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Original Article |

Telephone-Administered Psychotherapy for Depression FREE

David C. Mohr, PhD; Stacey L. Hart, PhD; Laura Julian, PhD; Claudine Catledge, MA; Lara Honos-Webb, PhD; Lea Vella, MPH; Edwin T. Tasch, MD
[+] Author Affiliations

Author Affiliations: Veterans Administration Medical Center, University of California, San Francisco (Drs Mohr, Hart, Julian, and Honos-Webb and Mss Catledge and Vella); and Kaiser Permanente Medical Care Group of Northern California, Santa Clara (Dr Tasch).


Arch Gen Psychiatry. 2005;62(9):1007-1014. doi:10.1001/archpsyc.62.9.1007.
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Published online

Background  Several studies have shown that telephone-administered cognitive-behavioral therapy (T-CBT) is superior to forms of no treatment controls. No study has examined if the skills-training component to T-CBT provides any benefit beyond that provided by nonspecific factors.

Objective  To test the efficacy of a 16-week T-CBT against a strong control for attention and nonspecific therapy effects.

Design  Randomized controlled trial including 12-month follow-up.

Setting  Telephone administration of psychotherapy with patients in their homes.

Participants  Participants had depression and functional impairments due to multiple sclerosis.

Interventions  A 16-week T-CBT program was compared with 16 weeks of telephone-administered supportive emotion-focused therapy.

Main Outcome Measures  Hamilton Depression Rating Scale score, Structured Clinical Interview for DSM-IV diagnosis of major depressive disorder, Beck Depression Inventory score, and Positive Affect scale score of the Positive and Negative Affect Scale.

Results  Of the 127 participants randomized, 7 (5.5%) dropped out of treatment. There were significant improvement during treatment on all outcome measures (P<.01 for all) and an increase in Positive Affect Scale score. Improvements over 16 weeks of treatment were significantly greater for T-CBT, compared with telephone-administered supportive emotion-focused therapy, for major depressive disorder frequency (P = .02), Hamilton Depression Rating Scale score (P = .02), and Positive Affect Scale score (P = .008), but not for the Beck Depression Inventory score (P = .29). Treatment gains were maintained during 12-month follow-up; however, differences across treatments were no longer evident (P > .16 for all).

Conclusions  Patients showed significant improvements in depression and positive affect during the 16 weeks of telephone-administered treatment. The specific cognitive-behavioral components of T-CBT produced improvements above and beyond the nonspecific effects of telephone-administered supportive emotion-focused therapy on evaluator-rated measures of depression and self-reported positive affect. Attrition was low.

Figures in this Article

Depression is common, with the 12-month prevalence of major depressive disorder (MDD) for the general population ranging from 7.6% to 10.3%1,2 and many more persons meeting the criteria for dysthymia and subthreshold depression. Depression impacts the ability to perform essential social roles, including work.3 While two thirds of depressed patients would prefer psychotherapy over antidepressant medication,48 only 10% to 45% ever even make a first appointment.9,10 Among those patients who attend the initial appointment, nearly half will drop out before the end of treatment.11 Even within the structure of a clinical trial, one third to half of all psychotherapy patients never complete treatment.12,13

There are numerous potential barriers to receiving psychotherapy, including physical impairments that interfere with attending regularly scheduled appointments, transportation problems, lack of available and appropriate services in the patient’s geographic area, child care problems, lack of time, stigma, and lack of financial resources.14,15

There have long been clinical reports of the use of telephone-administered psychotherapy as a method of overcoming some of these barriers.16,17 The use of telephone psychotherapy services increased in the 1990s in part because of the advent of 1-900 number counseling services and in part because of the increased use of telephone support services by insurance and medical groups.18

In the past few years, telephone-administered psychotherapy has begun to receive some empirical evaluation. Most telephone-administered psychotherapies have used a cognitive-behavioral approach, which teaches skills aimed at depressogenic thoughts and behaviors.19 This approach lends itself to telephone administration because it is structured and because it has been consistently shown to be effective at reducing depression and improving positive affect.20 An 8-session telephone-administered cognitive-behavioral therapy (T-CBT) has been shown to be more effective than usual care in reducing depressive symptoms in patients with multiple sclerosis (MS).21 Among depressed primary care patients, an 8-session T-CBT added onto usual care with antidepressants also has shown significant benefits.22 These studies suggest that T-CBT may be effective at reducing symptoms of depression. However, these studies have used usual care and other less intensive interventions as controls, and have, therefore, raised the question of whether the specific content of T-CBT adds anything to nonspecific treatment effects (attention, empathy, and being engaged in treatment).22

To our knowledge, we have performed the first randomized controlled trial comparing T-CBT with telephone-administered supportive emotion-focused therapy (T-SEFT). Telephone-administered supportive emotion-focused therapy, an adaptation of emotion-focused therapy,23 provided the strongest possible control for nonspecific effects of manualized psychotherapy, in that it controlled for attention, the nonspecific effects of therapeutic alliance (therapeutic bond, tasks, and goals), use of doctoral-level psychologists as therapists, and the effects of having a manualized treatment with specific therapist procedures that are clearly indicated, justified, and individualized to the patient. To our knowledge, this is also the first study to examine telephone-administered psychotherapy for depression in a sample selected based on having disabilities that pose substantial barriers to face-to-face psychotherapy. In this case, we selected patients with functional impairments resulting from MS. Multiple sclerosis is the most common debilitating neurological illness affecting young and middle-aged Americans.24

We hypothesized that while patients would significantly improve across both treatments, patients assigned to T-CBT would show significantly greater improvements in evaluator-rated and self-report measures of depression over 16 weeks of treatment, compared with patients assigned to T-SEFT. We also hypothesized that T-CBT would produce greater increases in positive affect, which is an important outcome independent of negative affect.25 Cognitive-behavioral therapy promotes active coping, resulting in increased positive affect.20 We further hypothesized that these improvements would be maintained over a 1-year follow-up and that patients receiving T-CBT would remain less depressed over the follow-up period.

INCLUSION/EXCLUSION CRITERIA

Inclusion criteria consisted of the following: (1) a diagnosis of MS confirmed by a neurologist, (2) functional impairment resulting in limitations in activity as measured by a score of at least 3 (of a total possible score of 6) on one or more areas of functioning on the Guy’s Neurological Disability Scale,26 (3) a score of 16 or higher on the Beck Depression Inventory (BDI) and 14 or higher on the Hamilton Depression Rating Scale (HDRS), (4) the ability to speak and read English, and (5) being older than 18 years. Patients were excluded if they (1) met the criteria for dementia (described later); (2) were currently undergoing psychotherapy; (3) showed severe psychopathological features, including psychosis, current substance abuse, or plan and intent to commit suicide; (4) were currently experiencing an MS exacerbation; (5) had physical deficits that prevent participation in treatment or assessment, including inability to speak or read and write; and (6) use medications other than antidepressants that affect mood (eg, steroidal anti-inflammatory agents). Use of antidepressant medications was not exclusionary.

