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Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment A Randomized Controlled Trial
Context
Both antidepressant medication and structured psychotherapy
have been proven efficacious, but less than one third
of people with depressive disorders receive effective levels
of either treatment. Objective
To compare usual primary care for depression with
2 intervention programs: telephone care management and
telephone care management plus telephone psychotherapy.
Design
Three-group randomized controlled trial with allocation
concealment and blinded outcome assessment conducted between
November 2000 and May 2002.
Setting and Participants
A total of 600 patients beginning antidepressant
treatment for depression were systematically sampled
from 7 group-model primary care clinics; patients already
receiving psychotherapy were excluded.
Interventions
Usual primary care; usual care plus a telephone care
management program including at least 3 outreach calls,
feedback to the treating physician, and care coordination;
usual care plus care management integrated with a
structured 8-session cognitive-behavioral psychotherapy
program delivered by telephone.
Main Outcome Measures
Blinded telephone interviews at 6 weeks, 3 months,
and 6 months assessed depression severity (Hopkins
Symptom Checklist Depression Scale and the Patient Health
Questionnaire), patient-rated improvement, and satisfaction
with treatment. Computerized administrative data examined
use of antidepressant medication and outpatient visits.
Results
Treatment participation rates were 97% for telephone care
management and 93% for telephone care management plus psychotherapy.
Compared with usual care, the telephone psychotherapy
intervention led to lower mean Hopkins Symptom Checklist
Depression Scale depression scores (P = .02),
a higher proportion of patients reporting that depression
was "much improved" (80% vs 55%, P<.001), and
a higher proportion of patients "very satisfied" with depression
treatment (59% vs 29%, P<.001). The telephone
care management program had smaller effects on patient-rated
improvement (66% vs 55%, P = .04) and satisfaction
(47% vs 29%, P = .001); effects on mean depression
scores were not statistically significant.
Conclusions
For primary care patients beginning antidepressant treatment,
a telephone program integrating care management and structured
cognitive-behavioral psychotherapy can significantly improve
satisfaction and clinical outcomes. These findings suggest
a new public health model of psychotherapy for depression
including active outreach and vigorous efforts to
improve access to and motivation for treatment.
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