 weekly sessions Individual Individual 8 sessions Group 12 90-min sessions Yes Yes Yes Yes No Yes Yes No 5 weekly sessions Individual Group Mental health specialist Number of sessions Tx format PhD psychologist PhD Psychologist Doctoral student/postdoctoral PhD psychologist Students (psychology/MD/nurse) MS/PhD psychologist MS/PhD psychologist Nurse Therapist NIH-PA Author Manuscript nt BDI-II BDI-II POMS-D HRSD HRSD BDI GDS POMS-SF-D Outcome measure 4/8 had current T-CBT: BDI = 27. Excluded Dxs: bipolar.0) Experimental Tx = 3.4 BDI = 22. Page 13 .39).

Control Tx = 10.0(0.62) Experimental Tx = 8. profile of mood states–short form–depression dejection scale. Individual n*** Individual Number of sessions NIH-PA Author Manuscript Tx format SCL-20 SCL-20 POMS-D GHQ-D Outcome measure Experimental Tx = 2. general health questionnaire–depression scale. current substance abuse. GHQ-D.9). geriatric depression scale. current plan and intent to commit suicide.7) MDD and the other 4 were in partial remission.5(8.5). Control Tx = 1. Control Tx = 14.8(5. available in PMC 2011 February 28.1) Excluded Dxs: Bipolar disorder.3(10. schizoaffective disorder. Yes Yes No Yes Mental health specialist Master's level Master's level Nurses Graduate student Therapist S. HRSD = 23. BDI = 34. schizophrenia.8(0.6(0. HRSD.9).7) Experimental Tx = 1.Individual Individual care ary 6 weekly sessions 4 weekly sessions + 4 sessions as needed 5 weekly sessions 8 weekly sessions Clin Psychol (New York).5(0.8(2.7) Experimental Tx = 14. Page 14 .3). schizophrenia Information unclear No information Dxs: severe psychopathology (psychosis. SCL-20. etc. Hamilton rating OMS-SF-D. substance abuse Excluded Dxs: bipolar disorder.7(10.58).) Psych Dx and exclusions NIH-PA Author Manuscript nt Primary-care patients—no information on comorbidities Primary-care patients—no information on comorbidities Breast cancer Lung transplant candidates Comorbid Med Dx 48 44 55 45 Mean patient age 65% female 76% female 100% female 69% female Patient gender NIH-PA Author Manuscript Baseline depression mean (SD) Mohr et al. symptom checklist–20 e of a control condition.4(2. Control Tx = 1. Author manuscript.

16.33. 0.3) (4. 1.18 (p < .78) (0.39) (−0.37) 0. ** (0.01. 0. 1.6) (−4.27.18 0.50.70) (1.4.86 0.33) (0.13. p = . 2.0001) Not included in overall mean.4) (5.0001) 0.45.2.0 18.50.0 10.50) (−0.17.17) (0. 0. available in PMC 2011 February 28.10.27 1. 12.9) (−2. 1.97 1.62 65 8 38 Mohr 2005 (T-CBT)** Mohr 2005 (T-SEFT)** Mohr 2006 Napolitano 2002 Z-value for overall effect Chi-squared value Overall effect size 28 16 Mohr 2000 Tutty 2000 18 Miller 2002 90 15 Lynch 1997 198 108 Heckman 2007 Simon 2004 44 Heckman 2006 Sandgren 2003 21 Bailey 2004 Study 94 195 55 39 N/A N/A N/A 16 15 14 107 46 20 N randomized to control treatment* Clin Psychol (New York). 0.35 0.15 Standard mean gain Outcome: depression severity Pretreatment versus posttreatment effects (4.16.02.13) (1.37 0.26 0. 0. *** Mohr (2005) compared two telephone-administered psychotherapies.58) (0. 2.0**** 6.9) (−0.0 1. 0.63) 0. 0. 2.14.7.38 0. 16.7. 0.08.2. p = .61. 54.2) (−0.8) (−0.4.07 (p < . 0.4 (df = 11. 1.0) (0.30 0.45 1.1. 10. 11.5 (df = 11.0 5. 1. **** Effect size from the random effects model.0 31.51) (0.0 Proportions (%) Outcome: attrition Attrition NIH-PA Author Manuscript Effect sizes change in depressive symptoms Mohr et al.35) (−0. 4.6 (df = 9. 1.7) 95% CI 4.2. * NIH-PA Author Manuscript N randomized to telephoneadministered psychotherapy* NIH-PA Author Manuscript Table 2 (0.0001) Q = 241.03.37.16.86.10 1.19.50 0.0 17. 0. 2.7.04 Standard mean difference Outcome: depression severity Telephone-administered psychotherapy versus treatment-as-usual For individual analyses N size changed according to data provided in each study (N = number).0 7.11.37) (0.43.52) (0.13) Q = 10. data presented separately for each treatment. 0.08 (−0.9.9) (−2.28) (1.68.0006) 7. p < .0 5. 0. 10.46) 95% CI 5.67) (0.58 0. 1. 29. Page 15 .0 27.4*** 7.79) (0.41) (0.07 1.47) (−0.8.8) (7. 0.81*** 2. different from 0) Q = 32.0.7) (3.0001.60 0.8. 48. 34.31) 0.26 0.71) (−0. 15.8) (6.7) (0.82) (0.17 0.0 5. 14.83.59) (−0. Author manuscript.08 (−0.0 0.44 (p < .03. 10. 0. 0.01 95% CI −0.36 0.