RECRUITMENT

Patients were recruited through Kaiser Permanente Medical Care Group of Northern California (KP) and regional chapters of the National Multiple Sclerosis Society. Within KP, patients with MS were identified through the KP database. Subsequent to approval by their neurologists, a letter was sent to patients inviting them to participate and asking that they return a stamped postcard if they did not want to be contacted further. Patients who did not return the postcards were called after 10 days. Following a brief description of the study, patients who were interested received a brief telephone screen assessing depressive symptoms and several exclusion criteria. Those who met the initial screening criteria were invited to participate in a longer eligibility assessment that included assessment of all inclusion and exclusion criteria. The consent process, approved by the University of California, San Francisco, and KP Human Subjects Review Committees, included initial verbal consent conducted by telephone followed by written consent obtained by mailing documents to the patient. Recruitment through regional National Multiple Sclerosis Society chapters was initiated via announcements in National Multiple Sclerosis Society chapter newsletters. Patients who called a toll-free number received a description of the study and a telephone screen, as previously described. The consent process was similar to that used with KP patients with the addition of a release of information that was mailed to the patient, which allowed study staff to confirm the MS diagnosis with the patient’s neurologist.

ASSESSMENT

Self-report materials were mailed to participants with stamped addressed return envelopes. Interview assessments were conducted over the telephone. Participants were asked to complete self-report measures on the same day as the telephone assessment. Participants were paid $10 to $50 per assessment, depending on the time point and the length of the assessment. Telephone interview assessments were conducted by clinical evaluators with at least a master’s degree in a mental health profession, who were blinded to treatment assignment. To facilitate preservation of the blinding, all assessment interviews commenced with a request by the interviewer that the participants not discuss any aspects of their treatment. Eight evaluators were used during the study. All interviews were audiotaped. All evaluators corated a tape once per month to calibrate and maintain reliabilities. All assessments occurred at baseline, at midtreatment (week 8), at posttreatment (week 16), and at 3-, 6-, 9-, and 12-month follow-up unless otherwise noted.

Current DSM-IV diagnoses of MDD and dysthymia and psychiatric exclusionary diagnoses were assessed using a telephone-administered Structured Clinical Interview for DSM-IV (SCID).27 The SCID is reliable and valid when used over the telephone, with 90% to 97% agreement with face-to-face assessments.2830 Our raters maintained 100% agreement on MDD diagnoses during reliability checks using randomly selected audiotaped assessments. The SCIDs were administered at baseline, at posttreatment, and at 6- and 12-month follow-ups.

Evaluator-rated severity of depressive symptoms was assessed using a telephone-administered version of the HDRS.31 This telephone version was developed and validated for use with the Medical Outcomes Study version of the HDRS.32 Raters received training involving listening to and rating previous tapes and engaging in mock interviews. Interrater reliability from monthly reliability checks, using interclass correlations, averaged 0.89 (range, 0.75-0.97).

Self-reported depression severity was assessed using the BDI-II,33 administered as a self-report instrument through the mail.All 3 measures of depression (SCID, HDRS, and BDI-II) contain somatic items that may be associated with MS.34,35 We elected to retain these items because (1) confounded symptoms in depressed MS patients are usually related to MS and depression35 and (2) the relatively slow rate of progression of MS symptoms would mean that much of the effect of MS on symptoms would be washed out in a repeated-measures design.

Positive affect was measured using the Positive Affect subscale of the Positive and Negative Affect Scale (PANAS-PA),25 a self-report measure administered by mail.

Multiple sclerosis–related functional impairment and exacerbation were assessed using standardized structured interviews. The Guy’s Neurological Disability Scale is a structured interview that assesses 11 basic areas of function (eg, limb function and vision) and produces a single score that is highly related (= 0.81) to objective measures of functional impairment based on neurologist examination.26 We dropped the item assessing mood because it is confounded with our outcome measures. Each item rates a basic area of functioning from 1 (no symptoms) to 5 (a specific criterion reflecting extremely severe impairment). A 3 on any item reflects the point at which the functional impairment interferes with normal daily functioning. An MS exacerbation was assessed using a self-report scale that has been validated for this purpose.36

Dementia was evaluated using telephone-administered neuropsychological tests. Attention and concentration were assessed using Digit Span,37 verbal memory was assessed using the California Verbal Learning Test,38 executive function was measured using the Controlled Oral Word Association Test–FAS version,39 and abstraction was measured using the similarities from the Wechsler Adult Intelligence Scale, third edition.37 Telephone administration of these tests, or their equivalents, has been shown to be valid, reliable, and equivalent to face-to-face administrations4043 and has been used in previous telephone-administered studies with MS patients.21,44 Previous research21 has led to the development of a set of instructions that requests that the patient be alone in a room with no distractions and that the patient have no writing implements within reach. Subjects who scored below the fifth percentile on 2 of 4 tests were determined to have dementia sufficient to be excluded.

TREATMENTS AND CLINICIANS

Participants were randomized to one of two 16-week telephone-administered psychotherapies, T-CBT or T-SEFT. Participants spoke with a psychologist for 50 minutes each week. Randomization was stratified based on whether the participant was currently diagnosed as having MDD and currently used antidepressant medication. All treatments were administered by doctoral-level psychologists with 1 to 5 years of postdoctoral clinical experience.

Psychologists were nested in, rather than crossed with, treatment arm. This was done to avoid the influence of systematic therapist effects, such as treatment preferences, therapeutic orientation, or incremental therapist bias resulting from observation of the superiority of one treatment over another.45 Nine psychologists were recruited based on their expertise and their theoretical orientation as expressed to one of us (D.C.M.) on interview and reports of references. The 5 T-CBT therapists were trained in that model and used it as their primary treatment modality in practice. The 4 T-SEFT therapists did not identify themselves as CBT therapists and did not report using any skills-training interventions in their practice. All T-SEFT therapists expressed a firm belief that the therapeutic relationship is the principal vehicle for change in psychotherapy.

