Delivering Treatment for

Depression into the Patient’s

Home: Telephone & Internet
David C. Mohr, Ph.D.
Northwestern University
&
Center for the Management of Complex Chronic Care
Hines VA
 What I will talk about today
 Describe our telephone psychotherapy research
program in depression.
 We began in 1995, when the telephone was the
principal option for reaching out
 Current state of internet treatments for
depression
 Our developing research in integrating internet
and telephone.
 Telephones in Psychotherapy

 In 1876 Alexander Graham Bell invented the

telephone
 Three years later, in 1879, BMJ published the first
report of a the use of a telephone to diagnose a
child’s cough.
 Another 70 years was required before the first
reports of the use of telephones in psychotherapy
were published (1949).
 A 1996 APA task force report stated that empirical
evidence of the efficacy of telphone-administered
psychotherapy was scant to non-existent.
 Why look at telephone
psychotherapy?

 Nearly 2/3rds of practicing clinical psychologists today

report using the phone to some degree to deliver care.
 Mental Health carve-outs, HMOs, the VA and others are
beginning to develop and implement tele-mental health
programs to
 Extend care
 Save costs
 Research to develop and validate tele-mental health
programs would
 Facilitate policy decision making
 Support standards for quality
 How we began
 We began in 1995, when
the telephone was the
principal tool for outreach
 Many patients at the UCSF
Multiple Sclerosis Center
were unable to attend
regularly scheduled
appointments due to
 Disability
 Distance from center

 Two-thirds of patients would prefer psychotherapy

or counseling to pharmacotherapy.
 Initial Pilot Research

 We developed a telephone-administered cognitive

behavioral therapy (T-CBT) that includes:
 A patient workbook to
 facilitate communication
 provide information
 provide support between sessions.
 32 Kaiser multiple sclerosis patients with POMS
depression > 15 were randomly assigned to:
 8 weeks of T-CBT administered by 2nd-3rd year graduate
students.
 Usual care control (UCC) through Kaiser Permanente
 Effect for time p=.003
Time X Treatment, p=.01

35
30
25
POMSDep-Dej

20 T-CBT (p=.001)
15 UCC (p=.72)
10
Pre-Tx Post-Tx
Mohr, D.C. et al., J Clin Conult Psychology. 2005;68:356-361
 T-CBT vs. T-SEFT

 Compared 16 weeks of T-CBT to T-Supportive Emotion-Focused

Therapy (T-SEFT).
 T-SEFT a manualized, client centered tx, aimed at enhancing awareness of
emotions and inner experience, with operationalized procedures for
enhancing therapeutic relationship. Interventions focused on behavior or
cognition were prohibited.
 127 Patients were randomized:
 MS
 BDI ≥ 16
 1+ physical symptoms causing participation restriction (handicap)
 99 (77%) women
 Therapists were Ph.D psychologists, with allegiance to their treatment
arm.
 Supervisors were specialists in CBT and SEFT
 Patients were followed for one year after treatment cessation
 Hamilton: Baseline To End of Follow-Up
Treatment Outcome: Time - p< .00001; Time X Tx - p =.019
Maintenance of Gains: Time - p =.004; Time x Tx - p =.42
22

20

18 * T-SEFT
T-CBT

*
HRSD

16

14

12

10 End of Tx
0 8 16 28 40 52 64
Mohr, D.C. et al., Arch Gen Psychaitr. 2005;62:1007-1014
Week
 MDD Diagnosis by Treatment
Treatment Outcome: Time - p<.00001; Time X Tx - p=.02
Maintenance of Gains: Time - p=.04; Time x Tx - p=.16
80%
72.6%
68.8%
70%

60%
Percent with MDD Present

50%
T-CBT
40% T-SEFT
30.5%
30% *
18.6%
20% 15.8% 15.3%
13.3%
8.6%
10%

0% End of Tx
0 16 40 64
Week
 Disability (GNDS) Controlling for HRSD
Treatment Effect (p=.002)
Time X treatment (p=.004)
24

22

T-SEFT
Disability (GNDS)

20 * T-CBT

18
*

16

14
0 8 16
Week
 T-CBT vs. T-SEFT

 A large literature has shown most

psychotherapies are equivalent in reducing
depression.
 CBT and SEFT, face-to-face, have been shown
to be equivalent in face-to-face administration
(Watson et al. JCCP 2003;71:773-81)
 Our finding that T-CBT is superior suggests that
this this may not be true with tele-therapy to
patients with barriers.
 Skills training is important!
 Attrition

 Attrition in trials of face-to-face

psychotherapy ranges from 15-60%
with a means of 26% to 47%
 Attrition was 7 (5.5%)
 3 (4.8%) for T-CBT
 One was removed secondary to trauma.
 4 (6.2%) for T-SEFT
 Barriers to Psychotherapy in
Primary Care

 Primary care is the de facto site for identification

and treatment of depression.
 Approximately 2/3rds of depressed patients
state that they would prefer psychotherapy to
antidepressant medications. But…
 Only approximately 20% follow-up on referrals by
their primary care physician.
 Of those who begin nearly half dropout of treatment.
 This suggests that there are significant barriers
to psychotherapy.
 Barriers to Psychotherapy in 290
UCSF Primary Care patients

 Depressed patients are more likely to perceive

barriers (74.0% vs. 51.4%, p=.0002)
 Among depressed patients 68.3% report
practical barriers including
 Transportation (21.2%)
 Time constraints (20.6%)
 Caregiving responsibilities (13.6%)
 19.2% report emotional barriers including
 Concerns about being seen while emotional (6.8%)
 People finding out they are in psychotherapy (6.8%)
 And so, can we reach
out?

