Tuesday, September 23, 2008

I Want To See Your Data

I've been resisting the urge to write about it, but Rach ( in her leg-warmers) has asked, so here are my comments about Tara Parker-Pope's New York Times Well blog called The Benefits of Therapy by Phone. It's a short piece, minus comments, so I'm simply going to paste the whole post. Ms. Parker Pope writes:

The Benefits of Therapy by Phone

INSERT DESCRIPTIONPhone-based therapy can be less hassle for patients. (Peter DaSilva for the New York Times)

Most therapists schedule face-to-face meetings with their patients. But new data suggest that therapy by phone may be a better option for some patients.

It has long been a concern among therapists that nearly half of their patients quit after only a few sessions. As a result, a number of health care providers and employee-assistance programs now offer therapy services by phone.

A new analysis of phone therapy research by Northwestern University shows that when patients receive psychotherapy for depression over the phone, more than 90 percent continue with it. The research showed that the average attrition rate in the telephone therapy was only 7.6 percent, compared to nearly 50 percent in face-to-face therapy. The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment.

“The problem with face-to-face treatment has always been very few people who can benefit from it actually receive it because of emotional and structural barriers,” said David Mohr, professor of preventive medicine at the Feinberg School of Medicine and lead author of the study, published in the September issue of Clinical Psychology: Science and Practice. “The telephone is a tool that allows the therapists to reach out to patients, rather than requiring that patients reach out to therapists.”

Among patients who say they want psychotherapy, only 20 percent actually show up for a referral, and half later drop out of treatment.

Dr. Mohr said he began using phone therapy because he was working with patients who had multiple sclerosis who could not get to a therapist’s office. Some patients don’t have regular transportation to a therapist’s office or can’t take time off work or away from their families. In addition, a patient with depression may simply not be capable of getting themselves to the therapist’s office on a regular basis.

“One of the symptoms of depression is people lose motivation,” Dr. Mohr said. “It’s hard for them to do the things they are supposed to do. Showing up for appointments is one of those things.”

Where should I begin? I'll guess I'll start by saying I don't want to talk about the value of phone therapy. Certainly, phone contact between sessions can help alleviate a crisis and may provide some comfort to a patient, but this isn't about 'between-sessions' with a known live entity, it's about telephone contact in place of live sessions, and my understanding is that this is from the get go.

It's a blog post, not a rigorous scientific article, but I'm going to start by saying I thought the post is irresponsible. That feels strong, and I'm an avid Well reader, but it's full of all these blanket statements, given as facts, with nothing that backs them up. There's a link to an abstract, and an email to request the full article, but I'm going to note that the abstract also gives very little information about the methods used and the conclusions reached. I didn't write for a copy of the full article (I will) -- maybe it was great science that warrants the conclusion that phone therapy for depression is as good as live therapy, but it's hard to get there from either the blog post or the abstract. Stay tuned: we'll use the full article for a future My Three Shrinks podcast.

Okay: The article starts by saying that therapists are concerned about patients leaving after only a few sessions. Is this true? Maybe people feel helped and leave. Maybe the therapist is horrible and they leave. And actually, insurance companies judge the best shrinks as those whose patients come the fewest times (presumably the quickest cured, but certainly the cheapest for the insurance company).

The next interesting assertion is that only 20% of people who want psychotherapy come for treatment? How do we know this? I suppose there could be a number for those who initiate treatment, but for those who Want?

Moving along, the issue is one for treatment of Depression, nothing is said about any other disorder, and I was left to wonder how the diagnosis was made: presumably over the phone? Is it just patients who self-diagnosed as Depressed? If a patient phone screened for another illness, were these results omitted so the finding could be positive for Depression? And is medication an option or perhaps these patients were identified by primary care docs who had already made the diagnosis and prescribed the medications? We have no idea what the pool of patients was, if medication has a role, or whether the patient or therapist initiated the calls. We do know that few dropped out of treatment: I do agree it's easier to call in than to deal with the hassles of getting to an appointment, but perhaps it's even easier if the therapist is doing the calling and the at-home patient (or on the cell out-and-about) just needs to answer the phone. How long did the patient need to remain engaged for the session to be called "therapy?"

And the patients got better, compared to controls, but even the abstract doesn't tell us if the control group is a face-to-face therapy cohort or a no-treatment group. There are no rating scales, no average score changes, not even a mention of how many patients were involved. The abstract says '12 trials of psychotherapy' so I'm thinking this means 12 patients. If so, that's hardly a number that has any real meaning as a measure to influence standards of care and attract the attention of the New York Times and I'll return to the word irresponsible. What happens when the person at the other end of the phone is acutely suicidal?
What happens when a patient lodges a complaint against a phone therapist who isn't licensed in their state? And might I wonder if insurance companies could use such articles as rationale for out-sourcing psychotherapy to phone sessions with therapists in other regions where care might be cheaper? I'll leave that one to your imagination.