Transcript Slide 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
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?
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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
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Extend care
Save costs
Research to develop and validate tele-mental health
programs would
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Facilitate policy decision making
Support standards for quality
How we began
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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
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
Disability
Distance from center
Two-thirds of patients would prefer psychotherapy
or counseling to pharmacotherapy.
Initial Pilot Research
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We developed a telephone-administered cognitive
behavioral therapy (T-CBT) that includes:
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A patient workbook to
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facilitate communication
provide information
provide support between sessions.
32 Kaiser multiple sclerosis patients with POMS
depression > 15 were randomly assigned to:
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8 weeks of T-CBT administered by 2nd-3rd year
graduate students.
Usual care control (UCC) through Kaiser Permanente
POMS Dep-Dej
Effect for time p=.003
Time X Treatment, p=.01
35
30
25
20
15
10
T-CBT (p=.001)
UCC (p=.72)
Pre-Tx
Post-Tx
Mohr, D.C. et al., J Clin Conult Psychology. 2005;68:356-361
T-CBT vs. T-SEFT
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Compared 16 weeks of T-CBT to T-Supportive Emotion-Focused Therapy
(T-SEFT).
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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
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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
*
HRSD
18
T-SEFT
T-CBT
*
16
14
12
10
End of Tx
0
8
16
28
Week
40
52
64
Mohr, D.C. et al., Arch Gen Psychaitr. 2005;62:1007-1014
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%
Percent with MDD Present
72.6%
68.8%
70%
60%
50%
T-CBT
T-SEFT
40%
*
30%
30.5%
18.6%
20%
15.8%
15.3%
13.3%
8.6%
10%
0%
End of Tx
0
16
40
Week
64
Disability (GNDS) Controlling for HRSD
Treatment Effect (p=.002)
Time X treatment (p=.004)
24
Disability (GNDS)
22
*
20
T-SEFT
T-CBT
*
18
16
14
0
8
Week
16
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!
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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%)
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3 (4.8%) for T-CBT
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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…
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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
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Transportation (21.2%)
Time constraints (20.6%)
Caregiving responsibilities (13.6%)
19.2% report emotional barriers including
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Concerns about being seen while emotional (6.8%)
People finding out they are in psychotherapy (6.8%)
And so, can we reach
out?
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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
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Internet penetration
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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
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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)
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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
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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.
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Assuring competence in a private endeavor
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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.
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Clarke 2002
299 Pts treated for depression in Primary Care
Time X Treatment: NS
I-CBT (N=144)
35
TAU (N=155)
CESD
30
25
20
15
10
Baseline
Week 4
Week 8
Week 16
Clarke, 2002 Cont’d
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Potential reasons for failure
 Low
compliance with website:
 Median
visits = 2
 Mean visits = 2.6 ± 3.5
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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)
I-CBT+Call (N=80)
TAU/I-CBT(N=100)
35
CESD
30
25
20
15
10
Baseline
Week 5
Week 10
Week 16
Clarke, 2005 cont’d
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Compliance somewhat better but not great:
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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
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I-CBT+postcard: 38.7%
I-CBT+telephone call: M = 46.3%
TAU: 20.0%
Christensen (2004)
Change in CESD (Effect
Size)
Sample recruited from internet
Time X Treatment p<.05
ITT Sample
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Completer Sample
Internet Information I-CBT + lay phone
(N=165)
(N=182)
No tx control
(N=178)
Christensen, 2005 Cont’d
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Compliance
 I-CBT
+ Lay phone calls: M = 14.8±9.7 of 29
exercises
 Internet information: M = 4.5±1.4 visits
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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.
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 34-47%
of I-CBT patients drop out.
 2-6 visits
 Phone calls from lay persons don’t help much
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I-CBT sites to date have not been tailored
to the patient.
Change in BDI (Effect Size)
Wright (2005)
Time X treatment: p=.02
3
ITT
2.5
Completers
2
1.5
1
0.5
0
C-CBT + 1/2
therapist time (N=15)
Standard CBT
(N=15)
WLC (N=15)
Strengths & Weakness
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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
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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
0
24
48
72
Wake
96
120
Hours in Week
Psychotherapy
144
168
Or…..
Sleep
ψ
0
24
48
72
Wake
96
120
144
168
Hours in Week
Web e-mail
Web Class
Brief
HW
Telephone
Coaching
e-mail
Web
HW
Web
HW
Brief
T-CBT
Web
HW
e-mail
Web
HW
Web
HW
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:
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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.