Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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More than words
- Michael C Smith, Helin B Smith (4 September 2006)
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Treament in absentia " Telepsychiatry"
- Jatinder Singh Randhawa (8 September 2006)
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CBT by telephone: Interesting finding
- AK Al-Sheikhli (16 September 2006)
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Economic Analysis required
- Taiwo A Ajayi (30 October 2006)
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Exploring newer frontiers in Cognitive Behavioural Therapies
- Suryanarayana Kakkilaya (1 November 2006)
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Cognitive Behavioural Therapy at a distance
- Tom P Marshall (1 November 2006)
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Dr. patient relationship
- Nabeela Nisar, E11 1NR (6 November 2006)
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Telephone Administered CBT for OCD: Some Critical Issues
- Rakhee Gupta, Nitin Gupta, Consultant Psychiatrist-South Staffordshire Healthcare NHS Foundation Trust, Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB. (13 November 2006)
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Cost-effective Treatment from NHS
- Vijayakumar M Shastry (23 November 2006)
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Knowledge of NI trials is crucial for readers
- David GT Whitehurst (2 February 2007)
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CSQ-8
- Dr. William Divin, Karina Lovell, Debbie Cox, Gillian Haddock, Christopher Jones, David Raines, Rachel Garvey, Chris Roberts, and Sarah Hadley (9 March 2007)
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Michael C Smith, SHO Ophthalmology Calderdale Royal Hospital HX3 0PW, Helin B Smith
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We read with interest the article on telephone therapy for obsessive compulsive disorder (OCD). The findings may be encouraging as many patients are unable to attend clinic due to their condition. In the study, very little difference was found between the telephone consultation and face-to-face consultation groups. The meaning of this may be twofold. It is possible that non-verbal communication has no impact on the outcome of behavioural therapy in this setting. Alternatively, in the face-to-face setting, non-verbal communication skills were not utilised to their full potential. I find it hard to believe that non-verbal communication could be such a redundant tool in the delivery of any psychological treatment. I was unable to find any evidence in the literature to support or contest the role of non-verbal communication skills in similar settings. I felt it necessary to raise this issue, as the results from the above study would suggest that we switch entirely to a telephone system for suitable patients with OCD. This has the potential of being both cost effective and beneficial to a wide range of patients. However, the full transition to telephone consultations at this time would be premature in view of the paucity of literature on non-verbal communication, and more evidence in this area would be valuable. Competing interests: None declared |
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Jatinder Singh Randhawa, Educational Staff Grade Psychiatrist, General Adult Leeds Mental Health NHS Trust, Bridge House CMHT, Leeds, LS10 2 TP
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I would say the above literature by Lovell et al ragarding telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder has brought on mixed emotions. It once again highlights on the usefulness of Telepsychiatry in delivering health care. I am sure everyone is familiar with Telepsychiatry or atleast Telemedicine ? Telepsychiatry is nothing but delivery of Psychiatry at a distance. A common example is a Psychiatrist doing a mental state examination of a patient, who didn't attend for his or her clinic appointment,on the phone.This is an example of 'real time'Telepsychiatry.Telepsychiatry can be particularly useful when the patients have to travel from far off places and where public transport system is not well organised. One example is India where majority of the people live in rural areas but only 2% of the qualified Doctors practice in the countryside. I beleive Non verbal communication (NVC) is too important to be ignored as pointed out by Michael C Smith, et al despite the fact that this study shows telephone CBT as effective as face-to-face therapy.I beleive NVC is important for formation of a therapeutic relationship.In a telephone only medium, it could be argued that exchange of emotions could be difficult or may be misinterpreted. However, Short et al, 1976 found that telephone messages contained more verbal expression of agreement or disagreement with other's opinion than those of the face-to-face interactions. It conveys the message that human communication is highly adaptive, and that non-verbal and verbal messages are interchangeable. Since telephonic conversation would deliver fewer cues than face-to- face conversation, would it amount to lower productivity ? Or is the other way round, that is, more efficient since unnecessary cues can be discarded! Telephonic CBT might be able to increase compliance with therapy in individuals who are not wanting to travel because of contamination fears. Some patients with OCD take particularly long time to get ready and might often turn up late for their appointments.In these cases, telephonic CBT will save resources.However, professionals might not feel adequately trained to deliver it on the phone and this might cause anxiety.There are issues about confidentiality as well apart from language being misinterpreted over the phone.On the positive side, telephonic CBT would mean reduced need for patients to travel, patients treated in their own less threatening home environment. Is is however important to stress how much Psychiatrists in general rely on NVC e.g, Schizophrenia with negative symptoms or depression secondary to OCD. Resistant patients might blame telephonic CBT for non- response and lose future hope. Nevertheless, Telephonic therapy does offer hope, particularly, Telepsychiatry. REFERENCES Lovell et all,Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non- inferiority trial;BMJ, doi:10.1136/bmj.38940.355602.80 Pilot studies of telemedicine for patients woth OCD; L Baer et al, Am J Psychiatry 1995;152:1383-1385 Dwyer TF.Telepsychiaty:Psychiatric consultation by interactive television. Am J Psychiatry. 1973Aug;130(8):865-9 Simon et al.BMj2000;320:550-554(26February) Paul Mclaren.Advances in Psychiatric Treatment(2003) 9: 54-61 Competing interests: None declared |