All psychologists received 2 hours of weekly group supervision by a more senior psychologist whose theoretical orientation and training were consistent with the treatment model. Because antidepressant medication was not an exclusion criterion, therapists were prohibited from discussing anything having to do with attitudes, feelings, or adherence behaviors related to antidepressant medications. This proscription was implemented because the T-CBT model would encourage therapists to help patients adhere to or better manage their antidepressant treatment while the T-SEFT model would not, thereby introducing a confound. To monitor therapist adherence to the treatment models, 2 sessions from each participant were rated by blinded research assistants on a modified version of the Cognitive Therapy Scale.46 The modified version of the Cognitive Therapy Scale included all Cognitive Therapy Scale items and items added to capture the focus on specific T-SEFT therapist procedures.

Telephone-administered cognitive-behavioral therapy is a structured cognitive-behavioral therapy based on standard CBT for depression.19,47 A patient workbook that guides treatment has been developed.21,48 The goal of T-CBT is to teach skills that help participants manage cognitions and behaviors that contribute to depression and improve skills in managing stressful life events and interpersonal difficulties. Initial sessions and chapters teach basic CBT skills, including behavioral activation, cognitive restructuring (including identification of automatic thoughts and negative thought patterns and methods to challenge these thoughts and thought patterns), and problem solving. These skills are then applied to problem areas identified by the participant and therapist, including social support, communication and assertiveness, and management of disabling symptoms.

Telephone-administered supportive emotion-focused therapy is an adaptation of the manual developed by Greenberg et al23 for process-experiential psychotherapy, which has the goal of increasing participants’ level of experience of their internal world. Therapeutic tasks included maintaining attention on empathic attunement, developing the therapeutic bond, and facilitating direct expression of present emotional experience and current needs. Interventions that promoted or indirectly focused attention on cognitions (eg, “What do you think about that?”), behaviors, or skills training were prohibited. In addition, telephone administration of T-SEFT, and the study goals, prevented implementation of some specific Gestalt therapy tasks suggested by Greenberg et al, such as empty chair work and 2-chair work. Thus, T-SEFT controlled for all nonspecific factors associated with T-CBT, including dosage, the therapeutic relationship, the use of a manualized treatment with a coherent theoretical justification and clearly described procedures, and individualized application of the treatment model.

DATA ANALYSIS

All analyses were conducted on an intent-to-treat basis. An initial analysis compared baseline demographics between treatment groups, using t tests for continuous data and χ2 analyses for categorical data. Baseline diagnoses were also compared across treatment groups.

Continuous outcome measures (HDRS, BDI-II, and PANAS-PA scores) were analyzed with a random-effects model for repeated measures, using restricted maximum likelihood methods. This type of model can handle subjects with some degree of nonrandom missing time points.49 Various within-patient error covariance structures (unstructured, simple, autoregressive, and compound symmetry) were tested, and nested models were compared using a likelihood ratio test. For each model, the unstructured covariance either fit best or was no different from any other covariance structure, and was, therefore, used in all models. Random-effects models also allow for individually varying intercepts and slopes. Each outcome model contains a random intercept and a random slope for the week of the study. Treatment outcome analyses included baseline and week 8 and 16 data. The treatment outcomes model evaluated the effects of treatment, time, and treatment × time interactions. Maintenance of gains analyses included week 16 and 3-, 6-, 9-, and 12-month follow-ups as dependent variables, treatment, and treatment × time interaction. All random-effects analyses were performed using SAS statistical software.50

Because the SCID MDD module was administered at baseline, at posttreatment (week 16), and at 6- and 12-month follow-up, analyses of treatment outcome or maintenance of gains would contain at most 2 time points as dependent variables, which is not sufficient to produce reliable results when modeling change over time in a random-effects model for repeated measures.51 Therefore, changes in MDD frequency from baseline to end of treatment (week 16), end of treatment to 6-month follow-up, and end of treatment to 12-month follow-up were tested with the McNemar test, while the treatment effect was analyzed using logistic regression. Treatment effect was analyzed using MDD status at end of treatment as the outcome; baseline MDD status was controlled for in this model. Maintenance of gains at 6- and 12-month follow-up was analyzed using similar strategies, controlling for week 16 MDD status. All logistic regression analyses were performed using STATA statistical software.52

SAMPLE

The progress of participants through the trial is shown in the Figure. Of the 748 patients who completed the initial telephone screening, 223 met the preliminary criteria for a full eligibility assessment. Of those patients, 150 were found eligible for randomization. Of these 150 patients, 23 (15.3%) refused randomization. Of the remaining 127 patients, 62 were randomized to T-CBT and 65 were randomized to T-SEFT.

Place holder to copy figure label and caption
Figure.

Flow of study participants through recruitment, intervention, and follow-up assessments. MS indicates multiple sclerosis; T-CBT, telephone-administered cognitive-behavioral therapy; and T-SEFT, telephone-administered supportive emotion-focused therapy.

Graphic Jump Location

The baseline characteristics of participants randomized to 1 of the 2 treatment groups are shown in Table 1. Employment status was significantly associated with BDI-II score at baseline (P = .045) but not at posttreatment (P = .21). No other demographic, diagnostic, medication, or disability variable was associated with any outcome variable at baseline (P > .06 for all), and none of these variables was associated with treatment assignment (P > .36 for all). Therefore, no demographic, diagnostic, medication, or disability variables were included in subsequent analyses.

Table Graphic Jump LocationTable 1. Baseline Demographic Characteristics and Diagnoses*
TREATMENT FIDELITY

Telephone-administered cognitive-behavioral therapy therapists were rated as performing significantly more cognitive-behavioral interventions on the modified version of the Cognitive Therapy Scale summary score (t240 = −49.36, < .001), on individual items (P < .006 for all), and on the overall rating of CBT performance (t240 = 54.40, < .001). Telephone-administered supportive emotion-focused therapy therapists were rated as making significantly more interventions aimed at evoking emotional expression (t240 = 33.67, < .001) and fostering participants’ awareness of internal experience (t240 = 4.03, P < .001).

ATTRITION

Seven participants (5.5%) did not complete the 16 weeks of therapy (3 in the T-CBT group and 4 in the T-SEFT group). Of these 7 participants, 6 dropped out by their own choice. One participant in the T-CBT group reported being sexually assaulted during treatment and began showing signs of dissociation. Appropriate face-to-face treatment in the participant’s community was arranged, and data collection was halted.

Of the 7 participants who discontinued therapy, 5 agreed to continue with follow-up assessments (2 in the T-CBT group and 3 in the T-SEFT group), while 2 dropped out of therapy and assessments (1 in each group). Five additional participants (3.9%) were unavailable for follow-up after treatment cessation (2 in the T-CBT group and 3 in the T-SEFT group).

