For Depression, Computer-Assisted Therapy Offers Little Benefit, Study Finds

It’s unlikely that your therapist will be replaced by a computer program anytime soon.

That’s the takeaway of recent study out of Britain looking at the effectiveness of computer-assisted therapy for depression.

The bottom line: The computer programs offered little or no benefit compared to more typical primary care for adults with depression. That’s largely because the patients were generally “unwilling to engage” with the programs, and adherence faltered, researchers conclude, adding that the study “highlighted the difficulty in repeatedly logging on to computer systems when [patients] are clinically depressed.”

In an accompanying editorial, Christopher Dowrick, a professor of primary care medicine at the University of Liverpool, stated what may seem obvious: Many depressed patients, he wrote, don’t want to interact with computers; rather, “they prefer to interact with human beings.” He noted that the poor result “suggests that guided self help is not the panacea that busy [primary care doctors] and cost conscious clinical commissioning groups would wish for.”

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

As part of the study, published in the BMJ, 691 patients suffering from depression were randomly assigned to receive the usual primary care, including access to mental health care, or the usual care plus one of two computer-assisted options that offer cognitive behavior therapy (CBT), a form of therapy that encourages patients to reframe negative thoughts. Patients were assessed at four, 12 and 24 months; those using the computer programs (one called “Beating the Blues” and the other “MoodGYM“) were also contacted weekly by phone and offered encouragement and technical support.

The context of all this is that demand for mental health services generally exceeds supply around the globe, and health systems are seeking ways to bridge the gap. According to the new paper, demand for cognitive behavioral therapy, for instance, “cannot be met by existing therapist resources.” So, the thinking goes, maybe a computer can ease some of the caseload. And in some cases, it works. Indeed, Britain’s National Institute of Health and Care Excellence (NICE) guidelines recommend computerized CBT as an “initial lower intensity treatment for depression….” based on studies that showed it can be effective.

However, results of this latest study may nudge clinicians and policymakers to rethink the computer’s role in therapy.

Here are the results, summed up in BMJ news release:

Results showed that cCBT offered little or no benefit over usual GP care. By four months, 44% of patients in the usual care group, 50% of patients in the Beating the Blues group, and 49% in the MoodGYM group remained depressed…. Continue reading

Darker Days: Talk Therapy May Be More Durable Than Light Treatment For Seasonal Affective Disorder

For me, it’s already started: As the darkness descends around 5 p.m., my mood starts to sink too. And it’s not even Thanksgiving.

Victims of SAD, or seasonal affective disorder, a form of depression marked by a dip in mood during the darker winter months, take note: Light therapy may help, but talk therapy may be more “durable” in the long-term.

Researchers at the University of Vermont report that light therapy (essentially, simulating sunrise by sitting in front of a device upon waking that emits high intensity artificial light, around 10,000 lux, for at least 30 minutes) was comparably effective as cognitive behavioral therapy for addressing acute episodes of SAD.

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

However, the researchers found that after two subsequent winters nearly half the subjects in the light therapy group reported a recurrence of depression, compared with just over one-fourth of those in the cognitive behavioral therapy (CBT) group.

Lead researcher Kelly Rohan, Ph.D. a professor in the Department of Psychological Sciences at the University of Vermont in Burlington, said in an interview that after two winters: “The CBT [patients] maintained their gains better, and we found a more enduring effect of the CBT treatment two years out. Fewer had recurrences of depression and, as a whole, their depressive symptoms were fewer and less intense than people with light therapy.”

Over 14 million Americans suffer from SAD, the researchers report, based on extrapolating a national number from a smaller U.S. sample; prevalence ranges from 1.5 percent of the population in southern states like Florida to over 9 percent in the northern regions of the country.

“There’s no argument that light therapy is a very effective treatment that can substantially improve winter depressive symptomsunder acute conditions, Rohan said in the interview. “But there’s an assumption that people stick to it, and interventions that require effort from people face compliance issues over time.”

The study’s bottom line, she said, is:

“I think the data show that consumers have choices — light therapy is very effective — the question is, ‘Am I willing to stick with it long term and then continue on through the whole winter and pick it up next fall through the winter?’…if so, more power to you. However, if you are willing to consider an alternative, that is CBT, it might be more durable  — you can carry it into the future like a toolbox, you’ve got coping techniques you can use over time.” 

(Full disclosure: Dr. Rohan receives book royalties from Oxford University Press for the treatment manual for the cognitive-behavioral therapy for SAD intervention.)

