Delivering Treatment for Depression into the Patient

1
Delivering Treatment for Depression into the
Patients 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 childs 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 gt 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.
200568356-361
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.
2005621007-1014
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
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 200371773-81)
• 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!

14
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

15
(No Transcript)
16
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.

17
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)

18
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.

19
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

20
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.

21
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.

22
I-CBT

• Opportunity to provide standardized care
• Provide over a long distance
• At minimal cost.

23
(No Transcript)
24
Clarke, 2002 Contd

• Potential reasons for failure
• Low compliance with website
• Median visits 2
• Mean visits 2.6 3.5
• Attrition
• 34.4 across both treatments

25
(No Transcript)
26
Clarke, 2005 contd

• Compliance somewhat better but not great
• I-CBTpostcard M 5.06.2
• I-CBTtelephone call M 5.65.8
• TAU (I-CBT access) M 2.62.5
• Attrition still not good
• I-CBTpostcard 38.7
• I-CBTtelephone call M 46.3
• TAU 20.0

27
(No Transcript)
28
Christensen, 2005 Contd

• Compliance
• I-CBT Lay phone calls M 14.89.7 of 29
  exercises
• Internet information M 4.51.4 visits
• Attrition
• I-CBT Lay phone calls 33.5
• Internet information 17.6
• No treatment control 11.8

29
Problems with I-CBT

• Assignment to I-CBT associated with greater
  dropout than no-tx or TAU.
• People arent using it.
• 34-47 of I-CBT patients drop out.
• 2-6 visits
• Phone calls from lay persons dont help much
• I-CBT sites to date have not been tailored to the
  patient.

30
(No Transcript)
31
Strengths Weakness

• Telephone-Psychotherapy (T-CBT)
• Low attrition (lt5)
• 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.

32
One hour of Psychotherapy per week
?
?
Psychotherapy
33
Or..
?
?
Brief T-CBT
e-mail
e-mail
e-mail
Web Class
Web HW
Web HW
Web HW
Web HW
Web HW
Brief Telephone Coaching
Web HW
34
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.