TREATMENT OUTCOMES

The means (SDs) for our continuous outcome measures are shown in Table 2. Results of the primary analyses of continuous variables are shown in Table 3. There were significant reductions during treatment for all depression measures, including the HDRS (βtime = −.43) and BDI-II (βtime = −.62) scores, a reduction in the frequency of MDD (P<.001), and a significant increase in the PANAS-PA score (βtime = .17). There were significant time × treatment interaction effects, indicating significantly greater improvements for T-CBT, compared with T-SEFT, for the HDRS (βtime × treatment = −.17) and PANAS-PA (βtime × treatment = .25) scores. The HDRS score was significantly different between treatment groups at weeks 8 and 16 (P = .01 at both time points). The PANAS-PA score was significantly different between treatment groups at week 16 only (P = .03). There was no significant time × treatment interaction effect for the BDI-II score.

Table Graphic Jump LocationTable 2. Outcome Data by Week and Treatment Arm
Table Graphic Jump LocationTable 3. Outcomes for the HDRS, PANAS, and BDI

The distribution of SCID MDD diagnosis among treatment groups is also shown in Table 2, and analysis results are given in Table 4. At week 16, there was a significant effect for treatment (βtime = −1.10). Telephone-administered cognitive-behavioral therapy produced a significantly greater reduction in MDD frequency, compared with T-SEFT (odds ratio, 0.33; 95% confidence interval, 0.13-0.85).

MAINTENANCE OF GAINS

There were no significant changes in the BDI-II and PANAS-PA scores from the end of treatment to the 12-month follow-up (P > .19 for all). However, there was a significant continuing decrease in HDRS score during the 12-month follow-up (βtime = −.05, P = .004). In the maintenance of gains analysis of SCID MDD, there was no significant change in MDD frequency from the end of treatment to the 6-month follow-up (P = .33), but there was a significant reduction in MDD frequency at the 12-month follow-up (P = .04). There was no significant treatment effect for any measure (P > .16 for all).

Our finding that patients improved significantly and substantially across both telephone therapies is consistent with growing evidence showing the efficacy of telephone-administered psychotherapies.21,22,53 This is particularly notable in this population, because depression among patients with MS has repeatedly been shown to remain unimproved in the absence of treatment.54

During treatment, T-CBT, compared with T-SEFT, produced significantly greater reductions in the frequency of MDD diagnosis and evaluator-rated severity of depressive symptoms and significantly greater increases in self-reported positive affect. Telephone-administered supportive emotion-focused therapy was a strong control treatment, because it included an equivalent number of sessions, used doctoral-level psychologists, provided equivalent therapist supervision, and was guided by manualized treatment that includes specific therapist procedures aimed at enhancing nonspecific components of therapy, including therapeutic alliance. Thus, these findings suggest that the specific cognitive-behavioral procedures provided in T-CBT produce improvements beyond other nonspecific factors in telephone-administered psychotherapy.

This finding is not entirely consistent with trials of face-to-face CBT. A recent meta-analysis of controlled trials of face-to-face CBT divided control treatments into “non–bona fide” treatments, which lack some of the essential components of psychotherapy (eg, relaxation training, which is generally applied in a uniform manner across patients), and “bona fide” treatments, which were defined as meeting several criteria, including therapists with doctorate degrees, treatment decisions being individualized to the patient (this includes a requirement for face-to-face meetings, which is not relevant in this study), and the use of a treatment manual.55 While face-to-face CBT was superior to non–bona fide treatments, there was no significant advantage of CBT when the control treatment met the criteria for a bona fide treatment, as does T-SEFT. This suggests that cognitive-behavioral skills training may be particularly suited to telephone-administered treatments, while treatment modalities that rely more heavily on other mediators of change (eg, therapeutic relationship) may be less suited to telephone administration.

To our knowledge, the 12-month follow-up in this study is the longest follow-up conducted in a trial of telephone-administered therapy. Treatment gains were maintained during the 12-month follow-up; however, the treatment differences evident during treatment disappeared during follow-up. These follow-up findings are similar to those found in trials of face-to-face psychotherapies, which often report that benefits are maintained over time, but that treatment differences are not maintained following treatment cessation.56 There are at least 2 explanations for these findings, which are not mutually exclusive. The cognitive-behavioral skills taught in T-CBT may produce a more rapid response to treatment, which also occurs, albeit more slowly, in treatments that rely more heavily on the nonspecific effects of therapy, such as T-SEFT. It may also be that with the cessation of treatment, the use of cognitive-behavioral skills begins to decline, resulting in a convergence of levels of depression across randomized groups. Several potential solutions have been suggested to maintain gains in depression and use of skill, including adding booster sessions or spreading out the latter sessions over a longer period.57,58

The attrition rate across both treatments was 5.5%, which compares favorably with the rates of one third to one half observed in trials of face-to-face psychotherapies for depression.12,13 A low attrition rate has been found in at least 1 other large controlled trial of a telephone-administered psychotherapy.22 One potential explanation for these low attrition rates is that the use of the telephone may reduce barriers. This is particularly relevant to this sample of depressed MS patients, many of whom would have had difficulty attending weekly face-to-face appointments. This sample of MS patients had impairments that affected their ability to engage in social roles, as evidenced by the assessed functional impairment and the fact that 74% of the sample was not in the workforce. The use of telephone-administered therapies may also overcome various other barriers in the general population arising from transportation problems, lack of services in the area, child care problems, lack of time, and stigma.14,15

There are several limitations in these data, none of which invalidate the findings, but which should be considered in drawing inferences. While we saw significant time × treatment interaction effects in 3 of 4 of our measures, we did not see such an effect for BDI-II score. There are several possible explanations for this. One might argue that there was some unblinding of evaluators that led to biases in the interview assessments. However, another self-report, positive affect, also showed significant treatment differences, suggesting that differences across treatments could be detected by self-report measures. Furthermore, the high interrater reliabilities of the interview assessments would suggest that any such bias would have had to be similar across all 8 evaluators—something that is unlikely. Alternatively, several studies59,60 have noted that the BDI-II score is less sensitive to change in clinical trials than the HDRS score, in part due to decreased sensitivity with repeated administrations. Finally, it may also be that these findings accurately reflect that the added benefit of T-CBT over T-SEFT is seen in evaluator-rated assessment of depression and self-reported positive affect, but not in self-reported depression.

Caution regarding generalizability should be maintained. This study was done with a sample of patients with MS and depression. This has the advantage of representing a disabled group for whom telemental health interventions can greatly improve access to care.61 However, it is not clear that these findings would generalize to a broader group of patients without chronic illness or disability. For example, specific skills-training components of CBT may be effective at targeting potential causative factors unique to disabled individuals through improving symptom management (eg, fatigue) or reducing restrictions in fulfilling meaningful social roles.

