Telephone psychotherapy

[euromd]

Telephone Psychotherapy May Provide Relief From Depression Symptoms

Cathy Tokarski

Medscape Medical News 2004. ? 2004 Medscape

Aug. 25, 2004 ? Psychotherapy and case management via telephone is helpful for patients with depression, a new study in the Aug. 25 issue of JAMA suggests. This alternative may help patients who have been unable or unwilling to stick to a conventional treatment program.

Currently, only 25% to 30% of the population receives an effective level of counseling or antidepressants, research has shown. Barriers that prevent patients from seeking treatment include the stigma associated with depression, the time lag before a patient realizes benefits, and an ongoing commitment of time and effort.

Researchers at Group Health Cooperative, a Seattle, Washington-based prepaid health plan, offered two interventions to primary care patients beginning antidepressant treatment. One intervention used a telephone care management approach involving three 10- to 15-minute telephone outreach sessions, in which case managers assessed patients' depressive symptoms and inquired about antidepressant medication use. Care managers also provided crisis intervention if needed and coordination with treating physicians; participants received self-management workbooks to guide their care plan.

The second intervention used the same telephone care management protocol as well as brief, structured psychotherapy in 30- to 40-minute sessions, also conducted over the telephone. A third "usual care" group did not receive any intervention after antidepressant treatment was initiated.

After six months, nearly two thirds (58%) of the 198 patients who received brief, structured psychotherapy reported a 50% improvement in their depression scores compared with 43% of the patients who received neither intervention, according to the study. Slightly more than half (51%) of the 207 patients who received the telephone care management intervention reported a 50% improvement in their depression score.

The findings bolster the argument for changing the treatment model for moderate depression to one that uses more aggressive public health outreach strategies, according to study lead author Gregory E. Simon, MD, MPH, a researcher at Group Health Cooperative's Center for Health Studies.

"I'd be the last person to say that the telephone is just as good as talking in person," Dr. Simon told Medscape. "We're turning the traditional notion on its head ? the people [with depression] who are most motivated are in least need of our help. If we wait in our office for people to come to us, we'll be waiting a long time," he said.

Participants in both intervention groups demonstrated a commitment to treatment that is often lacking among more traditional face-to-face therapeutic encounters, according to the study findings. Of those beginning psychotherapy, 25% attend only one session and only half attend four or more sessions, previous research has found.

Among the Group Health participants assigned to the telephone care management protocol, 97% completed at least one telephone contact and 85% completed all three. Seven percent of the participants in the telephone psychotherapy intervention failed to attend any sessions, 1% completed the first session (history and motivational enhancement), 84% completed four or more sessions (including behavioral activation), and 63% completed seven or more sessions.

Although the study did not compare the cost of providing services over the telephone compared with a traditional face-to-face encounter, Dr. Simon predicted costs would be less because of lower overhead expenses and costs associated with patients who fail to show up for appointments.

Nonetheless, "we're not touting this as a money-saving proposition," Dr. Simon said, because more people theoretically could take advantage of depression treatment services over the telephone than do now in an office setting, he said. Health insurers do not now reimburse for therapy sessions provided over the telephone.

Further research is needed to compare the outcomes of depressed individuals who receive telephone counseling compared with those receiving face-to-face counseling. "The issue for us is if in-person treatment is better, but it's not happening, telephone treatment is an alternative," Dr. Simon said. "It's a question of the optimal versus the possible."

JAMA. 2004;292:935-942

Reviewed by Gary D. Vogin, MD

---

Members don't see this ad.

 

[Hammer]

Telephone Psychotherapy May Provide Relief From Depression Symptoms

Cathy Tokarski

Medscape Medical News 2004. ? 2004 Medscape

Aug. 25, 2004 ? Psychotherapy and case management via telephone is helpful for patients with depression, a new study in the Aug. 25 issue of JAMA suggests. This alternative may help patients who have been unable or unwilling to stick to a conventional treatment program.

