New York Times (August 25, 2004).
Debates about the safety and effectiveness of treatments for
depression miss a basic reality about the disease: most people affected by it
do not seek help at all, and those who do commonly neglect to complete
counseling or drug regimens recommended by doctors. For at least a third of the
people who try them, treatments of any kind fall short, surveys show.
But improving success rates may be a matter of
picking up the phone, according to a report today in the Journal of the
American Medical Association. In a large-scale, 18-month study, doctors in
Seattle found that they could significantly increase recovery rates for
patients taking antidepressants by providing several 30- to 40-minute
counseling sessions over the phone.
In previous studies, researchers showed that
phone calls from nurses or other clinic staff members providing emotional
support could help people trying to quit smoking, stay on medication or shake
low moods. The Seattle study is the first to test the effect of a standardized
form of counseling, cognitive behavior therapy, delivered entirely over the
phone.
"It's thrilling to see these kinds of
results," said Dr. Jeanne Miranda, a professor of psychiatry at the
University of California, Los Angeles, who was not involved in the study.
"I do this kind of therapy in person, and it is often very hard getting
some people to come in; they want the help but are just too busy to find time
in their schedule, and on the phone they can do it on their time."
It is not clear from the study whether phone
counseling will be equally helpful for everyone with depression. The Seattle
researchers focused on patients who sought treatment and were motivated enough
to begin taking drugs. Dr. Jürgen Unützer, a psychiatrist at the University of Washington
who was not involved in the study, said that only about a quarter of all
Americans suffering from the illness try drug therapy each year. The rest do
not, because of lack of awareness, access or interest, psychiatrists say, and
many people with depression are wary of taking mood-altering drugs.
But because 40 percent of the people who begin
antidepressant therapy quit within the first month, doctors should consider the
telephone a powerful ally, said the study's lead author, Dr. Gregory E. Simon, a
psychiatrist at the Group Health Cooperative, a 500,000-member health plan in
Washington.
"This represents an important change in
the way we approach treatment," Dr. Simon said, "not only using the
phone, but being persistent, proactive, reaching out to people and finding them
where they are. Depression is defined by discouragement; very often they're not
going to come to you."
The researchers followed 600 men and women
receiving antidepressant treatment at Group Health clinics. The patients were
randomly assigned to one of three treatment plans: usual care, in which they
were instructed simply to follow their prescription; telephone management, in
which they received two phone calls and a mailer with advice and support for
continuing the prescription; and phone therapy, in which trained counselors
provided up to eight sessions of advice on how to combat the negative thinking
and inertia that fuel depression. Participants in the last group also had
workbooks that reinforced the phone therapy, and counselors encouraged them to
do homework between sessions.
"One thing we had them do was to list
their 10 most common negative thoughts, and then when they had one, to write it
down, 'O.K., that was Thought No. 3,'" Dr. Simon said. "This is a way
of practicing stepping back from those thoughts and seeing their effect."
By the end of the study, 80 percent of those
who had received phone therapy said their depression was "much
improved," compared with 55 percent of those who were given usual care. Of
those who received encouragement by phone but not explicit therapy, 66 percent
said they were "much improved."
The researchers do not know what component of
the phone therapy made it effective or whether the increased attention itself
made patients feel better. But for therapists trying to treat patients who are
overwhelmed or hard to reach-single parents, low-income people. for example -
the study may provide an alternative to in-person care.
In rural areas, where stigma can be a barrier
to treatment, it is nearly impossible to visit a therapist discreetly, Dr.
Miranda of U.C.L.A. said.
"I was working in rural Idaho, where
there's really only one mental health worker, and everyone knows where that
person works and what their car looks like," she said. "By working on
the phone, you can catch people at home and they have some privacy."