JAMA：比较电话施予的认知行为疗法治疗抑郁症的有效性研究

芝加哥–据6月6日刊《美国医学会杂志》JAMA上的一项研究披露，那些接受通过电话施予的认知行为疗法（T-CBT）的罹患严重抑郁症的患者与那些接受面对面CBT的患者相比有着较低的中断治疗的发生率，且在治疗结束时，电话施予的治疗就症状的改善而言不比面对面的治疗差；然而，在6个月随访的时候，那些接受面对面CBT的患者要比那些接受电话施予的CBT的患者的抑郁程度要低。

根据文章的背景资料：“心理疗法可有效地治疗抑郁症，大多数的初级诊疗患者更喜欢心理疗法而不是服用抗抑郁症药物。然而，当患者被转诊进行心理治疗时，只有一小部分比例的患者会自始至终地接受该疗法。在随机对照的试验中，心理疗法的减员率常常为30%或以上，而在临床实践中，这一比例会超过50%。”

芝加哥市西北大学Feinberg医学院的David C. Mohr， Ph.D.及其同事将面对面的认知行为疗法相对于电话施予的认知行为疗法在初级诊疗中对抑郁症的治疗进行了比较。这项试验包括了325名罹患严重抑郁症的患者，他们是在2007年11月至2010年12月间被纳入这一试验中的。试验的参与者被随机指派接受18次的T-CBT或面对面的CBT。本研究主要的检测结果是后续治疗时（18周时）的减员情况（完成治疗vs.没有完成治疗）。本研究的次级检测结果包括了对抑郁症的检测。

研究人员发现，在第18次治疗之前停止T-CBT的参与者 (n = 34； 20.9%)比面对面CBT的参与者(n = 53； 32.7%)明显要少。在第5周前，T-CBT的减员率（n = 7； 4.3%）比面对面CBT的减员率（n = 21； 13.0%）显著要低，但在第5次至第18次治疗之间的减员情况则没有明显的差异。T-CBT患者比那些接受面对面CBT的患者所参加的治疗次数显著要多。

就抑郁症的程度改变而言，研究人员发现，T-CBT于后续治疗时在减轻抑郁症状上不比面对面的CBT差。然而，在6个月的随访期间，面对面的CBT要显著优于T-CBT。在6个月随访的时候，有19%的T-CBT参与者 相对于32%的面对面CBT参与者得到了完全的缓解。

doi:10.1001/jama.2012.5588
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Effect of Telephone-Administered vs Face-to-face Cognitive Behavioral Therapy on Adherence to Therapy and Depression Outcomes Among Primary Care Patients

David C. Mohr, PhD; Joyce Ho, PhD; Jenna Duffecy, PhD; Douglas Reifler, MD; Leslie Sokol, PhD; Michelle Nicole Burns, PhD; Ling Jin, MS; Juned Siddique, DrPH

Context Primary care is the most common site for the treatment of depression. Most depressed patients prefer psychotherapy over antidepressant medications, but access barriers are believed to prevent engagement in and completion of treatment. The telephone has been investigated as a treatment delivery medium to overcome access barriers, but little is known about its efficacy compared with face-to-face treatment delivery. Objective To examine whether telephone-administered cognitive behavioral therapy (T-CBT) reduces attrition and is not inferior to face-to-face CBT in treating depression among primary care patients. Design, Setting, and Participants A randomized controlled trial of 325 Chicago-area primary care patients with major depressive disorder, recruited from November 2007 to December 2010. Interventions Eighteen sessions of T-CBT or face-to-face CBT. Main Outcome Measures The primary outcome was attrition (completion vs noncompletion) at posttreatment (week 18). Secondary outcomes included masked interviewer-rated depression with the Hamilton Depression Rating Scale (Ham-D) and self-reported depression with the Patient Health Questionnaire–9 (PHQ-9). Results Significantly fewer participants discontinued T-CBT (n = 34; 20.9%) compared with face-to-face CBT (n = 53; 32.7%; P = .02). Patients showed significant improvement in depression across both treatments (P < .001). There were no significant treatment differences at posttreatment between T-CBT and face-to-face CBT on the Ham-D (P = .22) or the PHQ-9 (P = .89). The intention-to-treat posttreatment effect size on the Ham-D was d = 0.14 (90% CI, −0.05 to 0.33), and for the PHQ-9 it was d = −0.02 (90% CI, −0.20 to 0.17). Both results were within the inferiority margin of d = 0.41, indicating that T-CBT was not inferior to face-to-face CBT. Although participants remained significantly less depressed at 6-month follow-up relative to baseline (P < .001), participants receiving face-to-face CBT were significantly less depressed than those receiving T-CBT on the Ham-D (difference, 2.91; 95% CI, 1.20-4.63; P < .001) and the PHQ-9 (difference, 2.12; 95% CI, 0.68-3.56; P = .004). Conclusions Among primary care patients with depression, providing CBT over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression at posttreatment. At 6-month follow-up, patients remained less depressed relative to baseline; however, those receiving face-to-face CBT were less depressed than those receiving T-CBT. These results indicate that T-CBT improves adherence compared with face-to-face delivery, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.