Phone Therapy Plus Pills Lifts Depression Better Than Meds Alone, Study Finds
By Jennifer Huget
Special to The Washington Post
Tuesday, April 3, 2007; HE01
Can psychotherapists just phone it in?
A new study in which patients receiving psychotherapy for depression improved without ever meeting their therapists face to face may encourage some psychologists to consider telecommuting. The research spotlights the changing role of the telephone in psychotherapy, its potential to extend help to reluctant or hard-to-reach patients and its limitations as a therapeutic tool.
In the study of 393 patients diagnosed with depression and placed on antidepressant medications, most (77 percent) of those who also received periodic psychological counseling over the phone found their depression "much" or "very much" improved after 18 months, found Evette Ludman, senior research associate at the Group Health Center for Health Studies in Seattle, and colleagues. Of those who received medication without phone counseling, only 63 percent saw similar gains, according to the study, funded by the National Institute of Mental Health and published in the April issue of the Journal of Consulting and Clinical Psychology.
The phone-therapy patients didn't initiate the calls; in a departure from usual practice, psychotherapists phoned them, after the patients' diagnoses by primary care physicians, to conduct eight half-hour talk therapy sessions for six months. The therapists then conducted shorter "booster" sessions every two months for up to a year. Researchers said they chose to test this care model because, in the United States, most depressed patients either don't seek psychotherapy after their diagnosis or cut short their therapy.
Ludman's study did not isolate which component of the phone-therapy program -- counselors' reminders to patients to stay on their meds, for example, or patients' feeling that somebody out there cared -- should be credited with patients' improved mental health. Whatever it was, Ludman said, the key was that "the results were maintained over time" -- months after therapy stopped. "This is the holy grail of psychotherapy: Can you help people not only get better but stay better over time?"
Ludman noted that the phone-therapy model used was similar to programs recently launched by pharmaceutical companies and insurers to support sick patients and ensure they follow prescribed treatments. "Telephone psychotherapy almost more resembles those programs than traditional therapy," she said, noting that "this program was about outreach to people who might not seek therapy themselves." Phone counseling, she said, is "a way to make sure people don't slip through the cracks" -- not necessarily better than face-to-face therapy but apparently better than no therapy at all.
The findings were consistent with earlier research by Ludman, published in 2004 in the Journal of the American Medical Association.
There are no good estimates on the number of therapists who counsel patients by phone; it's not a recognized subspecialty, and most who do it, do it as one aspect of their traditional practices. It's also a technique that the American Psychological Association has not completely assessed. The APA's most recent policy statement on the matter, issued in 1997, acknowledges that no formal phone-therapy standards have been set and urges practitioners to follow guidelines that govern traditional therapy.
Non-uniform licensing laws complicate the picture. Some states require therapists to be licensed both in their own state and in the state where the patient receives counseling. Some states waive such rules to allow for short-term treatment of people moving from one state to another. Nor is the insurance environment friendly to phone therapy. Aspen, Colo., psychotherapist Martin Manosevitz noted that all insurers limit reimbursement to sessions that are conducted face to face. That means that except where a waiver is granted, patients generally must pay for phone therapy out-of-pocket, he said.
Still, some psychologists say they are filling a need by picking up the phone.
"Usually the combination of medications and talk therapy seems to be the most efficacious way to go" in treating patients with depression, said Wendell Cox, a Washington psychotherapist who conducts phone therapy with some patients. "This study seems to support that idea that some personal contact helps, even over the phone."
Cox said he offers phone therapy only in cases in which he has a "well-established relationship with the patient." Otherwise, he said, "I don't think you can gauge mood, affect, body language, lots of stuff" that's important for a therapist to observe. In such cases, he said, "it's only slightly better than e-mail. It leaves too much to the imagination."
Herman Lowe, a clinical psychologist and owner of BriefCounseling.com, a phone therapy service based in Newton, Mass., sees his service as "not a substitute for face-to-face therapy but as pre-therapy."
Lowe's practice is aimed largely at "people in crisis who need to call for immediate help," he said. "We find there are a lot of people who would not go to [conventional] therapy," Lowe said. "Through BriefCounseling, their resistance is overcome, and they then seek [regular] therapy. We're helping people who would otherwise never get any professional help."
Manosevitz said he started offering occasional phone therapy while practicing in Austin, where some of his patients' jobs required frequent travel. "I'd work with them over the phone," he said. "That gave me some limited confidence that this might work as I made the transition" from Austin to Aspen 7 1/2 years ago. "Most of my [Austin] patients continued working with me [by phone] until their [psychological] work was done." Since then, Manosevitz has frequently worked with high school students, continuing to counsel them by phone after they leave for college.
Manosevitz said that, although he has found depression, anxiety and substance abuse to be highly treatable via phone therapy, other conditions aren't appropriately treated over the phone. "Patients who are not good candidates are those who are actively psychotic, suicidal, homicidal or highly impulsive," he said.
In entering a phone-therapy relationship, Manosevitz added, therapist and patient should make sure the therapist has contact information for psychiatric hospitals, outpatient clinics and other facilities that a patient might need in a crisis. It's also important, he said, to schedule sessions for times when both doctor and patient can go uninterrupted and undisturbed by distractions.
Finally, he said, both should be aware of potential compromises to confidentiality. "Both have to have an understanding that use of cell, mobile or cordless phones pose the risk that confidentiality might be pierced," he said. ·