Tuesday, September 23, 2008

I Want To See Your Data

I've been resisting the urge to write about it, but Rach ( in her leg-warmers) has asked, so here are my comments about Tara Parker-Pope's New York Times Well blog called The Benefits of Therapy by Phone. It's a short piece, minus comments, so I'm simply going to paste the whole post. Ms. Parker Pope writes:

The Benefits of Therapy by Phone

INSERT DESCRIPTIONPhone-based therapy can be less hassle for patients. (Peter DaSilva for the New York Times)

Most therapists schedule face-to-face meetings with their patients. But new data suggest that therapy by phone may be a better option for some patients.

It has long been a concern among therapists that nearly half of their patients quit after only a few sessions. As a result, a number of health care providers and employee-assistance programs now offer therapy services by phone.

A new analysis of phone therapy research by Northwestern University shows that when patients receive psychotherapy for depression over the phone, more than 90 percent continue with it. The research showed that the average attrition rate in the telephone therapy was only 7.6 percent, compared to nearly 50 percent in face-to-face therapy. The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment.

“The problem with face-to-face treatment has always been very few people who can benefit from it actually receive it because of emotional and structural barriers,” said David Mohr, professor of preventive medicine at the Feinberg School of Medicine and lead author of the study, published in the September issue of Clinical Psychology: Science and Practice. “The telephone is a tool that allows the therapists to reach out to patients, rather than requiring that patients reach out to therapists.”

Among patients who say they want psychotherapy, only 20 percent actually show up for a referral, and half later drop out of treatment.

Dr. Mohr said he began using phone therapy because he was working with patients who had multiple sclerosis who could not get to a therapist’s office. Some patients don’t have regular transportation to a therapist’s office or can’t take time off work or away from their families. In addition, a patient with depression may simply not be capable of getting themselves to the therapist’s office on a regular basis.

“One of the symptoms of depression is people lose motivation,” Dr. Mohr said. “It’s hard for them to do the things they are supposed to do. Showing up for appointments is one of those things.”

----
Where should I begin? I'll guess I'll start by saying I don't want to talk about the value of phone therapy. Certainly, phone contact between sessions can help alleviate a crisis and may provide some comfort to a patient, but this isn't about 'between-sessions' with a known live entity, it's about telephone contact in place of live sessions, and my understanding is that this is from the get go.

It's a blog post, not a rigorous scientific article, but I'm going to start by saying I thought the post is irresponsible. That feels strong, and I'm an avid Well reader, but it's full of all these blanket statements, given as facts, with nothing that backs them up. There's a link to an abstract, and an email to request the full article, but I'm going to note that the abstract also gives very little information about the methods used and the conclusions reached. I didn't write for a copy of the full article (I will) -- maybe it was great science that warrants the conclusion that phone therapy for depression is as good as live therapy, but it's hard to get there from either the blog post or the abstract. Stay tuned: we'll use the full article for a future My Three Shrinks podcast.

Okay: The article starts by saying that therapists are concerned about patients leaving after only a few sessions. Is this true? Maybe people feel helped and leave. Maybe the therapist is horrible and they leave. And actually, insurance companies judge the best shrinks as those whose patients come the fewest times (presumably the quickest cured, but certainly the cheapest for the insurance company).

The next interesting assertion is that only 20% of people who want psychotherapy come for treatment? How do we know this? I suppose there could be a number for those who initiate treatment, but for those who Want?

Moving along, the issue is one for treatment of Depression, nothing is said about any other disorder, and I was left to wonder how the diagnosis was made: presumably over the phone? Is it just patients who self-diagnosed as Depressed? If a patient phone screened for another illness, were these results omitted so the finding could be positive for Depression? And is medication an option or perhaps these patients were identified by primary care docs who had already made the diagnosis and prescribed the medications? We have no idea what the pool of patients was, if medication has a role, or whether the patient or therapist initiated the calls. We do know that few dropped out of treatment: I do agree it's easier to call in than to deal with the hassles of getting to an appointment, but perhaps it's even easier if the therapist is doing the calling and the at-home patient (or on the cell out-and-about) just needs to answer the phone. How long did the patient need to remain engaged for the session to be called "therapy?"

And the patients got better, compared to controls, but even the abstract doesn't tell us if the control group is a face-to-face therapy cohort or a no-treatment group. There are no rating scales, no average score changes, not even a mention of how many patients were involved. The abstract says '12 trials of psychotherapy' so I'm thinking this means 12 patients. If so, that's hardly a number that has any real meaning as a measure to influence standards of care and attract the attention of the New York Times and I'll return to the word irresponsible. What happens when the person at the other end of the phone is acutely suicidal?
What happens when a patient lodges a complaint against a phone therapist who isn't licensed in their state? And might I wonder if insurance companies could use such articles as rationale for out-sourcing psychotherapy to phone sessions with therapists in other regions where care might be cheaper? I'll leave that one to your imagination.

