Context Both antidepressant medication and structured psychotherapy have been
proven efficacious, but less than one third of people with depressive disorders
receive effective levels of either treatment.
Objective To compare usual primary care for depression with 2 intervention programs:
telephone care management and telephone care management plus telephone psychotherapy.
Design Three-group randomized controlled trial with allocation concealment
and blinded outcome assessment conducted between November 2000 and May 2002.
Setting and Participants A total of 600 patients beginning antidepressant treatment for depression
were systematically sampled from 7 group-model primary care clinics; patients
already receiving psychotherapy were excluded.
Interventions Usual primary care; usual care plus a telephone care management program
including at least 3 outreach calls, feedback to the treating physician, and
care coordination; usual care plus care management integrated with a structured
8-session cognitive-behavioral psychotherapy program delivered by telephone.
Main Outcome Measures Blinded telephone interviews at 6 weeks, 3 months, and 6 months assessed
depression severity (Hopkins Symptom Checklist Depression Scale and the Patient
Health Questionnaire), patient-rated improvement, and satisfaction with treatment.
Computerized administrative data examined use of antidepressant medication
and outpatient visits.
Results Treatment participation rates were 97% for telephone care management
and 93% for telephone care management plus psychotherapy. Compared with usual
care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom
Checklist Depression Scale depression scores (P =
.02), a higher proportion of patients reporting that depression was "much
improved" (80% vs 55%, P<.001), and a higher proportion
of patients "very satisfied" with depression treatment (59% vs 29%, P<.001). The telephone care management program had smaller
effects on patient-rated improvement (66% vs 55%, P =
.04) and satisfaction (47% vs 29%, P = .001); effects
on mean depression scores were not statistically significant.
Conclusions For primary care patients beginning antidepressant treatment, a telephone
program integrating care management and structured cognitive-behavioral psychotherapy
can significantly improve satisfaction and clinical outcomes. These findings
suggest a new public health model of psychotherapy for depression including
active outreach and vigorous efforts to improve access to and motivation for
treatment.