Using Telehealth to Treat Depression--Does One Size Fit All?

Telehealth—meeting with a health care provider over the internet—is being increasingly used. Does this approach work for psychological health care? Does using telehealth for depression treatment work as well as going to a clinician’s office? The intuitive answer to this question is, “no.”

In scientific studies, especially those dealing with living subjects, we expect variability. For example, taking acetaminophen for a headache should relieve the pain, but it varies from person to person how long it takes and how much pain reduction actually occurs. Why can’t we have a treatment that works the same way for all people, every time?

Well, to continue the headache example, we have to consider some factors that are likely in play. Is this an occasional headache or does the person have chronic headaches? Is the headache brought on by stress? By sinus problems? Is it a migraine? How severe is the headache? Does the person have other medical conditions or take medications that may affect how acetaminophen is metabolized? The list of potential factors—variables—is theoretically endless. All of these factors make it very difficult to create a treatment that will always perform in the same way for all people.

Just as in the treatment of physical health conditions, we see variability in the response to psychological health conditions. After performing a clinical trial, researchers are always interested in seeing who responded better to treatment—males or females, younger or older patients, etc. This is usually done by comparing the amount of change in each group; those that had more change responded better to the treatment. Note, however, that just like our overall expectation that acetaminophen will improve a headache, these differences normally reflect a change on average. So, just like they say in the world of infomercials, “individual results may vary”. Thus, we have what we think will happen (the average) and individual variability.

Our T2 research team recently completed a study that looked at how using telehealth to treat depression—providing psychotherapy using videoconferencing over the internet to patients in their homes—compared to the traditional practice of going into a therapist’s office. Well, it turned out that telehealth, on average, could improve a patient’s symptoms, although not as much as the improvement seen in the in-office group.

Why would there be a difference in how well the treatments worked? One possible explanation is called “therapeutic alliance,” which is a fancy way to say that folks who engage with someone in person would have a better relationship and thus have more commitment to the therapy. Another is that technical problems affected the internet group’s access to the intended treatment (had a bad connection, lost the connection, etc.). Both of these explanations could be valid, but they are difficult to test.

But after some statistical analysis (I’ll spare you the details), we did indeed find a difference between two groups—one group of participants who initially had mild-to-moderate symptoms before treatment and one group that initially had much more severe symptoms. In the mild-to-moderate group, there was no measureable difference between the telehealth and the standard, in-office approaches to treatment (as the study team thought might happen for the overall study finding). In contrast, the group with more severe symptoms responded better to the traditional in-office approach compared to telehealth.

The take-home message from all this is that, similar to other areas of medicine, every case is different and individual factors—like severity—should be considered in deciding how to proceed with patient care.

Derek Smolenski, Ph.D. is an epidemiologist & quantitative methodologist in the Research, Outcomes & Investigations division at the National Center for Telehealth & Technology (T2)

The views expressed are those of the author and do not reflect the official policy or position of the National Center for Telehealth & Technology, the Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, the Department of Defense or the U.S. Government.


Read other posts by Dr. Derek Smolenski