Currently, only 25% to 30% of the population receives an effective level of counseling or antidepressants, research has shown. Barriers that prevent patients from seeking treatment include the stigma associated with depression, the time lag before a patient realizes benefits, and an ongoing commitment of time and effort.

Researchers at Group Health Cooperative, a Seattle, Washington-based prepaid health plan, offered two interventions to primary care patients beginning antidepressant treatment. One intervention used a telephone care management approach involving three 10- to 15-minute telephone outreach sessions, in which case managers assessed patients' depressive symptoms and inquired about antidepressant medication use. Care managers also provided crisis intervention if needed and coordination with treating physicians; participants received self-management workbooks to guide their care plan.

The second intervention used the same telephone care management protocol as well as brief, structured psychotherapy in 30- to 40-minute sessions, also conducted over the telephone. A third "usual care" group did not receive any intervention after antidepressant treatment was initiated.

After six months, nearly two thirds (58%) of the 198 patients who received brief, structured psychotherapy reported a 50% improvement in their depression scores compared with 43% of the patients who received neither intervention, according to the study. Slightly more than half (51%) of the 207 patients who received the telephone care management intervention reported a 50% improvement in their depression score.

The findings bolster the argument for changing the treatment model for moderate depression to one that uses more aggressive public health outreach strategies, according to study lead author Gregory E. Simon, MD, MPH, a researcher at Group Health Cooperative's Center for Health Studies.

"I'd be the last person to say that the telephone is just as good as talking in person," Dr. Simon told Medscape. "We're turning the traditional notion on its head ? the people [with depression] who are most motivated are in least need of our help. If we wait in our office for people to come to us, we'll be waiting a long time," he said.

Participants in both intervention groups demonstrated a commitment to treatment that is often lacking among more traditional face-to-face therapeutic encounters, according to the study findings. Of those beginning psychotherapy, 25% attend only one session and only half attend four or more sessions, previous research has found.

Among the Group Health participants assigned to the telephone care management protocol, 97% completed at least one telephone contact and 85% completed all three. Seven percent of the participants in the telephone psychotherapy intervention failed to attend any sessions, 1% completed the first session (history and motivational enhancement), 84% completed four or more sessions (including behavioral activation), and 63% completed seven or more sessions.

Although the study did not compare the cost of providing services over the telephone compared with a traditional face-to-face encounter, Dr. Simon predicted costs would be less because of lower overhead expenses and costs associated with patients who fail to show up for appointments.

Nonetheless, "we're not touting this as a money-saving proposition," Dr. Simon said, because more people theoretically could take advantage of depression treatment services over the telephone than do now in an office setting, he said. Health insurers do not now reimburse for therapy sessions provided over the telephone.

Further research is needed to compare the outcomes of depressed individuals who receive telephone counseling compared with those receiving face-to-face counseling. "The issue for us is if in-person treatment is better, but it's not happening, telephone treatment is an alternative," Dr. Simon said. "It's a question of the optimal versus the possible."

JAMA. 2004;292:935-942

Reviewed by Gary D. Vogin, MD

JAMA knows almost nil about Psychtx.

You can't bill Medicare, Medical or HMO's for this.

In my life long experience, it does not work and would miss a suicidal pt and then you get sued.

Hammer Ph.D.

 

[euromd]

JAMA knows almost nil about Psychtx.

You can't bill Medicare, Medical or HMO's for this.

In my life long experience, it does not work and would miss a suicidal pt and then you get sued.

Hammer Ph.D.

I never said I agreed. I just posted what I found.

Doctors are starting to bill for previously "free" services, such as endless phone calls and emails from patients that can add up to several additional hours per day. Some insurances companies won't reimburse, I believe Medicare is one - don't know all of them - but others do.

But where I'm from, we have a suicide prevention line. Should that just be trashed? If people really want to die, why should we search for other measures to lower the suicide rate? We should let them kill themselves. Survival of the fittest! I don't know why everyone is so against suicide, euthanasia and Dr. Kevorkian!!!!!