25 comments:

Therapy Patient said...

By necessity I have had 4-5 telephone sessions (50 min. regularly scheduled sessions) with my normal psychiatrist and it's not as good as face-to-face so I was surprised at her article. For one thing I have a harder time concentrating when I am in an unusual location. Another problem is that my psychiatrist can't see my face and body movements so isn't getting as much information. I shudder to think of a future of having psychiatrists in India that the insurance company pays $10 who are "managed" by a script-writing stateside psychiatrist.

April said...

as much as i would LOVE to see my former shrink over the phone (I moved out of state), I can tell you it wouldn't be the same---even though we've already established a relationship.

first, i can't talk on the phone and not be distracted. second, there's just a lot to be said about sharing the physical space with someone. he can read my face/body and vice versa.

April said...

Jung At Heart disagrees...

Anonymous said...

Jung at heart concludes that it's nice when research confirms what one thinks.

I'm not arguing for or against phone therapy, I'm arguing that the "research" presented is so lacking in information that the conclusion that phone therapy for depression is as effective is not a reasonable conclusion unless there are a reasonable number of people in the trial, they were diagnosed in some valid and reliable way, and there are specific measures of depression, response and 'psychotherapy'. There may have been-- I was struck by the fact that this information wasn't in the abstract, that the statistics were all around the fact that patients continued in treatment longer.
Maybe a great study, but the post should have included a paragraph on how many patients, how they were chosen, what phone therapy is (how long a session) and measures of response.
Phone therapy may be great for some and not for others, but I was more interested in the concept of touting these conclusions without any clear data. Looked like it was 12 patients to me. Well, if I interviewed 12 people in an Italian restaurant perhaps I could conclude that people like pasta.

Alison Cummins said...

"What happens when the person at the other end of the phone is acutely suicidal?"

Well, what happens when a person without a therapist at all is acutely suicidal?

Of course face-to-face therapy is better. Probably it's even better because only those patients motivated enough to show up participate, because those who are too depressed to engage stay home.

Being too depressed to seek out therapy and follow through is absolutely an issue though. If you can't recommend phone therapy as an alternative to no therapy, then what do you recommend?

I've had phone consultations that were surprisingly effective. The really cool thing was that they only lasted an hour, not the three hours that going to and getting back from an appointment take, so I was ready and raring to go as soon as they were over.

No, these were not therapy for depression, but I had been sceptical about the effectiveness of this kind of phone consultation until I had one. Then I was a convert: they can be really good with the right person in the right context. Whether therapy for depression is the right context is an open question, but probably one worth asking.

After all, if you can do a lot of good in fifteen-minute med check, why is the idea of a 50-minute phone appointment for CBT so impossible?

(Point taken that the data are probably not there, but you seem to be just as outraged with the notion of phone therapy as with publishing prematurely.)

Cheryl Fuller, Ph.D. said...

Basically, science does not guide mental health treatment. The DSM is not based on theory or research -- "Mental Illnesses are defined as mixtures of symptoms packaged into syndromes. These syndromes are consensus statements from committees writing the nosologies of psychiatric disorders for the DSM of the APA and the ICD. Thus, mental illnesses are not diseases."*.

All of us in the field -- psychiatrists, psychologists, social workers and the rest -- practice what we believe. Those patients who share what we believe improve and report the treatment is successful. Those who do not go elsewhere.

People who find telephone sessions valuable find it valuable. Those who don't, don't. That is not science; that is anecdotal evidence. Which basically is all we have to measure outcome. All the questionnaires and similar measures to measure success of any form of treatment rely on patient self-report.

No doubt the most powerful tool any of us has is the placebo effect.

*Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, pg178

Anonymous said...

TP said: "I shudder to think of a future of having psychiatrists in India that the insurance company pays $10 who are "managed" by a script-writing stateside psychiatrist."

I had the same thought. Insurance companies will do anything to save money on therapy, regardless of its harm or benefit to the patient. And it seems nearly everything else related to the phone or computer has already been outsourced to India. Boggle.

Having said that, I think there have been other studies using teleconferencing between psychiatrists and patients in rural areas that reached similar conclusions, that is, that they were effective, but not necessarily more effective than face-to-face therapy, although I guess teleconferencing is more face-to-face than plain telephone contact. Now that's even less info than the Parker-Pope blog, but if I get up the ambition, I'll look for the studies later today.

Wouldn't work for me, though. I want to see the person I'm talking to, or I'm going to envision her painting her toenails through the whole session, or perhaps washing his car. Besides, I don't answer the house phone, and don't give out my cell number, so they wouldn't be able to catch me, anyway.

Novalis said...

