Dial for CBT
Dial “D” for Depression: Telephone Versus Face-to-Face Cognitive Behavior TherapyPrint This Post
A paper recently published in JAMA reports that patients with major depression who received telephone-administered cognitive behavioral therapy (T-CBT) had lower rates of discontinuing treatment compared with patients who received face-to-face CBT. Treatment administered by telephone was not inferior to face-to-face treatment in improvement in symptoms by the end of treatment. However, at six-month follow-up, patients receiving face-to-face CBT were significantly less depressed than those receiving T-CBT.
Cognitive behavioral therapy is a highly effective intervention for treating depression and anxiety disorders. CBT helps patients identify, understand, and modify how they think and behave, which helps them develop a renewed sense of control that fosters positive emotional changes. Theoretically, CBT can be used by adults and children in any situation that involves a pattern of unwanted behavior accompanied by distress and impairment.
CBT is particularly successful in treating patients with anxiety disorders, defined as panic disorder, agoraphobia, generalized anxiety disorder, social anxiety disorder, specific phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and separation anxiety disorder. Approximately 14% to 25% of the general population have at least one anxiety disorder[3-5] and the majority of them will seek help in primary care settings—predominantly for relief of generalized anxiety disorder, panic disorder, and PTSD.[6,7]
CBT is also a recommended treatment option for conditions such as mood disorders, personality disorders, eating disorders, substance abuse, agoraphobia, and attention deficit hyperactivity disorder (ADHD). It is also frequently used as a tool to help patients with chronic pain deal with illnesses such as rheumatoid arthritis, back problems, and cancer. Patients with sleep disorders may also find that CBT is a useful treatment for insomnia. There is a growing body of evidence showing that CBT, often used as an adjunct to medication, is an effective intervention for children with anxiety disorders, depression, self-mutilation, and ADHD.
While psychotherapy such as CBT is effective in treating depression and anxiety disorders, only a small proportion of patients follow through a complete course of treatment—despite claiming a preference for psychotherapy versus medication. And because nearly three-fourths of patients report barriers that make it difficult to attend regular therapy sessions, the telephone could be one way to improve follow-through. According to background information presented in the article, “The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery.”
The study was done by a team of Chicago-based researchers who compared face-to-face CBT with T-CBT for the treatment of depression in primary care. The trial included 325 patients with major depressive disorder, recruited from November 2007 to December 2010. Participants were randomized to 18 sessions of T-CBT or face-to-face CBT. The study’s primary measured outcome was attrition (continued or discontinued participation) at session 18. Secondary outcomes included measures of depression. Participants were offered eighteen 45-minute sessions: two sessions weekly for the first two weeks, followed by 12 weekly sessions, with two final booster sessions during four weeks.
Significantly fewer participants discontinued T-CBT (20.9%) before session 18 compared with face-to-face CBT (32.7%; P=.02). Attrition before week five was significantly lower in T-CBT (4.3%) than in face-to-face CBT (13.0%; P=.006), but there was no significant difference in attrition between sessions five and 18. Patients who received T-CBT attended significantly more sessions than those receiving face-to-face CBT.
At 18 weeks, the researchers found that T-CBT was not inferior to face-to-face CBT in reducing depressive symptoms at posttreatment. However, face-to-face CBT was significantly superior to T-CBT during the six-month follow-up period. By six-month follow-up, 19% of T-CBT versus 32% of face-to-face CBT participants were significantly less depressed, as measured on the Hamilton Depression Scale (P<.01) and the Patient Health Questionnaire-9 (P=.004).
The findings of this study suggest that telephone-delivered care has both advantages and disadvantages. However, the benefit of the phone-delivered therapy seems to occur in the early stages of treatment (up to 18 weeks), perhaps suggesting that for patients with access barriers or physical challenges, a hybrid treatment that starts with telephone therapy and moves to face-to-face therapy is a viable alternative.
Jill Shuman, MS, ELS
Published June 19, 2012
- Mohr DC, Ho J, Duffecy J, et al. Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients. JAMA. 2012;307(21):2278-2285.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
- Chavira DA, Stein MB, Bailey K, Stein MT. Child anxiety in primary care: prevalent but untreated. Depress Anxiety. 2004;20(4):155-164.
- Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8-19.
- Stein MB, Sherbourne CD, Craske MG, et al. Quality of care for primary care patients with anxiety disorders. Am J Psychiatry. 2004;161(12):2230-2237.
- Harman JS, Rollman BL, Hanusa BH, et al. Physician office visits of adults for anxiety disorders in the United States, 1985-1998. J Gen Intern Med. 2002;17(3):165-172.
- Stein MB. Attending to anxiety disorders in primary care. J Clin Psychiatry. 2003;64(Suppl 15):35-39.
- Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008; 359(26):2753-2766.
- Jaycox LH, Miranda J, Meredith LS, et al. Impact of a primary care quality improvement intervention on use of psychotherapy for depression. Ment Health Serv Res. 2003;5(2):109-120.