We also caution that while these data are valid and reliable for populations, they should not suggest that T-CBT is indicated for all individual patients. Many individual patients showed good improvement with T-SEFT, and some patients did not show substantial response to T-CBT. As with face-to-face treatments, future research should focus on determining those individual patient characteristics that can be used for differentialtreatment prognoses. For example, patients who are less reactant may show stronger responses to more directive T-CBT–oriented treatments while more reactant patients may do better with less directive treatments, such as T-SEFT.62,63

To our knowledge, this is the third controlled trial that has pointed to the efficacy of T-CBT for the treatment of depression21,22 and the first to use stringent controls for attention and nonspecific effects. There is growing evidence that telephone-administered psychotherapies are effective in treating depression. This study suggests that the inclusion of CBT skills-training components in psychotherapy may enhance outcomes during treatment. There is also growing evidence that T-CBT produces low levels of attrition. To overcome geographic and other barriers to treatment and to save costs, many health maintenance organizations and care-providing institutions are expanding telemental health services, such as telephone-administered psychotherapies.64,65 At the same time, many mental health specialists remain skeptical of telephone-delivered psychotherapy.64,66 To facilitate decisions about the benefits, risks, and utility of telephone-administered psychotherapies, it will be important to examine if the outcomes of telephone-administered therapies are equivalent to face-to-face interventions and if the apparent reductions in attrition associated with telephone administration of psychotherapy can be confirmed in such a comparative trial.

Correspondence: David C. Mohr, PhD, Veterans Administration Medical Center, University of California, San Francisco, 4150 Clement St (116-A), San Francisco, CA 94121 (dmohr@itsa.ucsf.edu).

Submitted for Publication: November 24, 2004; final revision received January 19, 2005; accepted February 16, 2005.

Funding/Support: This study was supported by grant MH59708 R01 from the National Institute of Mental Health, Rockville, Md (Dr Mohr).