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AK Al-Sheikhli, Loc.Consultant Psychiatrist Yew Tree House,Leamington Spa,UK
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EDITOR--This was an interesting study, CBT for OCD by telephone as effective as face to face delivery, and there are many implications: 1.To see whether CBT by telephone and face to face contact gives similar results in other psychiatric disorders in which CBT is the treatment of choice 2.With a big waiting list for CBT in many areas, CBT by telephone might be a useful way of tackling that problem 3.Gives the opportunity to some therapists of working from home, out of area, out of hours, etc 4.Gives the opportunity of treating patients who find it difficult to attend due to many causes e.g, work, family, ill health, transport issues. Dr.Al-Sheikhli Competing interests: None declared |
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Taiwo A Ajayi, Staff Grade Psychiatrist Substance Misuse Clinic, Kent & Medway NHS and Social care partnership,4 Manor Road Chatham ME4 6AG
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Lovell et al's findings certainly have promising prospects for optimising CBT therapist time.I however would like to see the results of a well designed economic analysis factoring in the additional but hidden costs of this new delivery method. I note the up to half hour telephone conversations eight times in the treatmnet adding up to 4 hours of telephone conversation per patient. There is also the additional cost of postage of literature between therapists and patients. I am no skeptic, but I would like to take a more universal look at resource implications of this new method before making final conclusions.Saving therapist time does not automatically equate to a cost effective service. An economic evaluation of telephone administered CBT in comparism with the traditional face to face method is the only true umpire in this case. Given the current dismal state of the NHS coffer, I would not be too optimistic until I see the economic analysis figures. Competing interests: None declared |
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Suryanarayana Kakkilaya, Staff Grade Psychiatrist 5 Boroughs Partnership NHS Trust, Whiston Hospital, L35 5DR
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Telephone administered and computerised cognitive behavioural therapies are gaining popularity because of the cost effectiveness and easy accessibility of these modes of treatment. This paper compares the effectiveness of telephone administered CBT with conventional therapy. It is interesting to note that although the two groups were randomised, the methodology used is not explicit and noteworthy differences existed at the beginning of the trial – there were more male and married patients in the telephone CBT group. These factors may have acted as confounders to sway the result. Moreover 39% of the patients in the group allotted to the telephone Cognitive Behavioural therapy had received previous treatment as compared to 31% in the other group. The telephone CBT might have served as a booster to the previous psychological treatment. The power calculation for this study was not done and the sample size is small and therefore the results might be a type II error failing to show the difference that might have existed. The authors have implied that a 40% savings on the therapist’s time may be achieved by switching over to telephone CBT without compromising on the effectiveness. If this were to be the case, then a similar outcome can be expected from a face to face therapy spanning over 30 minutes with similar cost effectiveness. This study opens grounds for the need of a further research in this area. Competing interests: None declared |
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Tom P Marshall, Senior Lecturer in Public Health University of Birmingham B15 2TT
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If CBT offered by telephone is of similar effectiveness to face-to- face contact there is no restriction on where the therapist can be based. Indeed there is no reason why it could not be delivered by clinical psychologists in India. Competing interests: None declared |
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Nabeela Nisar, SHO Elderly Care Medicine Whipps Croos Hospital, E11 1NR
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Dear Sir, It is really encouraging to learn that Teletherapy can be so effective and can save time and money but it raises a few questions in my mind ie what about relapse?what about the incidence of relapse in people receiving Teletherapy?I would be grateful if someone would mention what is the relapse rate in people receiving teletherapy?Is it as effective in the long term as Direct face to face Psychotherapy or is this just a short term result?It can be helpful in determining if Teletherapy can replace Face to Face Clinical Sessions all together Competing interests: None declared |
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Rakhee Gupta, SHO Psychiatry St. Tydfil’s Hospital, North Glamorgan NHS Trust, Merthyr Tydfil, CF47 0SJ., Nitin Gupta, Consultant Psychiatrist-South Staffordshire Healthcare NHS Foundation Trust, Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB.