Back to reality, being in the mental health profession yourself, would you do anything to reach out to desperate people? Not everyone is comfortable with face to face therapy but would benefit telephone therapy. Is it going to miss suicidal patients? Yes. Is it going to catch some? Yes.

-S

 

[Hammer]

I never said I agreed. I just posted what I found.

Doctors are starting to bill for previously "free" services, such as endless phone calls and emails from patients that can add up to several additional hours per day. Some insurances companies won't reimburse, I believe Medicare is one - don't know all of them - but others do.

But where I'm from, we have a suicide prevention line. Should that just be trashed? If people really want to die, why should we search for other measures to lower the suicide rate? We should let them kill themselves. Survival of the fittest! I don't know why everyone is so against suicide, euthanasia and Dr. Kevorkian!!!!!

Back to reality, being in the mental health profession yourself, would you do anything to reach out to desperate people? Not everyone is comfortable with face to face therapy but would benefit telephone therapy. Is it going to miss suicidal patients? Yes. Is it going to catch some? Yes.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I saw everyone. No charge. No phoney billing to Medicare.

No I would not scrap Hot lines. They are great.

Psychologists here were squeky clean. No billing problems with Medicare--Federal Government.

I had one pt who said my fees were so low. I asked him to add a zero. Working for yoursef, you can charge what you want and see who who want.

My MD friends had very high office fees. Hope that gives you some insight.

We must see everyone to r/o suicide. Suicide ideation comes and it goes. This is important to know. About 72 hrs is a fair estimate on the short side. No I never 5150ed a person.

Hope that is a fair response.

 

[euromd]

I saw everyone. No charge. No phoney billing to Medicare.

No I would not scrap Hot lines. They are great.

Psychologists here were squeky clean. No billing problems with Medicare--Federal Government.

I had one pt who said my fees were so low. I asked him to add a zero. Working for yoursef, you can charge what you want and see who who want.

My MD friends had very high office fees. Hope that gives you some insight.

We must see everyone to r/o suicide. Suicide ideation comes and it goes. This is important to know. About 72 hrs is a fair estimate on the short side. No I never 5150ed a person.

Hope that is a fair response.

Thanks for responding.

MDs usually have other office staff to pay - secretary, nurses, more overheard, and MALPRACTICE. Also more med school debt.

Billing insurance companies for phone calls and emails is not (or should not be) fraudulant billing. MD is giving professionnal advice, therefore, should be paid. Why doesn't the patient make another appointment? Do they need to be told right this very second that all those lab tests are normal? Doc can call if abnormal, then I would consider doc initiated, so no billing. But make an appointment. Those are the extra hours I was talking about, not consulting with other staff or paperwork, although that is extra also, but "unpaid".

Some psychologist state that there will be no therpay outside the scheduled time. The patient/client can call only to cancel/reschedule the appointment. MDs don't have that privilege.
Patient: I'M HAVING MY BABY NOW!!!!!!!!!
MD: You're appointment is next week. See you then.

Seeing patients for free is good, as apparently 15% of americans are uninsured. More MDs should consider at least seeing 1 free patient per year. Some do free procedures that would otherwise cost the patient too much.

You did have a fair response. I like to play the devil's advodate to illicit all sides of the debate.

-S

 

[Hammer]

Thank you

I had office expenses, too. They were less, at least in the beginning.

My wife did all the billing. She takes care of money issues in the family.

Gl hammer

 

[twiggers]

Why can an MD not bill for after hours services? He/she gets a phone call at 2 AM from a hysterical mother and he/she has to calm down mother, etc. etc. That phone call can turn into 30 minutes-1 hour. I'd bill it. Do you see other businesses providing an hour of free services after hours? NO In fact they usually charge premium rates for after hours services (ie; get the AC guy to come out on a Saturday night and that $50/hr rate just turned into double or triple).
Same goes for psychologists....after hours calls should be billed. You are providing a service that during normal hours would be billed.
If you want to give your time and money away then volunteer for a worthy cause or give to charity and get a tax deduction.
Sorry if that sounds kind of harsh....but I don't understand why people expect to get free services from the health care field. Maybe if ya lived in Canada (I miss my free medical care), but not here in the USA. Everything costs!