Kessler  RCBerglund  PDemler  OJin  RKoretz  DMerikangas  KRRush  AJWalters  EEWang  PS The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;2893095- 3105
PubMed Link to Article
Kessler  RCMcGonagle  KAZhao  SNelson  CBHughes  MEshleman  SWittchen  HUKendler  KS Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;518- 19
PubMed Link to Article
Wells  KBStewart  AHays  RDBurnam  MARogers  WDaniels  MBerry  SGreenfield  SWare  J The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262914- 919
PubMed Link to Article
Brody  DSKhaliq  AAThompson  TL  II Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med 1997;12403- 406
PubMed Link to Article
Dwight-Johnson  MSherbourne  CDLiao  DWells  KB Treatment preferences among depressed primary care patients. J Gen Intern Med 2000;15527- 534
PubMed Link to Article
Bedi  NChilvers  CChurchill  RDewey  MDuggan  CFielding  KGretton  VMiller  PHarrison  GLee  AWilliams  I Assessing effectiveness of treatment of depression in primary care: partially randomised preference trial. Br J Psychiatry 2000;177312- 318
PubMed Link to Article
Priest  RGVize  CRoberts  ARoberts  MTylee  A Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313858- 859
PubMed Link to Article
Churchill  RKhaira  MGretton  VChilvers  CDewey  MDuggan  CLee  ANottingham Counselling and Antidepressants in Primary Care (CAPC) Study Group, Treating depression in general practice: factors affecting patients’ treatment preferences. Br J Gen Pract 2000;50905- 906
PubMed
Weddington  WW  Jr Adherence by medical-surgical inpatients to recommendations for outpatient psychiatric treatment. Psychother Psychosom 1983;39225- 235
PubMed Link to Article
Blumenthal  REndicott  J Barriers to seeking treatment for major depression. Depress Anxiety 1996;4273- 278
PubMed Link to Article
Wierzbicki  MPekarik  G A meta-analysis of psychotherapy dropout. Prof Psychol Res Pr 1993;24190- 195
Link to Article
Casacalenda  NPerry  JCLooper  K Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry 2002;1591354- 1360
PubMed Link to Article
Pampallona  SBollini  PTibaldi  GKupelnick  BMunizza  C Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry 2004;61714- 719
PubMed Link to Article
Hollon  SMunoz  RFBarlow  DHBeardslee  WRBell  CCBernal  GClarke  GNFranciosi  LPKazdin  AEKohn  LLinehan  MMMarkowitz  JCMiklowitz  DJPersons  JBNiederehe  GSommers  D Psychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access. Biol Psychiatry 2002;52610- 630
PubMed Link to Article
Alvidrez  JAzocar  F Distressed women’s clinic patients: preferences for mental health treatments and perceived obstacles. Gen Hosp Psychiatry 1999;21340- 347
PubMed Link to Article
Mermelstein  HTHolland  JC Psychotherapy by telephone: a therapeutic tool for cancer patients. Psychosomatics 1991;32407- 412
PubMed Link to Article
Shepard  P Telephone therapy: an alternative to isolation. Clin Soc Work J 1987;1556- 65
Link to Article
Haas  LJBenedict  JGKobos  JC Psychotherapy by telephone: risks and benefits for psychologists and consumers. Prof Psychol Res Pr 1996;27154- 160
Link to Article
Beck  JS Cognitive Therapy: Basics and Beyond.  New York, NY Guilford Press1995;
Antoni  MHLehman  JMKilbourn  KMBoyers  AECulver  JLAlferi  SMYount  SEMcGregor  BAArena  PLHarris  SDPrice  AACarver  CS Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 2001;2020- 32
PubMed Link to Article
Mohr  DCLikosky  WBertagnolli  AGoodkin  DEVan Der Wende  JDwyer  PDick  LP Telephone-administered cognitive-behavioral therapy for the treatment of depressive symptoms in multiple sclerosis. J Consult Clin Psychol 2000;68356- 361
PubMed Link to Article
Simon  GELudman  EJTutty  SOperskalski  BVon Korff  M Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA 2004;292935- 942
PubMed Link to Article
Greenberg  LSRice  LNElliott  R Facilitating Emotional Change: The Moment-by-Moment Process.  New York, NY Guilford Press1993;
Noonan  CWKathman  SJWhite  MC Prevalence estimates for MS in the United States and evidence of an increasing trend for women. Neurology 2002;58136- 138
PubMed Link to Article
Watson  D Intraindividual and interindividual analyses of positive and negative affect: their relation to health complaints, perceived stress, and daily activities. J Pers Soc Psychol 1988;541020- 1030
PubMed Link to Article
Sharrack  BHughes  RAC The Guy’s Neurological Disability Scale (GNDS): a new disability measure for multiple sclerosis. Mult Scler 1999;5223- 233
PubMed Link to Article
First  MBSpitzer  RLGibbon  MWilliams  JB Structured Clinical Interview for DSM-IV Axis I Disorders: Patient Edition (SCID-I/P, Version 2.0).  New York New York State Psychiatric Institute1995;
Kobak  KATaylor  LHDottl  SLGreist  JHJefferson  JWBurroughs  DMantle  JMKatzelnick  DJNorton  RHenk  HJSerlin  RC A computer-administered telephone interview to identify mental disorders. JAMA 1997;278905- 910
PubMed Link to Article
Simon  GERevicki  DVonKorff  M Telephone assessment of depression severity. J Psychiatr Res 1993;27247- 252
PubMed Link to Article
Ruskin  PEReed  SKumar  RKling  MASiegel  ERosen  MHauser  P Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatr Serv 1998;491086- 1088
PubMed
Hamilton  M A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;2356- 62
PubMed Link to Article
Potts  MKDaniels  MBurnam  MAWells  KB A structured interview version of the Hamilton Depression Rating Scale: evidence of reliability and versatility of administration. J Psychiatr Res 1990;24335- 350
PubMed Link to Article
Beck  ATSteer  RABrown  GK Beck Depression Inventory: Second Edition: Manual.  San Antonio, Tex Psychological Corp1996;
Mohr  DCGoodkin  DELikosky  WBeutler  LGatto  NLangan  MK Identification of Beck Depression Inventory items related to multiple sclerosis. J Behav Med 1997;20407- 414
PubMed Link to Article
Moran  PJMohr  DC The validity of Beck Depression Inventory and Hamilton Rating Scale for Depression items in the assessment of depression among patients with multiple sclerosis. J Behav Med 2005;2835- 41
PubMed Link to Article
Verdier-Taillefer  MHRoullet  ECesaro  PAlperovitch  A Validation of self-reported neurological disability in multiple sclerosis. Int J Epidemiol 1994;23148- 154
PubMed Link to Article
Wechsler  D Wechsler Adult Intelligence Scale: Third Edition.  San Antonio, Tex Psychological Corp1997;
Delis  DCKramer  JHKaplan  EOber  BA California Verbal Learning Test: Adult Version.  San Antonio, Tex Psychological Corp1987;
Lezak  MD Neuropsychological Assessment. 3rd ed. New York, NY Oxford University Press Inc1995;
Debanne  SMPatterson  MBDick  RRiedel  TMSchnell  ARowland  DY Validation of a telephone cognitive assessment battery. J Am Geriatr Soc 1997;451352- 1359
PubMed
Desmond  DWTatemichi  TKHanzawa  L The Telephone Interview for Cognitive Status (TICS): reliability and validity in a stroke sample. Int J Geriatr Psychiatry 1994;9803- 807
Link to Article
Gallo  JJBreitner  JCS Alzheimer’s disease in the NAS-NRC registry of ageing twin veterans, IV: performance characteristics of a two-stage telephone screening procedure for Alzheimer’s dementia. Psychol Med 1995;251211- 1219
PubMed Link to Article
Welsh  KABreitner  JCSMagruder-Habib  KM Detection of dementia in elderly using telephone screening of cognitive status. Neuropsychiatry Neuropsychol Behav Neurol 1993;6103- 110
Mohr  DCDick  LPRusso  DPinn  JBoudewyn  ACLikosky  WGoodkin  DE The psychosocial impact of multiple sclerosis: exploring the patient’s perspective. Health Psychol 1999;18376- 382
PubMed Link to Article
Kazdin  AE Methodology, design, and evaluation in psychotherapy research. Bergin  AEGarfield  SLeds.Handbook of Psychotherapy and Behavior Change. 4th ed. New York, NY John Wiley & Sons Inc1994;
Vallis  TMShaw  BFDobson  KS The Cognitive Therapy Scale: psychometric properties. J Consult Clin Psychol 1986;54381- 385
PubMed Link to Article
Beck  ATRush  AJShaw  BFEmery  G Cognitive Therapy of Depression.  New York, NY Guilford Press1979;
Mohr  DCBoudewyn  ACGoodkin  DEBostrom  AEpstein  L Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol 2001;69942- 949
PubMed Link to Article
Brown  HPrescott  R Applied Models in Medicine.  New York, NY John Wiley & Sons Inc1999;
SAS Institute Inc, SAS Version 8.02.  Cary, NC SAS Institute Inc2001;
Singer  JDWillett  JB Applied Longitudinal Data Analysis.  New York, NY Oxford University Press Inc2003;
Stata Corp, Intercooled STATA Version 8.2.  College Station, Tex Stata Corp2003;
Miller  LWeissman  M Interpersonal psychotherapy delivered over the telephone to recurrent depressives: a pilot study. Depress Anxiety 2002;16114- 117
PubMed Link to Article
Mohr  DC Negative outcome in psychotherapy: a critical review. Clin Psychol Sci Pract 1995;21- 27
Link to Article
Wampold  BEMinami  TBaskin  TWCallen Tierney  S A meta-(re)analysis of the effects of cognitive therapy versus “other therapies” for depression. J Affect Disord 2002;68159- 165
PubMed Link to Article
Beutler  LEClarkin  J Systematic Treatment Selection: Toward Targeted Therapeutic Interventions.  New York, NY Brunner/Mazel1990;
Hedrick  SCChaney  EFFelker  BLiu  CFHasenberg  NHeagerty  PBuchanan  JBagala  RGreenberg  DPaden  GFihn  SDKaton  W Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. J Gen Intern Med 2003;189- 16
PubMed Link to Article
Whisman  MA The efficacy of booster maintenance sessions in behavior therapy: review and methodological critique. Clin Psychol Rev 1990;10155- 170
Link to Article
Lambert  MJHatch  DRKingston  MDEdwards  BC Zung, Beck, and Hamilton Rating Scales as measures of treatment outcome: a meta-analytic comparison. J Consult Clin Psychol 1986;5454- 59
PubMed Link to Article
Edwards  BCLambert  MJMoran  PWMcCully  TSmith  KCEllingson  AG A meta-analytic comparison of the Beck Depression Inventory and the Hamilton Rating Scale for Depression as measurements of treatment outcome. Br J Clin Psychol 1984;2393- 99
PubMed Link to Article
Hatzakis  M  JrHaselkorn  JWilliams  RTurner  ANichol  P Telemedicine and the delivery of health services to veterans with multiple sclerosis. J Rehabil Res Dev 2003;40265- 282
PubMed
Beutler  LEEngle  DMohr  DDaldrup  RJBergan  JMeredith  KMerry  W Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures. J Consult Clin Psychol 1991;59333- 340
PubMed Link to Article
Beutler  LEHarwood  MT Prescriptive Psychotherapy: A Practical Guide to Systemic Treatment Selection.  London, England Oxford University Press2000;
Maheu  MMPulier  MLWilhelm  FHMcMenamin  JPBrown-Connolly  NE The Mental Health Professional and the New Technologies: A Handbook for Practice Today.  Mahwah, NJ Lawrence A Erlbaum Associates2005;
VHA Telemental Health Field Work Group, Telemental Health Toolkit.  Washington, DC Veterans Health Administration2003;
Tanvetyanon  T Telephone psychotherapy and care management for depression. JAMA 2004;2922720- 2721

Figures

Place holder to copy figure label and caption
Figure.

