'Telepsychiatry' Works for Depression

[Mizmoon]

When people with depression can't easily get to a psychiatrist's office, they can be helped by telepsychiatry -- that is, remote treatment delivered over personal-computer-based videoconferencing equipment and cameras mounted on the monitors.

In a new study, patients treated through telepsychiatry were as satisfied and their symptoms resolved as early as those who were treated in person.

Dr. Paul E. Ruskin, a psychiatrist at the VA Maryland Health Care System in Baltimore, and his team enrolled 119 veterans with depression in a clinical trial involving eight therapy sessions over 6 months. Fifty-nine patients were assigned to telepsychiatry, and 60 were treated in person.

Depression scale scores were halved, at least, in 49 percent of patients in the remote group and 43 percent of those in the in-person group, a difference that was significant statistically.

http://story.news.yahoo.com/news?tmpl=story&cid=571&e=6&u=/nm/depression_treatment_dc

[ret5hd]

1. The next question to be answered...

(and maybe it already has) is:

will talking to an untrained but caring individual, either "tele" or face-to-face, have the same effect?

In other words, is merely having someone pay attention to a depressed person going to have an effect?

[Mizmoon]

2. You hit the nail on the head

I read about a man who advertises himself as "a friend to talk to". He charges a certain price per minute and says right up front he's not trained to do anything but be nice to people. He gets calls every single day.

The psychiatric community went wild and tried to make him stop.

The real question is: why?

[Philostopher]

3. I think this has been shown before.

I didn't see anything in the article about whether these people were being treated solely with talk/teletherapy or if this was an adjunct to treatment with prescription antidepressants. Wonder what the difference would be if so/not?

I think the combination of someone paying attention and the feeling that, by using technology to affect the teleconference talk therapy, one is 'doing something' probably does help. Often, depression makes you feel alienated.

However, having had this experience myself, I also know that 'dumping crap on people I love' was one of the things I had a very hard time with, not so much when I did it but after the fact. The guilt, in other words, sometimes flattened out any positive effect I got from talking to family or friends. The attention and advice of someone who's not invested in your situation sometimes is the only thing that helps, especially if guilt and one's inability to meet up to one's responsibilities is part of or aggravates the problem. (edit) I guess it wouldn't necessarily have to be a licensed therapist, in some cases, but somebody you trusted who wasn't going to be hurt or inconvenienced by the things you said.

[soothsayer]

4. Talk therapy and drug therapy have the same success rates

Used to be thay'd give drugs to minorities and lower class people and would offer talk therapies to white, straight, wealthier folks. Now everyone gets drugs, or more people do anyway.

[HuckleB]

7. CBT and SSRIs have about the same success rates.

CBT (Cognitive Behavior Therapy) has been shown to have about the same rate of success as simply SSRI treatment. However, no other talk therapy has yet been shown to have anywhere near the same level of success. Further, for those facing true, difficult to treat major depression, combined CBT and SSRI treatment has shown to lead to an almost 100 percent recovery, while offering one or the other only typically leads to a 60 percent recovery.

[A_Possum]

11. My experience

Was that talk therapy did nothing. SSRI's had excellent effect after 6 mos but then effect began to wear off.

What really worked in the end?

Getting offline.

Odd, huh? But now I believe that certain things in modern society, like TV and participatory internet use (forums, chats, etc.) tend to cause the brain to re-wire itself to demand instant gratification in the addictive sense. The brain keeps scanning and scanning for the gratification and when it doesn't come, the anxiety sets in, then a new gratification relieves the anxiety and the pattern starts to get wired in and starts on a downward spiral into depression.

Obviously this is only one factor in depression. Being caught in a "no-win" situation is another. (IE, studies of dogs given random electric shocks in their cages became depressed and wouldn't even leave cage when door was opened, vs dogs given shocks that they could escape by figuring out the pattern. Not that I like this kind of abuse in studying animals, but the study exists.)

I suspect the success of CBT relates directly to giving the individual some sense of control over the situation, which starts the spiral the other way.

[HuckleB]

12. I don't think you're the first.

There are more and more studies about online addiction, but I'm not sure if anyone has done the work to connect it to things like depression and anxiety. Still, we know the connection of other addictions (gambling, alcohol, drugs, an overindulgence into other escapes), so one can make a fairly educated guess that the comorbidity of online addiction and depression or anxiety may be fairly significant.

I think your explanation of the gratification piece is a very educated guess about what may be going on -- though, of course, it differs with the individual. Like any addiction used to relieve depression or anxiety symptoms, yeah, it provides gratification, and then the person's "automatic thoughts" (to use a CBT term) keep that person going back for more, even though the search for gratification, for the "high," if you will, is actually leading the person further and further down the road into a deeper depression or anxiety. I can attest to having worked with a number of adolescents whose social anxiety (once typical for their age) became severe and debillitating after the family went "online." It appears that the teens spent so much time online, because it was more comfortable for them that they spent less and less time in interpersonal contact with others, which led them to dread those situations to the point of panic attack in a couple of situations. Yes, this was only one part of the equation. However, limiting time online ended up being a huge factor in turning things around for these adolescents. I don't know if any of the other treatments would have done a thing, if online time hadn't been limited.

