Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: a randomized trial.

CONTEXT: 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. OBJECTIVE: 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. INTERVENTIONS: Eighteen sessions of T-CBT or face-to-face CBT. MAIN OUTCOME MEASURES: 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). RESULTS: 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). CONCLUSIONS: 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. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00498706.

Perceived barriers to psychological treatments and their relationship to depression.

In spite of repeated calls for research and interventions to overcome individual and systemic barriers to psychological treatments, little is known about the nature of these barriers. To develop a measure of perceived barriers to psychological treatment (PBPT), items derived from 260 participants were administered to 658 primary care patients. Exploratory factor analysis on half the sample resulted in 8 factors, which were supported by confirmatory factor analysis conducted on the other half. Associations generally supported the criterion validity of PBPT scales, with self-reported concurrent use of psychotherapy and psychotherapy attendance in the year after PBPT administration. Depression was associated with greater endorsement of barriers. These findings suggest that the PBPT may be useful in assessing perceived barriers.

Humanities Education at Northwestern University's Feinberg School of Medicine.

The Medical Humanities and Bioethics Program at Northwestern University's Feinberg School of Medicine is responsible for humanities education in all four years of medical school: five units of the required four-year Patient, Physician, and Society course, 37 to 40 medical humanities seminars in years one and two, more than 125 ethics case conferences in third-year clerkships, and electives for fourth-year students. The program faculty also participate in ethics and humanities education in residencies, and the program offers an annual one-year fellowship. The program introduced the small-group teaching that now characterizes much of the school's curriculum, and its course units and seminars have been a resource for faculty development and curricular innovation. Drawing on literature, religion, ethics, philosophy of medicine, film, history, social and cultural anthropology, and jurisprudence, humanities education is designed to foster habits of discourse on social and moral issues in medicine. Small-group teaching and interactive learning are its central pedagogical methods. Essential to their successful use in a school that enrolls approximately 170 students each year is a large cadre of volunteer clinicians who serve as tutors and the college system, a four-part division of each class instituted by the 1993 curriculum reform. Students are evaluated on preparation, class participation, and regular writing assignments. All course units and seminars are pass/fail (as are all first- and second-year courses); tutors supply narrative comments. The courses themselves are thoroughly evaluated by students and reviewed both by the relevant faculty-student committee and at an annual curriculum retreat.