Flow of study participants through recruitment, intervention, and follow-up assessments. MS indicates multiple sclerosis; T-CBT, telephone-administered cognitive-behavioral therapy; and T-SEFT, telephone-administered supportive emotion-focused therapy.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Demographic Characteristics and Diagnoses*
Table Graphic Jump LocationTable 2. Outcome Data by Week and Treatment Arm
Table Graphic Jump LocationTable 3. Outcomes for the HDRS, PANAS, and BDI

References

Kessler  RCBerglund  PDemler  OJin  RKoretz  DMerikangas  KRRush  AJWalters  EEWang  PS The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;2893095- 3105
PubMed Link to Article
Kessler  RCMcGonagle  KAZhao  SNelson  CBHughes  MEshleman  SWittchen  HUKendler  KS Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;518- 19
PubMed Link to Article
Wells  KBStewart  AHays  RDBurnam  MARogers  WDaniels  MBerry  SGreenfield  SWare  J The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262914- 919
PubMed Link to Article
Brody  DSKhaliq  AAThompson  TL  II Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med 1997;12403- 406
PubMed Link to Article
Dwight-Johnson  MSherbourne  CDLiao  DWells  KB Treatment preferences among depressed primary care patients. J Gen Intern Med 2000;15527- 534
PubMed Link to Article
Bedi  NChilvers  CChurchill  RDewey  MDuggan  CFielding  KGretton  VMiller  PHarrison  GLee  AWilliams  I Assessing effectiveness of treatment of depression in primary care: partially randomised preference trial. Br J Psychiatry 2000;177312- 318
PubMed Link to Article
Priest  RGVize  CRoberts  ARoberts  MTylee  A Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313858- 859
PubMed Link to Article
Churchill  RKhaira  MGretton  VChilvers  CDewey  MDuggan  CLee  ANottingham Counselling and Antidepressants in Primary Care (CAPC) Study Group, Treating depression in general practice: factors affecting patients’ treatment preferences. Br J Gen Pract 2000;50905- 906
PubMed
Weddington  WW  Jr Adherence by medical-surgical inpatients to recommendations for outpatient psychiatric treatment. Psychother Psychosom 1983;39225- 235
PubMed Link to Article
Blumenthal  REndicott  J Barriers to seeking treatment for major depression. Depress Anxiety 1996;4273- 278
PubMed Link to Article
Wierzbicki  MPekarik  G A meta-analysis of psychotherapy dropout. Prof Psychol Res Pr 1993;24190- 195
Link to Article
Casacalenda  NPerry  JCLooper  K Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry 2002;1591354- 1360
PubMed Link to Article
Pampallona  SBollini  PTibaldi  GKupelnick  BMunizza  C Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry 2004;61714- 719
PubMed Link to Article
Hollon  SMunoz  RFBarlow  DHBeardslee  WRBell  CCBernal  GClarke  GNFranciosi  LPKazdin  AEKohn  LLinehan  MMMarkowitz  JCMiklowitz  DJPersons  JBNiederehe  GSommers  D Psychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access. Biol Psychiatry 2002;52610- 630
PubMed Link to Article
Alvidrez  JAzocar  F Distressed women’s clinic patients: preferences for mental health treatments and perceived obstacles. Gen Hosp Psychiatry 1999;21340- 347
PubMed Link to Article
Mermelstein  HTHolland  JC Psychotherapy by telephone: a therapeutic tool for cancer patients. Psychosomatics 1991;32407- 412
PubMed Link to Article
Shepard  P Telephone therapy: an alternative to isolation. Clin Soc Work J 1987;1556- 65
Link to Article
Haas  LJBenedict  JGKobos  JC Psychotherapy by telephone: risks and benefits for psychologists and consumers. Prof Psychol Res Pr 1996;27154- 160
Link to Article
Beck  JS Cognitive Therapy: Basics and Beyond.  New York, NY Guilford Press1995;
Antoni  MHLehman  JMKilbourn  KMBoyers  AECulver  JLAlferi  SMYount  SEMcGregor  BAArena  PLHarris  SDPrice  AACarver  CS Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 2001;2020- 32
PubMed Link to Article
Mohr  DCLikosky  WBertagnolli  AGoodkin  DEVan Der Wende  JDwyer  PDick  LP Telephone-administered cognitive-behavioral therapy for the treatment of depressive symptoms in multiple sclerosis. J Consult Clin Psychol 2000;68356- 361
PubMed Link to Article
Simon  GELudman  EJTutty  SOperskalski  BVon Korff  M Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA 2004;292935- 942
PubMed Link to Article
Greenberg  LSRice  LNElliott  R Facilitating Emotional Change: The Moment-by-Moment Process.  New York, NY Guilford Press1993;
Noonan  CWKathman  SJWhite  MC Prevalence estimates for MS in the United States and evidence of an increasing trend for women. Neurology 2002;58136- 138
PubMed Link to Article
Watson  D Intraindividual and interindividual analyses of positive and negative affect: their relation to health complaints, perceived stress, and daily activities. J Pers Soc Psychol 1988;541020- 1030
PubMed Link to Article
Sharrack  BHughes  RAC The Guy’s Neurological Disability Scale (GNDS): a new disability measure for multiple sclerosis. Mult Scler 1999;5223- 233
PubMed Link to Article
First  MBSpitzer  RLGibbon  MWilliams  JB Structured Clinical Interview for DSM-IV Axis I Disorders: Patient Edition (SCID-I/P, Version 2.0).  New York New York State Psychiatric Institute1995;
Kobak  KATaylor  LHDottl  SLGreist  JHJefferson  JWBurroughs  DMantle  JMKatzelnick  DJNorton  RHenk  HJSerlin  RC A computer-administered telephone interview to identify mental disorders. JAMA 1997;278905- 910
PubMed Link to Article
Simon  GERevicki  DVonKorff  M Telephone assessment of depression severity. J Psychiatr Res 1993;27247- 252
PubMed Link to Article
Ruskin  PEReed  SKumar  RKling  MASiegel  ERosen  MHauser  P Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatr Serv 1998;491086- 1088
PubMed
