Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
JAMA. 2012 Jun 6;307(21):2278-85. doi: 10.1001/jama.2012.5588.
Primary care is the most common site for the treatment of depression. Most depressed patients prefer psychotherapy over antidepressant medications, but access barriers are believed to prevent engagement in and completion of treatment. The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery.
To examine whether telephone-administered cognitive behavioral therapy (T-CBT) reduces attrition and is not inferior to face-to-face CBT in treating depression among primary care patients.
DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial of 325 Chicago-area primary care patients with major depressive disorder, recruited from November 2007 to December 2010.
Eighteen sessions of T-CBT or face-to-face CBT.
The primary outcome was attrition (completion vs noncompletion) at posttreatment (week 18). Secondary outcomes included masked interviewer-rated depression with the Hamilton Depression Rating Scale (Ham-D) and self-reported depression with the Patient Health Questionnaire-9 (PHQ-9).
Significantly fewer participants discontinued T-CBT (n = 34; 20.9%) compared with face-to-face CBT (n = 53; 32.7%; P = .02). Patients showed significant improvement in depression across both treatments (P < .001). There were no significant treatment differences at posttreatment between T-CBT and face-to-face CBT on the Ham-D (P = .22) or the PHQ-9 (P = .89). The intention-to-treat posttreatment effect size on the Ham-D was d = 0.14 (90% CI, -0.05 to 0.33), and for the PHQ-9 it was d = -0.02 (90% CI, -0.20 to 0.17). Both results were within the inferiority margin of d = 0.41, indicating that T-CBT was not inferior to face-to-face CBT. Although participants remained significantly less depressed at 6-month follow-up relative to baseline (P < .001), participants receiving face-to-face CBT were significantly less depressed than those receiving T-CBT on the Ham-D (difference, 2.91; 95% CI, 1.20-4.63; P < .001) and the PHQ-9 (difference, 2.12; 95% CI, 0.68-3.56; P = .004).
Among primary care patients with depression, providing CBT over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression at posttreatment. At 6-month follow-up, patients remained less depressed relative to baseline; however, those receiving face-to-face CBT were less depressed than those receiving T-CBT. These results indicate that T-CBT improves adherence compared with face-to-face delivery, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.
clinicaltrials.gov Identifier: NCT00498706.
初级保健是治疗抑郁症的最常见场所。大多数抑郁患者更喜欢心理疗法而不是抗抑郁药物，但据信存在一些进入障碍，阻碍了他们接受和完成治疗。电话已被研究作为一种治疗传递媒介，以克服进入障碍，但与面对面治疗相比，其疗效知之甚少。
研究电话管理认知行为疗法（T-CBT）是否可以降低脱落率，并且在治疗初级保健患者的抑郁症方面不逊于面对面认知行为疗法（CBT）。
设计、地点和参与者：这是一项针对 325 名芝加哥地区主要抑郁障碍的初级保健患者的随机对照试验，招募时间为 2007 年 11 月至 2010 年 12 月。
接受十八次 T-CBT 或面对面 CBT。
主要结局是治疗结束时（第 18 周）的脱落（完成与未完成）。次要结局包括使用汉密尔顿抑郁评定量表（Ham-D）进行盲法评估的抑郁和使用患者健康问卷-9（PHQ-9）进行自我报告的抑郁。
与面对面 CBT（n=53；32.7%）相比，T-CBT（n=34；20.9%）的参与者显著较少退出（P=0.02）。两组患者的抑郁症状均显著改善（P<0.001）。T-CBT 和面对面 CBT 在治疗后在 Ham-D（P=0.22）或 PHQ-9（P=0.89）上均无显著治疗差异。Ham-D 的意向治疗治疗后效应大小为 d=0.14（90%CI，-0.05 至 0.33），PHQ-9 的效应大小为 d=-0.02（90%CI，-0.20 至 0.17）。这两个结果均在 d=0.41 的劣效性边界内，表明 T-CBT 不逊于面对面 CBT。尽管与基线相比，参与者在 6 个月随访时仍显著减轻抑郁（P<0.001），但接受面对面 CBT 的参与者在 Ham-D（差异为 2.91；95%CI，1.20-4.63；P<0.001）和 PHQ-9（差异为 2.12；95%CI，0.68-3.56；P=0.004）上的抑郁程度显著低于接受 T-CBT 的参与者。
在患有抑郁症的初级保健患者中，与面对面 CBT 相比，通过电话提供 CBT 可降低脱落率，并在治疗后接近等效地改善抑郁症状。在 6 个月随访时，与基线相比，患者仍然减轻了抑郁症状；然而，接受面对面 CBT 的患者比接受 T-CBT 的患者抑郁程度更低。这些结果表明，T-CBT 与面对面治疗相比可提高治疗的依从性，但也增加了治疗结束后疗效维持较差的风险。
clinicaltrials.gov 标识符：NCT00498706。