So how does CBT for SAD differ from therapy for general depression? Rohan says the approach is similar — with a bit of custom tailoring. For instance, the therapist might say something like: “‘We know the dark days are a big contributor to the onset of your symptoms and we can’t control that — we can’t control the sunrise and sunset. But we can control your reaction, and what you think and what you do in response to these light and temperature changes.’ ”

In general, CBT for this condition hinges on reframing the patient’s thinking about the approaching winter — away from a negative attitude about the shorter, darker, freezing, snowbound days, and toward a more positive approach, for instance: What kind of fun, frolicking things can I get out and do in the cold?

“Instead of hibernating and becoming more socially withdrawn,” Rohan said, “we try to get people more engaged in fun winter activities.”

And if you think escaping to the Caribbean will solve your problem, think again: “We don’t endorse jumping on a plane — that’s avoidance, that’s pretending it’s summer when it’s actually winter,” she said. “And dialing the heat up in your home or going to a tanning bed, we don’t advocate for that either — that’s denial, that’s never an adaptive coping strategy. We want people to take winter by the horns.”

Personally, sunshine-filled vacation therapy in winter has worked for me, but Rohan pushed me to rethink this strategy. “When you come back from a trip like that, re-entry can be really jarring,” she said. “Patients feel great when they’re there, when they come back to reality it can really bite.”

Here are some more specifics on the study, published online in the American Journal of Psychiatry, from the UVM news release:

In the study, 177 research subjects were treated with six weeks of either light therapy – timed, daily exposure to bright artificial light of specific wavelengths using a light box – or a special form of CBT that taught them to challenge negative thoughts about dark winter months and resist behaviors, like social isolation, that effect mood. Continue reading

Majority Of Young People With Depression Don’t Get Treatment, Report Finds

A new national snapshot of the state of mental health across America is, frankly, a little discouraging, especially when it comes to young people.

One startling finding from the annual report produced by the nonprofit Mental Health America: “[S]ixty-four percent of youth with depression do not receive any treatment.”

In addition, the report found:

Even among those with severe depression, 63 percent do not receive any outpatient services. Only 22 percent of youth with severe depression receive any kind of consistent outpatient treatment (7-25+ visits in a year).

I asked one of our frequent contributors, child psychiatrist Dr. Eugene Beresin, executive director of the Massachusetts General Hospital Clay Center for Young Healthy Minds and professor of psychiatry at Harvard Medical School, for his thoughts on the report.

Here, lightly edited, is his response:

First, I am not surprised. There are a number of issues not emphasized by this summary:

1. There is a huge shortage of child and adolescent psychiatrists in the U.S. Currently there are about about 7,000.

So while many parents seek help, the access to care is severely limited. Primary care pediatricians are inadequately trained in psychiatry and this has been addressed by the American Academy of Pediatrics. Their graduate training requires only two months in developmental behavioral pediatrics and few have any significant training in psychiatry. They are desperate to make referrals and often are at a loss to find qualified clinicians. Some states such as Massachusetts and New York have statewide efforts to assist them through consultation and education in psychiatry, but this only scratches the surface. Continue reading

Why To Exercise Today: It May Make Bullied Adolescents Feel Less Suicidal

How much better can exercise make you feel?

A new study suggests that the mood boost may be profound.

The nitty gritty of the study is that researchers at the University of Vermont report a 23 percent reduction in both suicidal thoughts and suicide attempts among bullied students who exercise four or more days a week. The analysis of national data from the Centers for Disease Control and Prevention showed that across the board, frequent exercise was associated with improved mood for adolescents, both bullied and not.

It’s important to note that the study shows an association only between exercise and improved mental health. Still, lead author Jeremy Sibold, an associate professor at the University of Vermont, and chairman of its Department of Rehabilitation and Movement Science, says this is an important first step. It…”shows a critical relationship between exercise and mental health in bullied adolescents,” he says. “These data do not prove that exercise will reduce sadness or suicidality, but certainly support more research in this area.”

(Nick Tonkin/Flickr)

(Nick Tonkin/Flickr)

The study, published online in the Journal of the American Academy of Child & Adolescent Psychiatry, concludes:

Physical activity is inversely related to sadness and suicidality in adolescents, highlighting the relationship between physical activity and mental health in children, and potentially implicating physical activity as a salient option in the response to bullying in schools.