Hamilton  M A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;2356- 62
PubMed Link to Article
Potts  MKDaniels  MBurnam  MAWells  KB A structured interview version of the Hamilton Depression Rating Scale: evidence of reliability and versatility of administration. J Psychiatr Res 1990;24335- 350
PubMed Link to Article
Beck  ATSteer  RABrown  GK Beck Depression Inventory: Second Edition: Manual.  San Antonio, Tex Psychological Corp1996;
Mohr  DCGoodkin  DELikosky  WBeutler  LGatto  NLangan  MK Identification of Beck Depression Inventory items related to multiple sclerosis. J Behav Med 1997;20407- 414
PubMed Link to Article
Moran  PJMohr  DC The validity of Beck Depression Inventory and Hamilton Rating Scale for Depression items in the assessment of depression among patients with multiple sclerosis. J Behav Med 2005;2835- 41
PubMed Link to Article
Verdier-Taillefer  MHRoullet  ECesaro  PAlperovitch  A Validation of self-reported neurological disability in multiple sclerosis. Int J Epidemiol 1994;23148- 154
PubMed Link to Article
Wechsler  D Wechsler Adult Intelligence Scale: Third Edition.  San Antonio, Tex Psychological Corp1997;
Delis  DCKramer  JHKaplan  EOber  BA California Verbal Learning Test: Adult Version.  San Antonio, Tex Psychological Corp1987;
Lezak  MD Neuropsychological Assessment. 3rd ed. New York, NY Oxford University Press Inc1995;
Debanne  SMPatterson  MBDick  RRiedel  TMSchnell  ARowland  DY Validation of a telephone cognitive assessment battery. J Am Geriatr Soc 1997;451352- 1359
PubMed
Desmond  DWTatemichi  TKHanzawa  L The Telephone Interview for Cognitive Status (TICS): reliability and validity in a stroke sample. Int J Geriatr Psychiatry 1994;9803- 807
Link to Article
Gallo  JJBreitner  JCS Alzheimer’s disease in the NAS-NRC registry of ageing twin veterans, IV: performance characteristics of a two-stage telephone screening procedure for Alzheimer’s dementia. Psychol Med 1995;251211- 1219
PubMed Link to Article
Welsh  KABreitner  JCSMagruder-Habib  KM Detection of dementia in elderly using telephone screening of cognitive status. Neuropsychiatry Neuropsychol Behav Neurol 1993;6103- 110
Mohr  DCDick  LPRusso  DPinn  JBoudewyn  ACLikosky  WGoodkin  DE The psychosocial impact of multiple sclerosis: exploring the patient’s perspective. Health Psychol 1999;18376- 382
PubMed Link to Article
Kazdin  AE Methodology, design, and evaluation in psychotherapy research. Bergin  AEGarfield  SLeds.Handbook of Psychotherapy and Behavior Change. 4th ed. New York, NY John Wiley & Sons Inc1994;
Vallis  TMShaw  BFDobson  KS The Cognitive Therapy Scale: psychometric properties. J Consult Clin Psychol 1986;54381- 385
PubMed Link to Article
Beck  ATRush  AJShaw  BFEmery  G Cognitive Therapy of Depression.  New York, NY Guilford Press1979;
Mohr  DCBoudewyn  ACGoodkin  DEBostrom  AEpstein  L Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol 2001;69942- 949
PubMed Link to Article
Brown  HPrescott  R Applied Models in Medicine.  New York, NY John Wiley & Sons Inc1999;
SAS Institute Inc, SAS Version 8.02.  Cary, NC SAS Institute Inc2001;
Singer  JDWillett  JB Applied Longitudinal Data Analysis.  New York, NY Oxford University Press Inc2003;
Stata Corp, Intercooled STATA Version 8.2.  College Station, Tex Stata Corp2003;
Miller  LWeissman  M Interpersonal psychotherapy delivered over the telephone to recurrent depressives: a pilot study. Depress Anxiety 2002;16114- 117
PubMed Link to Article
Mohr  DC Negative outcome in psychotherapy: a critical review. Clin Psychol Sci Pract 1995;21- 27
Link to Article
Wampold  BEMinami  TBaskin  TWCallen Tierney  S A meta-(re)analysis of the effects of cognitive therapy versus “other therapies” for depression. J Affect Disord 2002;68159- 165
PubMed Link to Article
Beutler  LEClarkin  J Systematic Treatment Selection: Toward Targeted Therapeutic Interventions.  New York, NY Brunner/Mazel1990;
Hedrick  SCChaney  EFFelker  BLiu  CFHasenberg  NHeagerty  PBuchanan  JBagala  RGreenberg  DPaden  GFihn  SDKaton  W Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. J Gen Intern Med 2003;189- 16
PubMed Link to Article
Whisman  MA The efficacy of booster maintenance sessions in behavior therapy: review and methodological critique. Clin Psychol Rev 1990;10155- 170
Link to Article
Lambert  MJHatch  DRKingston  MDEdwards  BC Zung, Beck, and Hamilton Rating Scales as measures of treatment outcome: a meta-analytic comparison. J Consult Clin Psychol 1986;5454- 59
PubMed Link to Article
Edwards  BCLambert  MJMoran  PWMcCully  TSmith  KCEllingson  AG A meta-analytic comparison of the Beck Depression Inventory and the Hamilton Rating Scale for Depression as measurements of treatment outcome. Br J Clin Psychol 1984;2393- 99
PubMed Link to Article
Hatzakis  M  JrHaselkorn  JWilliams  RTurner  ANichol  P Telemedicine and the delivery of health services to veterans with multiple sclerosis. J Rehabil Res Dev 2003;40265- 282
PubMed
Beutler  LEEngle  DMohr  DDaldrup  RJBergan  JMeredith  KMerry  W Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures. J Consult Clin Psychol 1991;59333- 340
PubMed Link to Article
Beutler  LEHarwood  MT Prescriptive Psychotherapy: A Practical Guide to Systemic Treatment Selection.  London, England Oxford University Press2000;
Maheu  MMPulier  MLWilhelm  FHMcMenamin  JPBrown-Connolly  NE The Mental Health Professional and the New Technologies: A Handbook for Practice Today.  Mahwah, NJ Lawrence A Erlbaum Associates2005;
VHA Telemental Health Field Work Group, Telemental Health Toolkit.  Washington, DC Veterans Health Administration2003;
Tanvetyanon  T Telephone psychotherapy and care management for depression. JAMA 2004;2922720- 2721

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