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 patient-reported 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.

Trial registration: ClinicalTrials.gov NCT00878150.

Keywords: TBI; behavior; clinical trial; head trauma; rehabilitation.

Figures

FIG. 1.

Flow of participants in the trial. CBT, cognitive behavioral therapy; MDD, major depressive disorder; PHQ-9, Patient Health Questionnaire-9; SCID, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).

FIG. 2.

(A) Mean HAMD-17 depression score for CBT and Usual Care groups. (B) Mean SCL-20 depression score for CBT and Usual Care groups. CBT, cognitive behavioral therapy; HAMD-17, 17 item Hamilton Depression Rating Scale; SCL-20, Symptom Checklist-20.

FIG. 3.

Percent of participants reporting that their depression was much or very much improved on the Patient Global Impression Scale. CBT, cognitive behavioral therapy.