An accompanying editorial, by Dr. Bradley D. Stein and Tamara Dubowitz of The Rand Corporation in Pittsburgh, says,

“…the evolving literature suggests that physical activity interventions appear to be potentially promising as preventive interventions for some children and adolescents at risk for developing mental health disorders and for augmenting more traditional interventions for children and adolescents being treated for depressive and anxiety disorders and attention deficit/hyperactivity disorder.

The “side effects” of such physical activity interventions are likely to be more positive for many children than those of many other therapeutic interventions and potentially less costly…”

I asked Sibold a few questions about the study. Here, via email, are his answers:

RZ: What’s the biggest surprise in the findings?

JS: We were not surprised really that exercise was associated with less sadness, etc., as exercise has been widely reported to have robust positive effects on a range of mental health markers.

However, our statistics were quite rigorous, and to see the positive associations extend to victims of bullying, including those who report suicidal behavior, was certainly a pleasant surprise and a first in the field we believe. It is also quite concerning that 25 percent of students overall report being bullied in the last year. This is a concern we cannot ignore in our schools. Continue reading

Stressed-Out Undergrads And The College Mental Health Crisis

In case you missed it this morning taking your possibly stressed-out kids to school, check out On Point’s excellent segment about the mental health crisis among college students.

The bottom line: undergrads are struggling, many of them suffering from mild, moderate and severe mental illness. And colleges are scrambling to figure out ways to cope, from setting up automated counseling kiosks to launching campaigns promoting the message that it’s all right to ask for help.

A special report, “An Epidemic of Anguish,” published in The Chronicle of Education is featured on the show:

“Colleges are trying to meet the demand by hiring more counselors, creating group-therapy sessions to treat more students at once, and arranging for mental-health coordinators who help students manage their own care. A couple of colleges have even installed mental-health kiosks,which look like ATMs and allow students to get a quick screening for depression, bipolar disorder, anxiety, and post-traumatic stress.

Meanwhile, the Boston Globe reports that MIT, a well-known hotbed of stress, is enhancing its mental health services for students:

Starting this academic year, the Cambridge school will provide more mental health counselors, create a drop-in center for students to talk with professionals, and make it easier for students to seek professional services off campus.

The changes come after campus officials reviewed the results of a survey administered to students in April and May, which found that 24 percent of undergraduate respondents have been diagnosed with one or more mental health disorders by a health professional.

Alli Stancil/Flickr

Alli Stancil/Flickr

The reality that many college students suffer from mental illness isn’t exactly new. Earlier this year, for instance, researchers at UCLA surveyed 150,000 college freshman and found an increase in the number of students who report they were “frequently depressed.”

I asked child psychiatrist Dr. Steve Schlozman, associate director of The MGH Clay Center for Young Healthy Minds and an assistant professor of psychiatry at Harvard Medical School, about the UCLA report back in February and whether depression among college-age kids is getting worse, and he said: “We are reaping what we sow.” He added:

The pressure we put on high school kids to get into college and the pressure then that college follows up with is highly correlated with increased rates of emotional distress that can become full-blown depression. Also, the age of onset of depression is the exactly the age of onset of college — there’s a perfect storm of stressors. Finally, there’s a greater willingness to come forward, which is good. So, despite the fact that we’re using the word ‘depression’ a little more glibly, I’d rather have that and then rule out clinical depression through appropriate channels, like college health services, than miss cases that can lead to real suffering and possibly even death.

Now, Schlozman says, it makes sense for colleges to boost their efforts to make mental health services more accessible. In an email, he writes:

It makes sound ethical, medical and common sense for colleges and universities to increase their surveillance for mental health challenges as the school year begins, and to provide easy and unfettered access for ongoing care. Ideally, a comprehensive plan that has multiple and coordinated entry points and multiple and coordinated means by which care is delivered is the best way to provide the essential help that the last two decades have shown us is sorely needed on college campuses.

Continue reading

Elderly And Drugged: Far More Psych Meds Prescribed To Old Than Young

Evidence suggests that anti-anxiety medications like Xanax increase the risk of falls in older adults, which can cause a cascade of problems. (johnofhammond/Flickr, with edits by WBUR)

Evidence suggests that anti-anxiety medications like Xanax increase the risk of falls in older adults, which can cause a cascade of problems. (johnofhammond/Flickr, with edits by WBUR)

By Nell Lake
Guest Contributor

Are we over-treating the elderly with psychiatric drugs?

