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Delivering Treatment for Depression into the Patient’s Home: Telephone & Internet

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.

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Delivering Treatment for Depression into the Patient’s Home: Telephone & Internet

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  1. 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

  2. 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.

  3. 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.

  4. 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

  5. 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.

  6. 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

  7. Mohr, D.C. et al., J Clin Conult Psychology. 2005;68:356-361

  8. 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

  9. Mohr, D.C. et al., Arch Gen Psychaitr. 2005;62:1007-1014

  10. 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!

  11. 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

  12. 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.

  13. 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%)

  14. 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.

  15. 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

  16. 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.

  17. 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.

  18. I-CBT • Opportunity to provide standardized care • Provide over a long distance • At minimal cost.

  19. 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

  20. 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%

  21. 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%

  22. 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.

  23. 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.

  24. One hour of Psychotherapy per week ψ ψ Psychotherapy

  25. Or….. ψ ψ Brief T-CBT e-mail e-mail e-mail Web Class Web HW Brief Telephone Coaching Web HW Web HW Web HW Web HW Web HW

  26. 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.

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