People just differ in their comfort levels with various media. I for one have never relished the disembodied quasi-intimacy of the telephone; if I couldn't have therapy face-to-face I would rather have it by email.

There are cases (particularly in remote/rural areas) where telemedicine may be really helpful, but in most situations I think it's therapeutic for someone to have to get out of the house (phone therapy could therefore enable a person's tendency to self-isolate).

Then there are those people who are out and about all the time but who would just prefer to get their therapy and/or meds over the phone because it's cheaper (often free!) and more convenient. But that's a different issue.

interested in mind machinations said...

Maybe this is addressed in a different post, but what does a psychiatrist do with a regular face-to-face client who calls in and leaves a message, in crisis? I mean, so obviously you as a doc call them back at some point if they're really in crisis. But what is the point of that phone contact? Is it essentially to assess their suicidality and tell them to go to an ER if they are? In other posts I've read about how psychs feel the need to have coverage for their practice when their out of touch on vacation. Okay, so this seems like a good idea, but if you're only going to tell a person to go to the ER between appointments, can't you just leave that on your phone message and otherwise not worry? Obviously you get other calls about scheduling and stuff like that, but I'm talking about crisis calls and what a pysch's objective is with them, especially in cases where you feel the current medications the patient is on are adequate though maybe like with depression the person just needs to give them more time.

Anyway, maybe this topic is addressed elsewhere, otherwise I'd love to hear more.

marcia said...

Thank you for the simple lesson in critical thinking!

I look forward to a podcast on this subject.

Shruti said...

Interesting topic!
I have no personal experience or idea about it though.

Shruti

Aqua said...

Until my recent pdoc I was one of those "patients who left after a few sessions" Here's my reasons in order or importance:
1) The therapist and I were incompatable
2) Cost (I was in university, or just beginning work with a high debt load from university
3) Employee Asistance programs only cover a few sessions (usually six
4) I suddenly felt better

I agree the post is irresponsible. I don't know how exactly you would read body language and thus agitation, anxiety, etc. over the phone. Often the only reason I tell my pdoc about my suicidal thoughts is because of the proximity of him in the room and the quiet patience he shows in waiting for me to open up. Having him in the room and not telling the truth feels really uncomfortable. I can see how on the phone it would be much easier to "keep secrets".

jcat said...

Response to 'interested in mind machinations' :-

I have regular face-to-face appts with both tdoc and pdoc. Well, regular depending on how stuff is going. Tdoc knows almost anything about my life. Pdoc knows a whole lot, but not quite all.

Tdoc is almost always available by phone. Pdoc is during the week, but shares Fri-Sun call with others.

I am never going to do phone-consults on a serious basis with either of them. That would play way too much into my tendency to isolate myself when things go bad. If I could talk to them via phone or email it would just be another very good reason to never actually have a real conversation with real people. For me, making myself be there in person is also important.

However, when it gets to personal crisis point, there have been times where a 15-min chat with pdoc by phone has been a real life saver. I guess that part of why he is regarded as brilliant is the ability to talk down ledge-people, and he has done that for me... we somehow ended up discussing the merits of various Chinese take-out places. And once you've declared allegiance to a particular form of shrimp chip, it kind of puts suicide into proportion. But, if after talking to him, he ends up saying hit the ER and I will see you at 06h00, it's a commitment to him personally. Not just to an arb answering service message.

I would never trust him that much if it weren't for the pre-existing personal relationship. But with that, talking to him does help, often.

Anonymous said...

Dr. Fuller, thank you for saying what I felt so wonderfully.

Dinah, with all due respect, I wish you guys were as critical of "mainstream" articles and blog posts that have the same issues as what you pointed out with this article.

For example, clink has made the statement on this blog that antidepressants are neuroprotective when the only research has been done on rats. That definitely is not scientific and in fact, is pretty irresponsible, especially when many people like myself have suffered cognitive damage.

I can provide scientific citations. In fact, I think I have provided some previously on this blog.

A psychiatrist on Newseek had the gall without any challenge other than a comment by me and someone else to say that psychotropic meds don't cause long term damage.

Also, there was an article that was passed as mainstream journalism about the fact that Prozac might cure strasmisbus (sp?) when again, the only research that had been done was on rats. Also, I felt it was a joke since many people have suffered visual problems as the result of SSRIS.

Sorry for my strong language. But frankly, I am tired of these inconsistencies.

AA

Anne said...
This comment has been removed by the author.
ClinkShrink said...

OK, since my blog name was mentioned I'll chime in here. I'm not sure I used the term 'neuroprotective', but it's a good one and I'll stand by it in the situation where I discussed it---a study on human subjects which showed that prophylactic antidepressants protected them from clinical depression following strokes. This is from my post An Ounce of Prevention.

Rach said...

Dinah - finally got around to reading this... WOW. Glad you finally addressed these issues - and you're right to call the post irresponsible, because it's not a fair post.

