More than 20% of patients in primary care have depressive disorders. Although primary care is the principal venue for treating depression, data suggest few patients receive adequate treatment for depression in primary care and more than half still meet criteria for major depressive disorder (MDD) after one year. These outcomes are even worse in rural areas where availability of mental health providers is limited and distances often preclude regularly scheduled follow-up appointments required by depression care guidelines.
Many studies have examined methods of improving depression outcomes in primary care. Interventions focused on improving physician knowledge or treatment have not generally been effective. Telephone-administered case management programs have demonstrated some improvement in outcomes through increasing patient adherence to pharmacotherapy. However, up to half of these patients still fail to show significant reductions in depressive symptoms. Patients who do poorly are more likely to have increased levels of stress and social dysfunction (e.g. conflictual relationships, low social support). Cognitive behavioral therapy (CBT), a behavioral treatment that teaches methods of coping with stress, distress, and social difficulties, has demonstrated particularly good results for depression. CBT delivered within primary care has been shown result in substantial improvements in 60-72% of depressed patients. However, CBT is largely unavailable to patients in rural areas both because of the lack of services and/or the distances patients must travel to obtain those services. This creates inequities in available care based on geography. We have developed a telephone administered CBT (T-CBT). We have shown that T-CBT can produce substantial improvements in depression. T-CBT can also overcome barriers to treatment found in rural areas.
Multiple trials have found telephone-administered cognitive behavioral therapy (T-CBT) to be effective for the treatment of depression. The aim of this study was to evaluate T-CBT for the treatment of depression among veterans served by Community Based Outpatient Clinics (CBOCs) outside of major urban areas.
Eighty-five veterans meeting DSM-IV criteria for Major Depressive Disorder were randomized to receive 16 sessions of T-CBT over 20 weeks or treatment as usual (TAU) through the CBOC. Veterans were assessed at baseline, 12 weeks, 20 weeks (post-treatment), and 6-month follow-up using the Hamilton Depression Rating Scale, the PHQ-9, and a standardized psychiatric interview.
There were no significant time X treatment effects (ps > .20). Patients were compliant, with 38 (92.7%) completing at least 12 sessions, and 32 (78.0%) having no missed sessions whatsoever. Ratings of audiotaped sessions showed the therapists to be highly competent. Conclusions: This trial yielded negative results for an intervention that has been shown to be effective under other circumstances. We speculate that veterans served within the VA system are more refractory to treatment than other populations, and may require a more rigorous intervention.
This study underscores that veterans are a population that is vulnerable to depression and who can be refractory to treatment. A growing body of evidence underscores the mental health needs of veterans returning from combat (Hoge, et al., 2004), who settle in geographically diverse areas. These findings suggest that improving the reach of our interventions alone, even using methods validated in other settings, may not be sufficient to improve depression outcomes within the VA system. Research into methods of improving the efficacy of telemental health intervention is needed, and might include more intensive care, the use of other treatment modalities, the use of additional treatment delivery media such as videoconferencing (Richardson, Frueh, Grubaugh, Egede, & Elhai, 2009), and the integration of telepsychiatry and pharmacotherapy into telemental health intervention.
- Mohr DC, Carmody T, Erickson L, Jin L, Leader J. Telephone-administered cognitive behavioral therapy for veterans served by community-based outpatient clinics. Journal of consulting and clinical psychology. 2011 Apr 1; 79(2):261-5.
- Mohr DC, Vella L, Hart S, Heckman T, Simon G. The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis. Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association. 2008 Jan 1; 15(3):243-253.
- Mohr DC. Barriers to Psychological & Behavioral Intervention in Primary Care. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD.