Telephone and In-Person Cognitive Behavioral Therapy for Major Depression after Traumatic Brain Injury: A Randomized Controlled Trial

Abstract

Major depressive disorder (MDD) is prevalent after traumatic brain injury (TBI); however, there is a lack of evidence regarding effective treatment approaches. We conducted a choice-stratified randomized controlled trial in 100 adults with MDD within 10 years of complicated mild to severe TBI to test the effectiveness of brief cognitive behavioral therapy administered over the telephone (CBT-T) (n = 40) or in-person (CBT-IP) (n = 18), compared with usual care (UC) (n = 42). Participants were recruited from clinical and community settings throughout the United States. The main outcomes were change in depression severity on the clinician-rated 17 item Hamilton Depression Rating Scale (HAMD-17) and the patientreported Symptom Checklist-20 (SCL-20) over 16 weeks. There was no significant difference between the combined CBT and UC groups over 16 weeks on the HAMD-17 (treatment effect = 1.2, 95% CI: -1.5-4.0; p = 0.37) and a nonsignificant trend favoring CBT on the SCL-20 (treatment effect = 0.28, 95% CI: -0.03-0.59; p = 0.074). In follow-up comparisons, the CBT-T group had significantly more improvement on the SCL-20 than the UC group (treatment effect = 0.36, 95% CI: 0.01-0.70; p = 0.043) and completers of eight or more CBT sessions had significantly improved SCL-20 scores compared with the UC group (treatment effect = 0.43, 95% CI: 0.10-0.76; p = 0.011). CBT participants reported significantly more symptom improvement ( p = 0.010) and greater satisfaction with depression care ( p < 0.001), than did the UC group. In-person and telephone-administered CBT are acceptable and feasible in persons with TBI. Although further research is warranted, telephone CBT holds particular promise for enhancing access and adherence to effective depression treatment.

Depression Trajectories during the First Year after Traumatic Brain Injury

“…A populationbased study of depressed persons who received treatment has shown that 25% received an inadequate dose or duration of antidepressants and 50% received an inadequate dose of counseling. 63 Even if persistently depressed persons in this study received adequate treatment, high quality controlled trials of depression treatment in persons with TBI demonstrate that antidepressants 18 and cognitive behavioral therapy 19 have modest efficacy in persons with TBI. To reduce the proportion of persistently depressed people with TBI, greater efforts are needed to improve: depression recognition and treatment initiation, delivery of adequate treatment dose and duration, and research on single or combined therapies that effectively treat persons with MDD in this population.…”

“…1,19 We coded participants as having a pre-injury history of depression if they reported ever receiving a diagnosis of or treatment for depression or making a suicide attempt. We asked participants whether they ever received any of the following mental health diagnoses before injury: post-traumatic stress disorder (PTSD), bipolar disorder or manic depression, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, any phobia, schizophrenia, schizoaffective disorder, or any psychotic disorder.…”

“…Compared with the delayed depression group, the persistently depressed group was significantly more likely to be 30-44 years old (vs. [18][19][20][21][22][23][24][25][26][27][28][29] and report a history of PTSD. There were also nonsignificant trends for the persistently depressed group to have higher pre-injury rates of MDD and other mental health disorders relative to the delayed depression group.…”

“…[12][13][14] Thus far, there is mixed evidence for the efficacy of telephone counseling or antidepressants to prevent [15][16][17] or treat patients with depression after TBI. [18][19][20] A major gap in our knowledge has to do with the course of depressive symptoms after TBI. Cohort studies have produced conflicting results regarding whether depression increases 6,21 or decreases [22][23][24] over time.…”

A Pilot Study on Telephone Cognitive Behavioral Therapy for Patients Six-Months Post-Bariatric Surgery

“…Telephone interventions offer an alternate to face-to-face treatments that may overcome these challenges in delivering psychosocial support. Telephone-based psychotherapy has been shown to be effective in treating depression and anxiety [5], and has been beneficial in a range of clinical populations, including patients with Parkinson disease, chronic insomnia, and traumatic brain injury [6][7][8].…”