I would add that it's posts like TPP's that give uninformed/uneducated people false hope.

We, however, know better - because we read your blog.

healthskills said...

Great post - why do these sort of articles get published?!
One advantage of good blogging is there is usually a direct link or at least reference to the original paper so the questions you ask are answered.
But hey, headlines around the world are full of new treatments that are so much more effective than old ones - the equivocal results are never so newsworthy.

Anonymous said...

Clink,

Thank you for responding. I wasn't referring to that situation although since you mentioned the issue, I did want to address it in a minute.

Here is the link to what I was referring to which was January of this year:

http://tinyurl.com/4fovla

In response to someone expressing concern about using antidepressants long term, you said that they protect people against brain fry.

Roy made a similar type statement in the stroke thread.

I feel those statements are irresponsible because all the work that suggests this is possible has been done on rats and can't be extrapolated to humans.

But my point is that if I made the same type of claim that antidepressants didn't work based on work done with rats, you would be all over me and rightfully so. It just seems like you're not very consistent about what you do or don't label as scientific.

Anyway, I have provided citations on this blog that suggest that antidepressants cause cognitive damage long term. One was from a psychiatry journal.

Regarding antidepressants being helpful for stroke victims, frankly, I find that thought horrifying. I have a learning disability in which I have milder versions of what stroke victims suffer and feel that ADs long term greatly worsened those problems. Many people without LD end up with LD like symptoms after years of being on these meds.

Some people, including Dinah, expressed concern that the number to treat would be too high to justify medicating one person.

If you really want to prove that these meds work long term, as I previously suggested, you should conduct frequent neurospych testing. Of course, you would have to factor in other issues but that shouldn't be that hard to do. If the meds work as well as you think they do, people's abilities will stay as expected once you factor in age issues. That is alot more scientific than making assumptions based on work with rats.

AA

ClinkShrink said...

I think part of the difficulty in discussing the utility (or harm) of medication is that the risks and benefits will vary depending on the disorder. As Anon correctly points out, the potential benefit (or harm) of antidepressants as prophylaxis in post-stroke patients is unclear yet because the studies, although conducted in humans, not rats, are small and preliminary. There's a lot we don't know.

But in other disorders, say bipolar disorder, we do know a fair amount about the disease and the natural course of the untreated illness. The kindling phenomenon is well known and studied, in humans. Treatment can lessen the frequency and severity of these episodes. Anon is correct to point out that we haven't yet identified the biological substrate that either the disease or the medication is acting upon, but I wouldn't be quite as nihilistic about the state of research regarding efficacy.

Roy may something to add to that from his experience as a consult-liaison doc who treats psychiatric disorders in medical patients. Roy, anything to add about the issue of 'brain fry' (as used in the cited January post)?

Anonymous said...

In addition to "brain fry," what about the recent news that antipsychotics appear to shrink the brain (pun not intended) over time?

Anonymous said...

Clink, with all due respect, you avoided addressing most of the points I made.

This site suggests the kindling theory is not supported:

http://tinyurl.com/4g4cv6. It is from the bipolar about.com website.

Dr. Danny Carlat on his blog, called it a worn out theory.

Restating the previous point I made - The psychiatric profession, particularly psychiatrists seems to be very inconsistent in what they call scientific.

AA

ClinkShrink said...

Anon: Your main point seemed to be that psychiatry isn't scientific because most of the research was done on rats and can't be extrapolated to humans. I think I addressed that. Your secondary point I think was that psychiatrists are hypocritical regarding the science they criticize. I didn't address that because it's not really something that can be argued with data. It's a matter of opinion and I respect differences of opinion.

Anonymous said...

As my pdoc says, there is still a great deal that we do not yet know about bipolar and we discussed kindling, an idea borrowed from epilepsy ,and the response was:there is still a great deal we cannot say for certain. And Lithium is the gold standard but it seems to work better for some than others and when you have a disease and segment it into as many subtypes as bipolar has been chopped up into I would say you are dealing in the realm of art, abstract art, not so much science. Every doc suggests a new treatment;I am wandering in a supermarket. And look . Over there. A billion other people with bipolar. Pick a flavor.The magical mixer is spitting us out faster than you can buy shares in Astra Zeneca. Sell sell sell. MMM bipolar.

Anonymous said...

As a person whose extreme anxiety was a barrier to getting anything else done (half the appt was dedicated to guided imagery and its ilk), and who cried only once with her therapist in a year, and it happened to be the one time we spoke at length on the phone, and who thinks trying therapy again in the face of clear need is more attention to taking care of myself than I can muster at the moment...this sounds like great news to me. Though still probably won't follow through.

To reiterate, the anxiety was primarily due to be vulnerable without some sort of distance. At least that's my best guess. Anxiety was an issue for other things, but it wasn't causing panic attacks.