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The Effect of Telephone-Administered Psychotherapy

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© 2008 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.All rights reserved. For permissions, please email: [email protected] 243 Blackwell Publishing IncMalden, USACPSPClinical Psychology: Science and Practice0969-5893© 2008 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association. All rights reserved. For permission, please email: [email protected] Articles TELEPHONE-ADMINISTERED PSYCHOTHERAPY • MOHR ET AL.CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V15 N3, SEPTEMBER 2008 The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis David C. Mohr, Northwestern University, Hines Veterans Administration HospitalLea Vella, San Diego State UniversityStacey Hart, Ryerson UniversityTimothy Heckman, Ohio UniversityGregory Simon, Group Health Cooperative Increasingly, the telephone is being used to deliverpsychotherapy for depression, in part as a means toreduce barriers to treatment. Twelve trials of telephone-administered psychotherapies, in which depressivesymptoms were assessed, were included. There was asignificant reduction in depressive symptoms for patientsenrolled in telephone-administered psychotherapy ascompared to control conditions ( d ==== 0.26, 95% confi-dence interval [CI] ==== 0.14–0.39, p <<<< .0001). There wasalso a significant reduction in depressive symptoms inanalyses of pretreatment to posttreatment change ( d ==== 0.81, 95% CI ==== 0.50–1.13, p <<<< .0001). The mean attritionrate was 7.56% (95% CI ==== 4.23–10.90). These findingssuggest that telephone-administered psychotherapycan produce significant reductions in depressive symp-toms. Attrition rates were considerably lower than ratesreported in face-to-face psychotherapy. Key words: depression, meta-analysis, psychotherapy,telemental health. [Clin Psychol Sci Prac 15: 243 – 253 , 2008] The telephone was invented by Alexander Graham Bellin 1876. The first report of telemedicine in a major medicaljournal, which described the use of the telephone todiagnose a child’s cough, occurred three years later in1879 (“The Telephone as a Medium of Consultation andMedical Diagnosis,” 1879). The telephone quickly becamea widely used tool in the practice of primary-care medi-cine. In contrast, providers of psychotherapy were slowto adopt the telephone to deliver mental health–relatedservices. To the best of our knowledge, the first report ofthe use of the telephone in the administration of psycho-therapy was published in 1949, 70 years after the firsttelemedicine report (Berger & Glueck, 1949). In 1996, areport developed by an American Psychological Associa-tion task force found that empirical evidence concerningtelephone-administered psychotherapy was scant to non-existent (Haas, Benedict, & Kobos, 1996). In the lastdecade, this has changed considerably.Most of the work in telephone-administered psycho-therapy has focused on treating depressive symptoms.Depression is common and is a significant cause ofdisability (Murray & Lopez, 1997). Psychotherapy is anattractive treatment option for many patients, as evidencedby the finding that approximately two-thirds of depressedpatients prefer psychotherapy over antidepressant medica-tion (Bedi et al., 2000; Brody, Khaliq, & Thompson, 1997;Dwight-Johnson, Sherbourne, Liao, & Wells, 2000; Priest,Vize, Roberts, Roberts, & Tylee, 1996). However, only20% of all patients referred for psychotherapy ever entertreatment (Brody et al., 1997; Weddington, 1983) and, of Address correspondence to David C. Mohr, Department ofPreventive Medicine, Northwestern University, FeinbergSchool of Medicine, 680 North Lakeshore Drive, Suite 1220,Chicago, IL 60611. E-mail: [email protected] study was supported by National Institute of MentalHealth grant R01 MH59708 to Dr. Mohr.CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V15 N3, SEPTEMBER 2008 244 those who enter, nearly one-half will drop out (Wierzbicki& Pekarik, 1993). One reason for this discrepancybetween interest and failure to initiate or follow throughwith psychotherapy is that there are considerable barriersfor many patients, including time constraints, transporta-tion problems, caregiving responsibilities, stigma concerns,disability, or living in a rural area that lacks adequatemental health services (Alvidrez & Azocar, 1999;Hollon et al., 2002; Mohr et al., 2006; Yuen, Gerdes, &Gonzales, 1996). Indeed, a recent study of primary-carepatients found that 74% of depressed patients identifyone or more barriers that make it very difficult orimpossible to attend regularly scheduled psychotherapysessions (Mohr et al., 2006). Many of these barrierscould potentially be mitigated through the use of thetelephone in administering psychotherapy.The telephone, found in 95.5% of all households inthe United States (Federal Communications Commission,2003), is the most widely available telecommunicationsmedium. Recognizing the potential for outreach, manyprovider organizations, including insurance companies,health maintenance organizations, the United StatesVeterans Health Administration, and others, have begunimplementing telemental health procedures, includingtelephone-administered psychotherapy (Maheu, Pulier,Wilhelm, McMenamin, & Brown-Connolly, 2005; VHATelemental Health Field Work Group, 2003). Further-more, more than two-thirds of psychologists use telephone-administered psychotherapy to some extent in their practice(VandenBos & Williams, 2000).Accordingly, telephone-administered psychotherapy—while slow to be developed and implemented—is nowincreasingly part of the mental health care landscape. Therehave also been a growing number of empirical studiesevaluating the utility of telephone-administered psycho-therapy. In light of these developments, it is time to takea first “snapshot” of this research. Accordingly, we haveundertaken a meta-analytic review with the following aims:(1) To evaluate the efficacy of telephone-administeredpsychotherapies in reducing symptoms of depression.We planned to evaluate telephone-administered psycho-therapy compared with treatment-as-usual (TAU) and,if significant, evaluate the magnitude of change indepressive symptoms from pretreatment to posttreat-ment in telephone-administered psychotherapy.(2) To obtain an


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