 

[euromd]

twiggers, I definitetely agree with after-hours charging. However, the AC guy is not an essential service, but an emergency room visit b/c you're having a heart attack is. Being stuck paying that off for years sucks. Death or debt, hmmm. The hysterical mother should just shut it.

And yeah free health care in Canada is good, but it comes at a price - major doctor shortage, especially primary care, that no developed country should have. But you will get that hip replacement done free (tax dollars), after a painful 6-9 month wait. You can also see any specialist with no HMO crap getting in the way.

-S

 

[twiggers]

I agree....something needs to be done about essential services specifically defining what an essential service is..but if Mom with crying baby has insurance then either A) pay for the phone call or B) go to emergency room if you're that scared. If you don't have insurance well that is an argument policy makers have been having for years...I've seen friends take second mortgages because their insurance didn't start until a week after car accident....HMO system just plain sucks. Luckily I have insurance down here through my school.....never have used it, but pay for it anyways.
As for Canada.....yea there's a doctor shortage, and yea you might wait months for a surgery but it's almost getting to be the same down here. And it's not the doctor shortage that slows down getting surgery it's the availability of operating rooms (I know from personal experience waiting 6 months for an elective surgery). If you're having a heart attack you're getting services right away! And.....you can see whatever doctor you want....oh so nice! The shortage of doctors basically comes from the low pay that government reimburses for services and the higher pay in US, and our taxes up there are high enough without charging more to pay them. Although a survey done a couple years ago showed an oncologist making well over $700K a year and a GP still making around 90-100K. Not too shabby when factoring in low cost of living.

But back to other topic............I still think it is totally valid to charge insurance company or patient for after hours calls. If a patient is feeling suicidal there are other people who can be called in the middle of the night, or if doc is willing to accept late night crises calls then it should be implicitly stated that they will be charged. Hey a lawyer charges for thinking about a case...why should health care field be different? I understand what you are saying about essential services, and maybe that is the fine line that needs to be drawn. What do we label as essential? A heart attack vs. colicky baby? Someone feeling angry at neighbor with no intent on harm vs. someone ready to slit their wrists? Tough calls to make....I'm glad I'm not the one who has to define that!

 

[Limerick Gal]

Sorry if this is a bit off the point but when I read this thread it reminded me of a circular I was sent earlier this week. I do some volunteer facilitation with an online support group for people with eating disorders in Ireland. The feedback we have been receiving is that the service is a useful adjunct to other interventions and for several users (esp those with BN) it has served as the first place where they could actually 'talk' about their problems. I certainly don't think that internet or telephone-based interventions are the 'be all and end all', but I do think they can provide a very important complimentary service and may help reduce the amount of people slipping through the net.

Anyway, here's the latest development I've just received information about, if anyone is interested:


>Online Self Help Tool for the treatment of bulimia
>
>The world's first on-line self help tool for the treatment of bulimia was
>unveiled by a European Commission funded project. The multi-language tool,
>is called Salut!, and is a seven step programme based on cognitive
>behavioural therapy methods. It invites patients to observe and track their
>eating behaviours by filling in food diaries and to complete scenario-based
>exercises, which encourage them to confront problems and develop their own
>strategies for dealing with them. It also tries to change patient's thought
>patterns, which are often characterised by self-hate and self-blame, and to
>raise self-esteem.
>While most of the programme is carried out online, including weekly email
>contact with a therapist, patients are also required to have three
>face-to-face sessions. The co-ordinator of the project Tony Lam points out
>that patients can only access the programme through healthcare professionals
>in a hospital, clinic or psychiatric unit as the service needs to be
>mediated in a healthcare environment.
>
>Clinical trials were carried out in Switzerland and showed that it made
>treatment more accessible to a greater number of people. One of the most
>significant findings was that the programme helped patients to overcome
>feelings of shame about their eating disorder, empowering them to help
>themselves. Further trails are currently underway in other European
>countries.
>For more information on the project see http://www.salut-ed.org

