Rates of depression tend to be higher in rural areas than in urban ones, yet rural residents may have a harder time accessing mental health care. Driving to see a psychiatrist or counselor may take hours, and wait times for an appointment may take months.
West Virginia University researcher Robert Bossarte has received a $13.3 million award from the Patient-Centered Outcomes Research Institute to compare three treatment strategies for rural depressed patients: antidepressants alone; antidepressants combined with unguided cognitive behavior therapy provided online; and antidepressants combined with guided online cognitive behavior therapy.
"Cognitive behavior therapy is a way of retraining your brain to react to things differently. It's breathing, muscle relaxation, the way you think about things," said Bossarte, who directs the WVU Injury Control Research Center.
During the unguided therapy, patients will follow the steps provided on a website to determine what exacerbates their depression symptoms and change how they respond to those triggers. For example, a patient might acknowledge feeling sad, identify money worries as the cause, realize the financial catastrophe she envisions doesn't reflect reality and gain a more accurate perspective on her financial situation-;one that doesn't cause her symptoms to flare up.
During the guided therapy, patients will check in with a coach who will walk them through the process instead. Coaches will also engage with patients to "make sure they're not having any problems," said Bossarte, who is also an associate professor in the WVU School of Medicine's Department of Behavioral Medicine and Psychiatry and teaches epidemiology in the WVU School of Public Health.
"This is more than just 'let's see if the cognitive behavior therapy works.' It's 'let's see who the therapy works for,'" Bossarte said. "Our ultimate goal is to drive down the treatment failure rate. It's precision medicine. How do we get the right kind of treatment to the right patient?"
The study will include 8,000 depression patients who live in West Virginia.
"Unfortunately, major depressive disorder is very common among West Virginia's citizens, and we have one of the highest suicide rates. As part of our mission as a School of Public Health, we are committed to serving the needs of the Mountain State. This project is focused on getting the right kind of help to those in need," said Jeffrey Coben, dean of the WVU School of Public Health and associate vice president for health affairs at the WVU Health Sciences Center.
In the future, the data that the study generates may inform an algorithm that predicts which patients should get a recommendation to try online cognitive behavior therapy. Perhaps patients who score high in impulsivity, for instance, will benefit from it more than their less spontaneous counterparts do. Or maybe depressed patients who also have anxiety disorders will profit more than others from online therapy.
Bossarte suspects that the online therapy could be a suitable treatment for depressed patients who live in rural areas and have specific psychosocial characteristics, which their study will illuminate. He hypothesizes that, for some patients, it could be a useful replacement for in-person therapy.
"It's unrealistic to think that live psychotherapy can be provided to all the many depressed patients living in rural areas," said Ronald Kessler, Bossarte's research partner on the project and the McNeil Family Professor of Health Care Policy at Harvard Medical School. "Too few psychotherapists reside in these areas. Travel times are prohibitively long to the nearest therapists. And telephone psychotherapy providers are in short supply. Online cognitive behavior therapy is a practical solution to these problems that will be effective for many patients."
Stacey Whanger also collaborates with Bossarte on the project. She manages the West Virginia Clinical and Translational Science Institute's Practice-Based Research Network. She and PBRN will help recruit West Virginia clinic sites to participate in the study.
Bossarte's award has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.
"Because depression is so stigmatized, people don't reach out. People don't like other people to think they're crazy. I'm on a mission to get people to stop thinking like that. I don't understand why we'll go to a podiatrist when our feet hurt, but we won't go to a specialist with the most complicated organ in our body," Bossarte said.
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