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It is heartening that CBT delivered by telephone (CBT-T) is found comparable to that by face-to-face (CBT-F). However, we would like to allude to the issue of ‘motivation’ in psychological therapies (including CBT) that has not been discussed by the authors. We suspect that all patients in the two groups probably had good motivation to undergo CBT for their OCD leading to promising results for both arms of the study. This assertion is based on the following indicators- marked distress or severity of OCD, long duration of illness, less number of patients having received any form of treatment (31%-53%), fewer patients receiving psychological treatment (31%-39%) than pharmacological treatment (47%- 53%), and low attrition rates. Treatment-naïve patients show better response to treatment (1), and the long waiting periods for psychology input in the NHS (2,3) could have acted as an ‘incentive’ for all the patients to adhere better to the CBT offered. On similar lines, it may be argued that the patients who received CBT -T were more motivated than those who received CBT-F as they had received less exposure to either psychological or pharmacological treatments. Also, it is not clear whether both groups had similar profile of OCD patients, as certain sub-types tend to show poorer response to treatment (1). More patients in the CBT-F group were on additional medications (61% vs 42%); data supports that combination pharmacotherapy and psychotherapy works best for patients with OCD (1,2) and hence, the CBT-T group may have actually been less efficacious than CBT-F group. It would have been useful if more information (especially on the waiting times for this study, and access to specialist and the local psychology services) had been presented on these variables as to how they influenced motivation or acted as potential confounders to the results obtained in the study. The authors conclude by saying that they did not have a control (no treatment) group. This could have been probably addressed by having the patients who were on the wait-list for CBT for OCD to be taken as the ‘control’ arm during the same time frame (keeping in view-the long wait periods of many months for patients to access psychological therapy in the NHS). Nevertheless, notwithstanding these caveats, CBT-T appears a promising option to research further and consider for the cash-strapped NHS (4) where patient choice (5) is assuming great importance. CBT-T offers both ‘choice’ and ‘convenience’ for scheduling of time and day of the sessions for both patient and therapist, saves on additional indirect costs related to travel and time, and hence can be a viable option for primary care to consider due to possibly lowered commissioning costs. REFERENCES: [1] Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge: Cambridge University Press, 1999. [2] National Institute for Health and Clinical Excellence. Obsessive compulsive disorder. Clinical Guidance 31. www.nice.org.uk/CG031 (last accessed 12 November 2006). [3] http://www.ocdaction.org.uk/ocdaction/index.asp?id=132 (last accessed 12 November 2006). [4] http://news.bbc.co.uk/1/hi/health/4815986.stm; (last accessed 12 November, 2006). [5] www.nhs.uk; (last accessed 12, November 2006). Competing interests: None declared |
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Vijayakumar M Shastry, Associate Specialist in General Adult Psychiatry St.Michaels Hospital, Lichfield, WS13 6EF, Staffs
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Dear Sir This is an interesting article and is cost effective treatment for the National Health Service. There are big waiting lists for CBT and shortage of trained therapists. I am not sure whether one can call it a randomised controlled trial as there were no control group in this particular study. Also reasons for drop-out from the study was unclear. I wanted to know whether this may lead to attrition bias. Telephone treatments may be of use in other psychiatric disorders and this study has thrown some light on this issue and makes professionals think about future research on teletherapy in other mental disorders. This may be useful in Indian rural settings but one needs to think about the costs involved in arranging for video conferencing, telephone installations in a typical village with lack of financial resources. Competing interests: None declared |
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David GT Whitehurst, Health Economist Primary Care Musculoskeletal Research Centre, Keele University
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I read with interest the trial by Lovell and others, and also the rapid responses this paper has generated. Although I have not worked within the OCD clinical area, I do have a particular interest in the methodology of noninferiority (NI) trials. The first thing that struck me was the large noninferiority margin - could a difference on 4.99 points on the Yale Brown scale be deemed clinically irrelevent? Given the scale has a maximum of 40, I find this hard to accept. No justification is given for the choice of 5 points. Also, analysis was based on the ITT approach. In a NI trial more information is required about the possibility of protocol violation, with the likely need for a per-protocol analysis. Although there may not have been a great deal of scope for protocol deviation in this trial, this issue should be addressed. Competing interests: None declared |
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Dr. William Divin, Research Associate University of Ulster, Karina Lovell, Debbie Cox, Gillian Haddock, Christopher Jones, David Raines, Rachel Garvey, Chris Roberts, and Sarah Hadley
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This article cites the CSQ-8 as being scored from 0 - 32. This is incorrect. Each item in the scale generates a score in the range of 1-4. It follows that the maxium score is 32 - as the authors quite rightly claim. The minimum score however is 8; unless the scale is scored from 0 - 3 . . . in which case the maximum score would then be 24. Otherwise an interesting paper. Competing interests: None declared |
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