The other day one of my patients came into my office upset and sobbing. She told me that life is too difficult to go on, and the day’s events did not help.
On the way to my office, she got stuck in heavy traffic. Fearing she would miss our session, she entered the car pool lane and put the pedal to the medal. And so did a Seattle motorcycle cop. The yellow ticket she held in her hand listed an infraction fine for $286.
Not the best way to start a session, especially for a patient suffering from depression.
Experiences like this prompted me to ponder if there were other ways for delivering mental health care that could sidestep some of these in-person treatment obstacles, such as transportation, requesting time off from work, the stigma of the waiting room, etc.
When I suggested the telephone to my colleagues, they were skeptical. I remember one expert in the field said, “Are you crazy? Where will your patients sit?”
In 1998, I tested the first generation of CBT by telephone in a small pilot for adults initiating antidepressant treatment for major depression. Not only was it acceptable, significant reductions in depressive symptoms were found at follow up. The same pattern held up in a large-scale trial (n=600) published in JAMA several years later (over 90 percent agreed to participate and 85 percent to 90 percent completed the program with significant reductions in depressive symptoms at 6, 12, and 18 months.)
The next question on my mind was how this program might fare in an everyday (as opposed to research) setting as a stand-alone treatment (i.e., without pharmacotherapy).
In this second generation trial, we offered depressed adults seeking counseling at a community-based clinic the opportunity to receive care either in-person or by phone.
Two-thirds chose the telephone and 77 percent of that sample completed the eight-session CBT phone program. Approximately 70 percent were very satisfied with treatment and 42 percent were evaluated as “recovered” at termination.
Similar outcomes were observed at follow up – high interest, low attrition and cost-effective – despite starting treatment at a high depressive severity and without antidepressant medication. When we asked participants what they liked most about the program, the top answers were privacy (e.g., delivered in their own home) and flexibility (e.g., phone sessions delivered during evenings and weekends.)
Given the acceptability, ease of delivery and cost-effectiveness of this model, the next steps will likely involve additional research and large scale training/dissemination at the national level. This last step, of course, presents several challenges that will require support and revisions among insurance and state licensure regulatory boards.
In the meantime, others and I are considering novel ways for delivering this care model on a macro level. I’m pretty sure my depressed patient with the $286 fine would say “yes” and may choose to sit down, stand up or take a stroll around her backyard during our next session.
Steve Tutty, Ph.D., is associate director of cognitive behavioral clinical services for Free & Clear – a phone and web-based health organization that currently provides tobacco cessation and weight loss services nationwide. Tutty has developed clinical protocols for Group Health Cooperative and Brigham Young University in the fields of major depression and AD/HD social skill interventions. He was a co-author on a landmark trial of telephone treatment of depression published in the Journal of the American Medical Association and recently in Behavioral Therapy showing a stand-alone CBT phone program for adult depression is feasible and effective.