 

[euromd]

Online and telephone interventions are/were never meant to replace "traditional" therapy. There is still something to be said about seeing the other person. I won't get into video conferencing... we'll assume both parties are in the same room.

I still thing the bottom line is, well, the bottom line - $$$. Online and telephone therapy will be billed for less therefore the therapist will make less money. However, realistically, how many clients will be online/telephone? Probably transitional clients. These people are shy or ashamed for whatever reason to go to face-to-face therapy right off the bat. I don't see anything wrong with that. But I can see how online/telephone therapy could not be as effective as face-to-face therapy in the long run.

Now back to after-hours billing. I think Canadian doctors should start billing their respective provincial governments for this. I have a chronic health problem so if/when it flares up the ED is pretty much useless as it is not a "real" emergency. The ED doc will just tell me to call my doc!!!!! So I call my doc - a specialist - and spare myself the 6hr wait in the ED. It sometimes takes him a few days or a week to call back. But like I said, it's not terribly urgent. I had just always expected him to phone back during the day or early evening, like before 6pm. One day, he phoned me back at 9.45pm. Now I would bill the Quebec gov't 3X the price for that garbage. But he can't. I guess a lot of patients had phoned him that week.

-S

 

[twiggers]

Are you from Canada Euro? BY your name I had simply assumed (I know a dumb thing to do) that you were in Europe.

 

[euromd]

I am from Montreal, studying in europe for med school. my quebec health insurance is valid there. I just had to purchase supplemental insurance which is valid all around the world!. whodathunk??? socialized medicine put do good use.

-S

 

[twiggers]

Wow....I didn't know that! I've been in USA for 5 years, so I'm more permanent and it probably wouldn't have worked for me....but how cool! I'm originally from Winnipeg. Are you putting your French to good use out there in Europe? LOL
My French was absolutely useless down here (I'm not 100% fluent but took French for 9 years in school so I can get by)..everything is Spanish and when I went to learn Spanish I kept switching the words to French and using a French accent LOL The languages are too close together so I gave up after one semester of Spanish.

 

[euromd]

I took 5 years of spanish. it was really confusing at first b/c i kept getting words mixed up with french. but it's more sorted out now. I hope to use both, and more, in europe. hopefully do some electives, erasmus exchange or summer research in spain, france, belgium or switzerland. god bless my uk passport! (don't live or study there, nor was I born there. mummy was - yay)

-S

 

[Briana]

Just wanted to comment on a few things real quick.

I'm in DBT (dialectical behavior therapy) and they have phone consultation that I use quite often. I'm struggling with depression, anxiety, SI, and ED-NOS. I do find phone consultation the most helpful part about the therapy because my problems are not really in crisis during the hour long session each week. My therapist usually coaches me through my problem, giving me advice, talking to me, asking me questions, etc. I find this very helpful.

I don't agree with replacing telephone consultation with face-to-face time, because it is not at all the same and don't think it would work as well. I see my therapist once a week AND I have phone consultation available to me 24/7.

It helps alot.

 

[euromd]

That's exactly what the JAMA article was saying, that telephone psychotherapy/interventions were complementary and not meant to replace traditional forms of therapy.

In the same vein, I don't think that anyone would claim that fellowships such as alcoholics anonymous would ever replace traditional rehabs although they coexist and do not post any theat to each other. These fellowships help people to various extents but no one would refer someone only to AA for an alcohol problem. A professionnal would offer the patient a variety of resources, including rehab and AA, no?

-S