by Michael D. Anestis, M.S.
Psychologists are always looking for novel ways to provide therapy in an effort to reach more people and keep them in therapy until it has had a chance to impact symptoms. As a result, we have seen the development and dissemination of psychotherapy through self-help books, the internet, and countless other methods. Today, I want to discuss a study that looked at the efficacy of cognitive behavioral therapy (CBT) conducted over the phone for adults diagnosed with depression. The study was conducted by Steve Tutty, Diane Spangler, and Landon Poppleton of BYU and Evette Ludman and Gregory Simon of Group Health Cooperative.
Prior work has indicated that teletherapy for depression is efficacious when used as an addition to antidepressant medication (e.g., Ludman, Simon, Tutty, & VanKorff, 2007), but the authors of this paper were interested in seeing whether CBT Teletherapy (CBT-TT) could be effective as a stand alone treatment. To do this, the authors recruited depressed patients, none of whom were psychotic or diagnosed with bipolar disorder, to take part in a treatment study. During the course of the study, which included both a 3-month and 6-month follow-up, participants were free to seek additional help (e.g., antidepressant medications). 68 adults were approached and asked if they were interested in participating. 23 of those individuals declined to take part, 21 because of a preference for face-to-face therapy and two due to an inability to commit to a treatment program. That left 45 participants, 15 of whom did not meet inclusion criteria (e.g., did not meet criteria for depression, met criteria for bipolar). That left the authors with a total sample of 30 individuals, which is obviously quite small. Rather than randomize the participants to different treatment groups (e.g., CBT-TT vs waitlist or face-to-face CBT), the authors administered CBT-TT to all thirty participants and compared their results to those of participants in a previously published study in which CBT-TT was used as an adjunct to antidepressant medication (Simon et al., 2004).
Before getting into the results, we should acknowledge the potential issues with this method. First, there is a very real potential for selection bias. All of the clients chose to participate in this trial because they wanted to receive teletherapy, so we have no idea whether this only works for the type of people who not only prefer this method of therapy, but would choose to take part in a study testing its efficacy. Randomization allows us to control for such vulnerabilities. Additionally, because there was no comparison within this particular sample (and all clients were treated by the same therapist), it is unclear whether the results might simply reflect this particular sample or therapist. All that being said, this is an interesting initial step that offers us an opportunity to look at some preliminary data with a cautious eye.
One significant result was the lack of attrition. 87% of the participants completed all follow-up assessments through six months and those who did not were not more severely depressed than those who did. This indicates that individuals motivated to partake in CBT-TT will, in large part, see it through rather than dropping out. 69% of participants indicated that they were "very satisfied" with the treatment at 6-month follow-up. The baseline severity of the sample in this particular study was significantly higher than that of the comparison study (Simon et al., 2004), which is a point we will return to in a moment.
Participants in this study exhibited significant decreases in depression from baseline to 3 months and from 3 months to 6 months. This means that the clients continued to get better even after treatment ended. At 3 months, 23.3% of the sample no longer met criteria for depression and at 6 months, 50% no longer met diagnostic criteria. 42% of the sample was considered "recovered." Importantly, these results were comparable to those from the comparison study (Simon et al., 2004), meaning that CBT-TT on its own produced effects similar to those produced by a combination of CBT-TT and antidepressant medications. When participants in this study who used antidepressant medications where compared to those who did not, no differences were found at 3-months or 6-months. That last finding is important; however, the small sample size makes finding a significant effect highly difficult and renders that analysis severely underpowered.
The improvement demonstrated by the participants in this study was relatively strong; however, we must consider the highly elevated baseline scores on depression here. Any time somebody has an extreme score on a symptom measure, they are likely to improve over time. This is a phenomenon known as "regression to the mean." Now, given that the results were comparable to another trial in which active treatments were utilized and compared to a control condition, this possibility seems highly unlikely, but I like to avoid assumptions on this site whenever possible, so acknowledging the possibility seems like the right thing to do.
The weaknesses in this study are notable; however, keep in mind the purpose of this particular work. The use of CBT-TT to treat adult depression as a stand alone treatment is a new idea devoid of empirical backing. To test this on a large group in an RCT without initial preliminary evidence could be considered unethical, so the authors were right to aim a little lower here. That being said, the results need to be interpreted with caution and future replications are needed to ensure that the findings a legitimate. Also, as the authors noted, CBT-TT does not produce as impressive results as face-to-face CBT. As such, more work is needed to determine who is most likely to respond better to teletherapy (or at least, of people unlikely to follow through with face-to-face therapy, which are most likely to give teletherapy a chance).
What are you thoughts about this phenomenon? Do the benefits (e.g., low cost, convenience of therapy from home) outweigh potential costs (e.g., enhanced therapeutic alliance due to body language, etc...)? Is teletherapy a dinosaur even before it has been established due to the potential of the internet? Are there dangers inherent in teletherapy that are not likely to occur in face-to-face interactions (e.g., noticing physical agitation in a client with acute suicide risk)?
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Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center
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