 Depression is both a indication for psychotherapy and a

barrier to receiving it.
 Inserting behavioral medicine into primary care has not
been widely adopted.
 Data suggest T-CBT may increase access for and reduce
attrition from psychotherapy for depression.
 A current trial is examining T-CBT for the treatment of
depression in veterans in rural areas with limited mental
health services.
 A randomized trial of T-CBT compared to face-to-face
CBT for depression in primary care has been funded by
the NIMH and will begin in the coming months.
 Telecommunications
innovations since 1995
 Internet penetration
 73% of Americans have internet access (compared to 95% with
telephone access).
 42% have broadband access (40% increase in one year).
 Access is much higher in urban areas
 Promise of Internet CBT
 Standardized presentation of therapy material
 Interactive programming for exercises
 No geographic limitations to services.
 Patient access 24/7
 Costs are potentially minimal
 Multiple avenues for contact with therapist
 Why should we be worried about
standardization of content?
 RCT data shows CBT is largely equivalent to
antidepressant medication.
 Among 6,047 pts treated with psychotherapy in
HMOs, CMHCs, EAPs etc. (Hansen 2002,2003)
 8.2% deteriorated
 56.8% showed no change
 20.9% showed some measurable improvement
 14.1% met criteria for recovery
 After 16 sessions, only 50% of patients show
measurable improvement.
 Why are psychotherapy outcomes
so bad in the community,
compared to RCTs
 Patients in the community may be more difficult
than those selected for clinical trials.
 Multiple psychiatric problems, substance abuse, etc.
 But RCTs rule most people out for not being severe
enough.
 Assuring competence in a private endeavor
 Evidence that adherence to tx model improves
outcomes.
 Even in RCTs at least 25% of sessions do not meet
criteria.
 Nobody knows what therapists in the community do.
 I-CBT
 Opportunity to provide standardized care
 Provide over a long distance
 At minimal cost.
 Clarke 2002
299 Pts treated for depression in Primary Care
Time X Treatment: NS

I-CBT (N=144)
35 TAU (N=155)
30
25
CESD

20
15
10
Baseline Week 4 Week 8 Week 16
 Clarke, 2002 Cont’d
 Potential reasons for failure
 Low compliance with website:
 Median visits = 2
 Mean visits = 2.6 ± 3.5

 Attrition
 34.4% across both treatments
 Clarke 2005
255 Pts Receiving Care for Depression in an HMO
Time X Treatment: p = .03
I-CBT+Postcard (N=75)
35
I-CBT+Call (N=80)
30 TAU/I-CBT(N=100)

25
CESD

20

15

10
Baseline Week 5 Week 10 Week 16
 Clarke, 2005 cont’d
 Compliance somewhat better but not great:
 I-CBT+postcard: M = 5.0±6.2
 I-CBT+telephone call: M = 5.6±5.8
 TAU (+I-CBT access): M = 2.6±2.5
 Attrition still not good
 I-CBT+postcard: 38.7%
 I-CBT+telephone call: M = 46.3%
 TAU: 20.0%
 Christensen (2004)
Sample recruited from internet
Time X Treatment p<.05

ITT Sample
0.7
0.6 Completer Sample
0.5
Change in CESD(Effect

0.4
Size)

0.3
0.2
0.1
0
Internet Information I-CBT + lay phone No tx control
(N=165) (N=182) (N=178)
 Christensen, 2005 Cont’d
 Compliance
 I-CBT + Lay phone calls: M = 14.8±9.7 of 29
exercises
 Internet information: M = 4.5±1.4 visits
 Attrition
 I-CBT + Lay phone calls: 33.5%
 Internet information: 17.6%
 No treatment control: 11.8%
 Problems with I-CBT
 Assignment to I-CBT associated with
greater dropout than no-tx or TAU.
 People aren’t using it.
 34-47% of I-CBT patients drop out.
 2-6 visits
 Phone calls from lay persons don’t help much
 I-CBT sites to date have not been tailored
to the patient.
 Wright (2005)
Time X treatment: p=.02

3
ITT
2.5 Completers
Change in BDI (Effect Size)

2
1.5
1
0.5
0
C-CBT + 1/2 Standard CBT WLC (N=15)
therapist time (N=15) (N=15)
 Strengths & Weakness

 Telephone-Psychotherapy (T-CBT)
+ Low attrition (<5%)
+ Strong efficacy under controlled conditions
+ Excellent outreach / reduction in barriers
- Relies on therapist adherence to tx model
- No significant cost savings
 I-CBT
+ Standardized presentation of material
+ Geographic coverage, 24/7 coverage
+ Minimal cost
- Effect sizes appear much lower than other treatments
- Attrition high (comparable to face-to-face therapy)
- Compliance (visiting site) is low.
 One hour of
Psychotherapy per week

Sleep

ψ Wake

0 24 48 72 96 120 144 168

Hours in Week

Psychotherapy
 Or…..

Sleep

ψ Wake

0 24 48 72 96 120 144 168

Hours in Week
Brief
Web e-mail e-mail T-CBT e-mail
Web Class Brief Web Web Web Web Web
HW Telephone HW HW HW HW HW
Coaching
 Conclusions
 Telephone administered psychotherapy is
effective in treating depression.
 The inclusion of CBT skills training
components add benefit during 16 weeks
of treatment.
 These skills may be taught more efficiently
using tele-communications technology that
brings training into patients’ lives.
 Future research:
 Compare telephone administered
psychotherapy to face-to-face administered
psychotherapy
 Evaluate new procedures for integrating
treatment into patients’ lives using internet and
other telecommunications technologies.