Telemedicine gives larger access to therapy for depression

Talk therapy delivered by two-way video call helped older veterans with depression as much as in-person therapy sessions, a U.S. study found.

Many seniors face obstacles to getting help for depression, including mobility issues and fear of social stigma, researchers say, so telemedicine might expand their access to treatment.

“Psychotherapy works for depression whether you deliver it by face-to-face or the telemedicine approach,” and telemedicine is a good option for “older adults who have barriers to mobility, stigma, or geographic isolation,” said lead author Dr. Leonard Egede

“At our facility, we have almost 40 percent of people who live in rural areas, so this is a good opportunity to be able to provide care for them without them having to drive long distances,” noted Egede, the Allen H. Johnson Endowed Chair and professor of medicine at the Medical University of South Carolina in Charleston, by email.

About 10 percent of the U.S. population will experience clinical depression in their lifetimes, according to the Centers for Disease Control and Prevention.

Among people over age 65, another 20 percent have “substantial” depression symptoms that may not meet diagnostic criteria for the full disorder, Egede and colleagues write in The Lancet Psychiatry. This “minor depression” puts them at increased risk of progressing to major depression, though, “and may warrant treatment,” the study team adds.

Depression is a particular problem among veterans, whose risk is two to five times that of the general population, the researchers note. Another barrier for this group is disability, with many veterans home-bound and unable to go to a clinic for care, Egede said.

Past studies have found telemedicine to be as effective as in-person talk therapy for treating post-traumatic stress disorder, but there has been less research on depression, he noted.

“Our goal was really to understand whether you can actually provide good psychotherapy via telemedicine,” Egede said.

The researchers recruited 204 veterans over the age of 58 with diagnosed major depressive disorder. They excluded patients who were psychotic, suicidal or had addiction problems.

Participants were randomly divided into two groups, with members of each receiving about eight one-hour therapy sessions, and a minimum of four. Both groups got the identical treatment – behavioral activation for depression, an approach that emphasizes reinforcing positive behaviors.

One group received their therapy in traditional in-person sessions, while the other group received treatment in their own homes, speaking to a psychotherapist using a video phone that connected over phone lines.

The study team measured the participants’ progress using two standard questionnaires in which patients rated their own symptoms. Participants were considered to be responding to treatment if their symptoms were reduced by at least half.

After four weeks, the questionnaires showed that only a small proportion of patients in either group had reduced their symptoms by that much, and only half as many in the telemedicine group (5 percent to 7 percent) as in the in-person therapy group (15 percent).

But by the three-month point, 15 percent of telemedicine patients and 19 percent of in-person therapy patients were responding.

At the one-year mark, the groups were about even, with 19 percent to 22 percent of the telemedicine patients and 19 percent to 21 percent of in-person patients meeting the treatment-response definition based on the questionnaires.

At that point, the researchers also assessed improvement using a structured clinical interview, in which a clinician determined if the veterans would still be diagnosed with major depressive disorder.

By that standard, 39 percent of telemedicine patients and 46 percent of in-person therapy patients were no longer depressed. The small percentage-point difference between the groups is not statistically significant, meaning it could have been due to chance.

Although there were no adverse events during the study, Dr. Charles Hoge, a psychiatrist and senior scientist at the Walter Reed Army Institute of Research who wrote a commentary accompanying the study, noted that in-home therapy raises the question of safety, because there are no professionals present if an emergency arises.

“The most important consideration is ensuring that there are procedures in place to address emergencies, such as if a patient reports intent to commit suicide or homicide,” Hoge said in an email.

Hoge noted, though, that he is optimistic about the use of telemedicine. “It can expand patients’ options for receiving needed mental health treatment,” he said.

SOURCE: The Lancet Psychiatry, online July 16, 2015.


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