Friday, September 26, 2008

After the Data: More on the Phone Therapy Study.


Okay, if you read my last post, you know I ranted (who me, rant?) about Tara Parker-Pope's NYTimes Well blog post where she asserted that phone therapy is effective for Depression-- as effective as real life therapy with less attrition. People wrote in to talk about their feelings about phone therapy, but really my gripe was with the idea of presenting a conclusion without any details-- I had a lot of questions about how this conclusion was reached, and I thought perhaps there were only 12 patients in the study.

So I emailed the author of the study, David C. Mohr, pH.D. at Northwestern, and within hours, I had a reprint of the study. It was a lot of data and I only did a quick read, but my questions were all answered, and here's the scoop:

This wasn't a research study: the journal article is a review of the literature of ALL phone therapy studies done, and 51 such studies were identified. All but 12 were excluded because they did not meet the authors' specific criteria to be included-- for example, some were surveys, not therapy trials, and any study that had ANY face-to-face contact was excluded. Mohr goes into detailed discussions of therapist training, treatment orientation, co-morbid illnesses, treatment format, and other variables. Mohr discusses how many of the patients and control subjects may have been on medications prescribed by primary care doctors or oncologists (--some of the studies looked at phone therapy in patients suffering from specific illnesses). I couldn't find any data from these studies that revealed that phone therapy worked as well as the traditional in-person stuff in a face off controlled trial.

The Well blog said: "The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment."

Actually, the researchers wrote:
We also want to emphasize that it is premature to generalize
the results of this meta-analysis broadly. Individual studies suggest specific uses under specific circumstances; for example, telephone therapies may provide added benefit compared to care for depressive symptoms by a primarycare physician or to no care at all. However, because the depression symptom outcomes used in this meta-analysis were self-report instruments, the generalizability of these findings to clinically diagnosable depressive disorders is limited (Kendall & Flannery-Schroeder, 1995). Furthermore, the measures of depression used in this study had a wide range of specificity and sensitivity (Minami, Wampold, Serlin, Kircher, & Brown, 2007). Thus, the aggregated effect size estimates for depressive symptom severity should not be used as any sort of benchmark. In addition, the level of heterogeneity across studies suggests that we do not yet understand the characteristics of patients for whom such telephone interventions may be effective, and those for whom telephone intervention may not be appropriate. The heterogeneity in the severity of depressive symptoms and in medical comorbidities in the samples also limits generalizability.

AA noted in his/her comments that we here at Shrink Rap sometimes make statements without fully backing them up or giving a full assessment of the literature. I have to agree. We're rambling for fun, we try to be accurate, we look up and link, but psychiatry is sometimes vague, still a mix of art and science with more questions than answers and the it never ceases to amaze me that how differently individuals react to the same intervention-- be it a word muttered or a medication prescribed. We try to be careful, but we can't be exact and some of this is about ducks and chocolate and us just venting about our days. I promise, however, that the moment the New York Times wants to pay me a salary to do this, I'll become really really careful about the conclusions I draw!


Thanks to Dr. Mohr for providing the paper:
The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis David C. Mohr, Northwestern University, Hines Veterans Administration Hospital Lea Vella, San Diego State University Stacey Hart, Ryerson University Timothy Heckman, Ohio University Gregory Simon, Group Health Cooperative

4 comments:

Battle Weary said...

A bit off topic....
It's really cool to see you doing this on the blog! In my physio class this semester, each student has to complete a semester project. Find a health related report in a popular news source (google news, yahoo news...along those lines). Find the study being cited (or not cited but merely alluded to...as the case may be). Select a citation that the study uses, and find that study as well. Then we write a paper and do a presentation in lab about the popular report, what is wrong (or right) about it, what the study really indicates, etc. Seeing you do this on the blog does get rid of my favorite grumble though...now I can't say "when will I ever use this after I graduate?". :P

Anonymous said...

Dinah,

Thank you for mentioning me in your blog entry. I am flattered:))

I do understand that each blog is going to reflect specific viewpoints and biases. However, using that specific article just rubbed me the wrong way, especially after seeing the Newsweek article that claimed that psychotropic meds don't cause long term damage when there are plenty of citations in mainstream medical journals that suggest differently.

I have a question about this exert:

"However, because the depression symptom outcomes used in this meta-analysis were self-report instruments, the generalizability of these findings to clinically diagnosable depressive disorders is limited"

In psychiatric drug trials, the effectiveness of a drug is determined by self report methods. What is the difference between that and the telephone study?

I realize that a placebo is used in drug trials but that has been called into question as it is quite easy unless you have a placebo that causes side effects, to figure out who is getting one and who isn't.

AA

Shruti said...

Another place where i saw the same topic discussed.

http://shine.yahoo.com/channel/health/would-you-quot-see-quot-a-therapist-by-phone-267491/

Shruti

integrativepsychiatry said...

TPP's blog too often presents partial information and information taken out of context as fact.

I think its a wonderful idea for a newspaper to have a health blog which educates the public about common or interesting health topics, unfortunately, I believe the Well Column misses the mark.