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Q Does telephone delivered cognitive behavioural therapy improve depression in people with multiple sclerosis compared with telephone delivered supportive emotion-focused therapy?
METHODS
Design:
Randomised controlled trial.
Allocation:
Unclear.
Blinding:
Single blind: assessors were blinded.
Follow up period:
Twelve months.
Setting:
Northern California, USA; time period not stated.
Patients:
127 people (98 female) with a neurologist confirmed diagnosis of multiple sclerosis (MS), and with depressive symptoms (score >16 on the Beck Depression Inventory and score >14 on the Hamilton Depression Rating Scale), and functional impairment (score ⩾3 on at least one Guy’s Neurological Disability subscale). Exclusion criteria: dementia, psychosis, substance dependence, serious suicidal ideation, a current worsening of MS symptoms, and receiving psychoactive medication other than antidepressants.
Intervention:
Telephone delivered cognitive behavioural therapy (T-CBT; n = 62) or telephone delivered supportive emotion-focused therapy (T-SEFT; n = 65). Both therapies involved a weekly 50 minute session with a doctoral level psychologist for 16 weeks.
Outcomes:
DSM-IV diagnosis of Major Depressive Disorder, depression severity (Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI-II), Positive Affect subscale of the Positive and Negative Affective Scale (PANAS-PA)).
Patient follow up:
92% with T-CBT and 89% with T-SEFT; analysis was by intention to treat.
MAIN RESULTS
Telephone CBT reduced major depressive disorder at the end of treatment compared with supportive emotion-focused therapy (13.3% with T-CBT v 29.0% with T-SEFT; OR 0.33, 95% CI 0.13 to 0.85). At the end of treatment, telephone CBT reduced depressive symptoms on the HDRS (p = 0.01) and PANAS-PA (p = 0.03) more than supportive emotion-focused therapy, but there was no difference between treatments on the BDI-II. Although major depressive disorder and HDRS score decreased in both groups by 12 month follow up, there was no difference between treatments on any measure at 12 months (p>0.16).
CONCLUSIONS
Telephone delivered CBT reduces depression in people with multiple sclerosis at a faster rate than telephone delivered supportive emotion-focused therapy. However, telephone delivered CBT is not superior to supportive emotion focused therapy at one year follow up.
NOTES
Randomisation was stratified to balance the groups for the number of people with major depressive disorder and antidepressant use.
Commentary
Despite the high prevalence rates for major depressive disorder (MDD), research indicates undertreatment for this condition is common.1 Barriers to treatment include a lack of available treatment services, geographical restrictions, financial difficulties, and, for people with a comorbid medical condition, limited mobility. Non-traditional treatment methods hold promise for increasing access to treatment.2 The study by Mohr et al examines this problem by comparing two forms of telephone administered depression treatment; cognitive behaviour therapy (T-CBT), and supportive emotion-focused therapy (T-SEFT) for people with multiple sclerosis and MDD. A strength of the study is its evaluation of two active manual-based treatments of equal length that were led by doctoral level psychologists receiving equivalent supervision. Results indicated that patients treated with T-CBT showed a greater reduction in their depression during acute treatment (16 weeks) but that gains over a 12 month follow up no longer discriminated between the two treatments. The ability to achieve a rapid response in treating depression is relevant in light of the high morbidity associated with this condition.
These findings raise two interesting issues. One is whether there are significant differences in treatment components between T-CBT and T-SEFT. For example, T-CBT may include specific components that better target distress quickly whereas T-SEFT may include components that require a certain amount of time to significantly impact depressive symptoms. Alternatively, certain skills from CBT may be more easily administered initially over the phone.
Another issue is the role of telephone administered psychotherapy in the healthcare system. This form of psychotherapy could reach a disabled population that often has difficulties attending face-to-face treatment, greatly increasing their access to care. An important question is what the role is for this type of treatment with individuals without such physical disabilities, but who may face other barriers to accessing care.
Footnotes
For correspondence: David C Mohr, PhD, Veterans Administration Medical Center, University of California, San Francisco, 4150 Clement St (116-A), San Francisco, CA 94121, USA; dmohr{at}itsa.ucsf.edu
Source of funding: National Institute of Mental Health, Rockville, MD.