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Telephone treatment of depression is effective, but for how long?

This article first appeared in the St. Louis Beacon, June 18, 2012 - Many therapists turn to the telephone to counsel patients for depression when issues such as work schedules, transportation or an inability to make or keep appointments prevent the patients from showing up for face-to-face counseling.

But a recent study in the Journal of the American Medical Association suggested that there were pros and cons to telephone therapy. The researchers targeted 325 people with major depressive disorder, treating them by either telephone or face-to-face therapy. They noted that with treatment over the telephone, fewer patients dropped out of therapy, and that telephone therapy was especially effective during the initial engagement period.

"The acceptability of delivering care over the telephone is growing, increasing the potential for individuals to continue with treatment," researchers said. The study's lead author was David C. Mohr of Northwestern University School of Medicine.

"The telephone offers the opportunity to extend care to populations that are difficult to reach, such as rural populations, patients with chronic illnesses and disabilities and individuals who otherwise have barriers to treatment."

While praising the telephone approach, the researchers said that a six-month follow-up found that patients getting face-to-face treatment tended to be less depressed than those receiving help by telephone.

So does this mean patients and psychotherapist should abandon treatment by telephone? Not at all, says Eileen Schmitz, who reviewed the findings at the request of the Beacon. She's director of operational services for Personal Assistance Services, an employee assistance program. It provides behavioral health consultative services for the Behavioral Health Services Division of SSM health care.

"I'm not surprised at this six-month finding," Schmitz says. When patients engage with counselors face-to-face, "it is expected that the outcome of the therapeutic relationship will be more enduring and more impactful."

On the other hand, she says other variables might have affected the study's outcome. For example, she says it's possible that clients who got in-person counseling happened to be those more able to take part in face-to-face counseling and were "able to engage better" with therapists.

She says telephone counseling can be helpful in cases of both mild and severe depression. Depression itself can stem from three general issues. One is genetic or biological, which is treated primarily with medication. Another involves how people think, and the third involves the way they react to what's going on in their lives. The latter psychological problems are helped by therapy, either in person or by telephone, she says.

On the mild side of depression, a client "may need to learn how not to go straight to negative thinking and look for options on how to respond to what's going on in their lives. Those patients could respond very well to short telephone counseling."

So, too, can patients on the severe side, such as people who "may be literally too sick to get out of the house" and "make the drive to the counselor's office. So they would benefit from telephone counseling."

She says families are facing more challenges that require therapy. "You have kids at home (while) working eight, nine hours a day, having to commute on top of that, then find a babysitter while you go to a session." If these adults can get counseling, "they need to do it on the telephone and if they are committed to that, then definitely that's the way to go."

But she says clients getting this type of therapy need to understand they cannot do the sessions in between catching up on their email.

"Just because they are on the phone (in therapy), it doesn't mean they can go about cooking their dinner or driving and talking while in the car. That's just not a good arrangement."

Instead, she urges clients to "go to a quiet place and shut the door. Kids need to leave them alone." Clients who aren't able to sequester themselves and "make the therapy their priority are not going to get what they need out of telephone counseling."

She says, "The healing power of therapy is in the interaction; it's in the rapport that the client establishes with the therapist. It's the soul to soul that develops between the client and therapist."

She is concerned that the rapport is undermined because "as we become more virtualized, we also run the risk of becoming more isolated from each other. If our entire lives are conducted via email, chat, Skype, and phone, we will become more and more fragmented as a society and we'll need more and more therapy."

She says that the telephone approach is effective in some cases for those getting medication for depression. Weekly check-ins by phone can help remind patients to take their medications at the right time and frequency and "help and support clients with the behavioral changes that support recovery from depression."

While the study won't convince Schmitz to change her practice patterns, she says it "tells me to look into (the issue) more." She adds "we certainly shouldn't rule out telephone counseling for clients for whom that's appropriate."

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