Anyway, thanks for sharing your wonderful insights. Great post. Best to you.

[A_Possum]

13. LOL, which reminds me, I'd better get offline

DU is an absolute killer if I don't take care. Especially now!

Thanks, and good work on your side.

[soothsayer]

15. Very interesting. I wish my depressed girlfriend would get into therapy

in addition to her antidepressants.

[HuckleB]

16. That's a hard situation.

I don't envy you at all. My wife dealt with me from that end of things for years. Even as someone in the field, and someone who knew that his genes were prone to the depression/bipolar/anxiety diagnosis (my brother committed suicide, after facing depression, and possibly bipolar disorder), I kept myself away from treatment (other than a year focused on grief after my brother died), despite ever-increasing symptomology going back to my high school days. I waited until I was practically frozen, doing only the absolute necessities to get through life while hiding my state from my wife, friends, family and colleagues. Only after I allowed the bills to go unpaid for some time did my wife have the leverage necessary to get me into treatment. I have been doing very well for some time now, after an initial treatment of Lexapro, followed a few months later by CBT. I'm now off the medication (though I thank it for helping me through, getting me back to base), with infrequent refocusing based on the principles of CBT keeping me quite balanced and happy.

Anyway, there are a number of books out for loved ones who live with someone with depression:

++"What to Do When Someone You Love Is Depressed" by Mitch Golant and Susan K. Golant

++"How You Can Survive When They're Depressed: Living and Coping With Depression Fallout" by Anne Sheffield

++"Depression Fallout : The Impact of Depression on Couples and What You Can Do to Preserve the Bond" by Anne Sheffield

++"When Someone You Love Is Depressed" by Laura Rosen and Xavier Amador

I have not actually read any of these books yet, so I can't recommend one over another. However, I gave a book that I have read to my wife as I entered treatment because I felt that it gave a very powerful, responsible look at what depression is all about. That book is:

++"Unholy Ghost: Writers on Depression" edited by Nell Casey

Also, while I cannot recommend a trial of actual CBT with a professional for most people with Major Depression enough, if a loved one refuses to go to therapy but is open to reading, the one and nearly only self-help book that I ever recommend is:

++"Feeling Good: The New Mood Therapy" by David D. Burns, MD

I often use the book as part of CBT treatment with adolescents and young adults, depending on the patient. And I often send the book home with patients who've completed the initial CBT treatment. It's based on the hard-science of CBT research, and I've consistently gotten rave reviews from patients who read it and use it.

Best to you.

:hi:

[soothsayer]

23. Hey, thanks!

This is really helpful advice. I had no idea there were books like that for me (guess I should have figured, but it never occurred to me).

You rock!

[HuckleB]

24. You're welcome.

Good luck.

¡Salud!

[AndyTiedye]

8. Maybe That's What DU Is For

and many other Internet sites as well.

Curious that the remote therapy fared better in the survey than the real thing.
Perhaps a lot of people are used to doing this by computer.
Or maybe it's just that all doctors' waiting rooms are depressing places.

[HuckleB]

10. It's one study.

One actually can't make much of it until it's been replicated across populations.

[HuckleB]

5. Certainly, having support helps.

In fact, those who have friends and family around them are less likely to develop depression -- support is a wonderful anti-risk factor, if you will -- and, those diagnosed with Major Depression are more likely to lead typical, active lives if they have a strong support of folks around them. However, an untrained person doesn't know when something more is needed. Failing to diagnose signs that someone is heading somewhere that will seriously affect that person's life and those that said person is responsible for could be disastrous. In addition, Further, the one therapy that has been shown to provide strong results for those diagnosed with true Major Depression, Cognitive Behavior Therapy, can't be offered by an untrained person. Major Depression is a biological-chemical disorder, and those who face it deserve the same professional treatment that anyone facing such a disorder get. I wouldn't send my diabetic grandma to a good friend to treat her diabetes, nor would I contradict that notion by sending my anxiety disordered half-uncle to said friend. He deserves the same level of professional treatment that she does.

[tlcandie]

6. So, maybe all those unemployed Americans can now get a cell

phone and charge per minute for caring phone calls?

I know people are relieved to have someone listen n/m whether something is resolved or not. It is just a relief to get it all out to someone who has nothing at stake in the matter and is more objective.

[HuckleB]

9. More on Telepsychiatry from the Canadian Journal of Psychiatry: Jan '04.

Psychiatry, Technology, and the Corn Fields of Iowa
http://www.cpa-apc.org/Publications/Archives/CJP/2004/January/guesteditorial.asp

Clinical and Educational Telepsychiatry Applications: A Review
http://www.cpa-apc.org/Publications/Archives/CJP/2004/January/hilty.asp

The Internet’s Impact on the Practice of Psychiatry
http://www.cpa-apc.org/Publications/Archives/CJP/2004/January/styra.asp

[Radius]

14. Real Disease

Some depression is caused by brain chemical imbalances. Some people do not respond at all to CBT.