That’s the natural question arising from a recent report that found adults over 65 are receiving psychotropic medications at twice the rate of younger adults. The study, published in this month’s Journal of the American Geriatrics Society, also found that elders are much less likely to get their mental health care from psychiatrists or to receive psychotherapy.

What’s the problem? First, psychotropic drugs generally pose greater risks to the elderly than they do to younger patients, and non-drug approaches, from therapy to meditation, may be as effective as psychotropic medications for some seniors’ mental disorders, without the risks.

The findings suggest that physicians and insurers should reassess psychotropic drug use among the elderly, says lead author Donovan Maust, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.

Maust’s team used 2007-2010 data from the CDC’s National Ambulatory Medical Care Survey and from the U.S. Census to compare the rates at which older and younger adults — those 65 and older, and those 18-64 — get prescribed psychotropic medications during outpatient doctors’ visits. After analyzing more than 100,000 of these doctor visits, and taking into account the fact that the younger population is much larger than the older one, the researchers found that older adults were much more likely to be prescribed psychiatric drugs for anxiety, depression and other mental health conditions. Researchers also found that these seniors were less likely to receive other types of non-drug treatment for their mental distress.

The importance of all this is fairly clear: The elderly population is booming, and seniors use the health care system more than any other demographic. So, finding safe, effective and appropriate treatments for their mental health problems is critical — for the well-being of a large swath of people, and as a policy matter.

Too Many Meds, And The Wrong Kind?

Psychotropic drugs pose both direct and indirect risks to the elderly: First, the drugs themselves can be dangerous. The American Geriatrics Society lists many psychotropic medications as potentially inappropriate for elderly patients. Continue reading

When My Mother Died: A Story Of ‘Incomplete Mourning’

By Sarah Baker

I was 8 years old and the sky was black the day my mother died.

That morning, after a five-year struggle with a brain tumor, she’d passed away at Bethesda Naval Hospital, where she had been admitted a couple of days earlier. I hadn’t seen her since.

Grieving wasn’t an option in our house. We were a “chin up, shoulders back” group led by Dad, a rising star in the Navy. At my mother’s graveside in Arlington National Cemetery, my 10-year-old brother and I stood like little replicas of John F. Kennedy Jr. 12 years earlier when he saluted his father’s coffin. There were no tears, no signs of weakness. Long periods of mourning or sadness were not in our family culture — our grief was put on hold. There were bags to pack, and new ports of call. I was Soldiering On.

The Hardest Thing

According to the advocacy group SLAP’D (Surviving Life After a Parent Dies), 1 in 9 Americans loses a parent before age 20. Of those, nearly half said it was difficult to talk about their grief and only 7 percent said a guidance counselor helped. Six out of 10 adults interviewed, who lost a parent when they were children, said it’s the hardest thing they’ve had to deal with.

Sarah Baker at age 6, two years before her mother died (Courtesy)

Sarah Baker at age 6, two years before her mother died (Courtesy)

For us, the coping mechanism of Soldiering On worked splendidly for years, even decades. I survived all of the moves due to Dad’s deployments, even thrived, people might say. I went to college, graduate school, found great jobs, married a wonderful man, and had two beautiful children. All seemed well, at least on the surface.

But years of anxiety and disassociation gripped me. Recently, though, I felt all that emotional baggage was not sustainable. My external world appeared blissful (and it was!) but my internal world reeled. I had periods of blankness, inability to focus, sleeplessness, feelings of isolation when I was surrounded by loving people; despair, longing for something else, numbness, repeating negative loops in my mind, and sensations of being half dead. These feelings came in waves — days of it followed by lightness and connection. The longest darkness lasted three months — the world drained of its colors and none of my usual “reset,” or coping, tools seemed to work.

Necessary Grief

Importantly, coping is not grieving. “There is a kind of sanity to grief,” says Kay Jamison, a professor of psychiatry at the Johns Hopkins School of Medicine and author of “An Unquiet Mind.” “It provides a path — albeit a broken one — by which those who grieve can find their way. Grief is not a disease; it is a necessity.”

Funerals and other rituals bring people together and defend against loneliness. But if the grief lingers too long, is too severe, or unprocessed, it might begin to resemble depression. It’s a fine line indeed.

I now know I had never fully experienced the pain and sorrow of my grief. Continue reading

Researchers Say They Can Lift Depression In Mice By Activating Happy Memories



You know when you’re feeling really down, or worse, in the throes of depression, and there’s always that chirpy person who earnestly says: “Just try to focus on happy thoughts; think positive!” Well, it turns out, that unshakeable optimist may have a point.

MIT scientists report that they are able to “cure” the symptoms of depression — in mice — by artificially activating happy memories that were formed before the depression took hold.

The findings, published in the journal Nature, hint at a future in which depression might be treated by manipulating brain cells where memories are stored.

MIT graduate student Steve Ramirez, the lead author on the paper, explains that while the work is tantalizing, it’s a long way from any real-world application in people:

“We’re doing basic science that aims to figure out how the brain works and how it can produce memory,” Ramirez said in an email. “The more we know about how the brain works, the better equipped we are to figure out what happens when brain pieces break down to give rise to broken thoughts. In my opinion, we’re a technological revolution away from being able to do this in humans; everything that exists currently is too invasive and not targeted enough. That said, the underlying proof-of-principles are there, as we can do these kinds of manipulations in animals. The question is how we can do this in humans in an ethically responsible and clinically-relevant manner.”

Still, he says, researchers did not expect such clear results:

“The finding that stimulating positive memories over and over actually forces the brain to make new brain cells was surprising,” he wrote. “We did not expect to have such a clean result demonstrating that artificially activated positive memories correlates with an increase in the number of new brain cells that are made.” Continue reading

Study: Even After Depression Lifts, Sufferers Face Higher Stroke Risk

(mac keer/Flickr)

(mac keer/Flickr)

In case you missed this piece on NPR today, it’s worth a listen: Harvard researchers have found that long after the dark symptoms of depression have lifted, those of us who suffered from the disorder have an increased risk of stroke later in life.

Patti Neighmond reports on the new study, published in the Journal of the American Heart Association:

Medical researchers have known for several years that there is some sort of link between long-term depression and an increased risk of stroke. But now scientists are finding that even after such depression eases, the risk of stroke can remain high.

“We thought that once people’s depressive symptoms got better their stroke risk would go back down to the same as somebody who’d never been depressed,” says epidemiologist Maria Glymour, who led the study when she was at Harvard’s T.H. Chan School of Public Health. But that’s not what her team found.

Even two years after their chronic depression lifted, Glymour says, a person’s risk for stroke was 66 percent higher than it was for someone who had not experienced depression.

The study authors conclude that to mitigate this risk of stroke, depression should be identified and treated early:

This study, in conjunction with other work confirming that depressive symptoms are causally related to stroke risk, suggests that clinicians should seek to identify and treat depressive symptoms as early as possible relative to their onset, before adverse consequences begin to accumulate.

Continue reading

Traumatic Turning Point: How The Marathon Bombing Shifted One Woman’s Depression

By Annie Brewster, M.D.

Jennifer on Marathon Monday 2013, before the runners started coming in (Courtesy)

Jennifer on Marathon Monday 2013, before the runners started coming in. (Courtesy)

Jennifer’s depression was deep and at times debilitating. For years, she tried various treatments but success was always temporary.

Something changed on the finish line at the Boston Marathon in 2013. It was, Jennifer says, “a turning point” in her life, but not in the ways you might expect.

As a marathon volunteer stationed a block from where the first bomb exploded, she witnessed the confusion and terror that ensued, and played an important role in helping one scared runner reunite with his family.

After the ordeal, Jennifer felt lucky to walk away alive. Her life goals changed that day and she says she now feels it’s her responsibility to help others. She continues to find concrete ways to do so.

Listen to Jennifer here:

She had already signed up to participate in a program at the  Benson-Henry Institute of Mind-Body Medicine at Massachusetts General Hospital the week following the bombing. Primed by her experience during and after the race, Jennifer devoured the class, which focused on relaxation techniques.  It deepened her sense of self-acceptance and gave her skills to manage her own depression, but also strengthened her resolve to help others. She ultimately went on to become a peer counselor at the institute.

Now, her central message is this: while we can’t necessarily control what happens to us in life, we can control the meaning we make of our experiences.

Jennifer says she’s determined to make the events of April 15, 2013, mean something, and to translate this meaning into action. As far as her depression, she has come around to recognizing “some of the good things about depression” — namely her appreciation for the small things in life, and her increased sense of empathy for others. “It’s like any other illness,” she says. “It doesn’t have to limit you. It’s all about making it mean something.”

Dr. Annie Brewster, M.D., is founder and executive director of Health Story Collaborative, a nonprofit in Boston.