In some people depression is medical and just as "real" as cancer. There are different types and severities of depression.

SSRI's like zoloft and paxil are one of many treatments for depression.

Others do not respond to these drugs and require other drugs to stop symptoms.

Face to face treatment with a psychiatric doctor reduces the risk of suicide. This is a tried and effective method. Teleconferences, may raise serious ethical questions.

The web is a great tool to help people understand how to live with depression and help with their treatments.

[Mizmoon]

18. That's not proven

It's likely. There are studies that point strongly in that direction, but it is not proven that depression is caused by a "chemcial imbalance".

The problem is that even if it's proven beyond a doubt that some people are depressed due to chemistry, then society starts to assume that all emotional difficulties are chemical. And then no one gets the emotional support that talk therapy offers because the HMOs decide that pills are all they'll cover.

I am certain (in my own unscientific way) that some people really are depressed because of the usual litany of crap that life has to offer: abuse, rape, unloving parent(s), missing fathers, etc.

[skygazer]

19. My theory and it's only a theory

Is that certain people have a predisposition to depression/bipolar. Often it is latent but crops up when the person experiences major stress situations (death in the family, poverty, crime victim, whatever).

One of the most difficult things to deal with in regards to depression/bipolar is the lack of coping mechanisms to deal with stress. "Normal" people have those mechanisms - I, who have suffered with bipolar illness virtually my entire life, do not. Being unable to cope with the stress creates still more stress. It turns into a very vicious cycle especially when you are undiagnosed and so don't know what the hell is going on! (20 years, man - I'm still amazed I didn't just blow my head off and get it over with)

What helped me the most was recognizing that I'm never going to be "cured" - but I can learn to live with it. I took anti-depressants for a number of years and they helped as did seeing my shrink. But what helped the most was figuring out my own coping methods - methods that would work for my unique situation.

For example, I cannot argue in the heat of passion. If I have a dispute, I have to step away from it, marshal my thoughts, decide if I really have a case or if I was overreacting and then when I have my head straight, rationally and calmly put forth my opinion. Naturally, I can't always do that but i can with loved ones and they are the ones with whom I get stressed when arguing.

[HuckleB]

20. There are theories, and then there are theories.

However, the genetic link to depression and other mental health disorders via family and twin studies is as strong as the links for cancer, heart disease and other medical disorders, where folks don't spend much time hemming and hawing about whether or not it's "just theory." The risk factor is clear enough to recommend lifestyle changes, if needed for those folks. And the same really should be honored when it comes to mental health, IMHO.

Is our knowledge of the specific biochemical exchanges still in its infancy? Oh, yeah. No doubt about it. However, we have been able to see changes in brain chemistry via medication and CBT that correspond to changes in mood and behavior. Thus, it's fairly clear that biochemical changes are involved, even if one is talking about traumatic grief or PTSD, where a less studied theory corresponds to your point about differences in coping mechanisms, as the reactions to the same trauma vary greatly over any set of people.

Anyway, you bring up a wonderful point. Medication can and does help many people, as can certain types of therapy, and social supports are almost a must for those dealing with mental illness, but the person facing the disorder who recovers and lives most typically in the world also learns to recognize that which puts him or her in danger of recurrence. And that person often recognizes those things that help keep his or her mood stable.

Thanks for your wonderful post. Best to you.

----------

Just for reference, here are a couple of pieces on the biology of depression and suicide:

Why? The Neuroscience of Suicide:
http://www.sciam.com/article.cfm?articleID=0006AF90-5BC7-1E1B-8B3B809EC588EEDF&pageNumber=1&catID=2

The Neurobiology of Depression:
http://www.lib.calpoly.edu/infocomp/modules/05_evaluate/WIC2b.html

[Mizmoon]

21. Maybe yes, maybe no

This sort of mixed up statement from the APA to Mindfreedom.org makes me have my doubts. They seem awfully sure that mental illnesses are caused by biology alone, but then admit they can't prove it.:

"... It is unfortunate that in the face of this remarkable scientific and clinical progress, a small number of individuals and groups persist in questioning the reality and clinical legitimacy of disorders that affect the mind, brain, and behavior. One recent challenge contended that the lack of a diagnostic laboratory test capable of confirming the presence of a mental disorder constituted evidence that these disorders are not medically valid conditions. ..."

"Brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group.

"Ultimately, no gross anatomical lesion such as a tumor may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. ...

"In the absence of one or more biological markers for mental disorders, these conditions are defined by a variety of concepts. ...

"As noted in the Diagnostic and Statistical Manual of Mental Disorders, which is published by the APA, the lack of a laboratory-based diagnostic test is not unique to mental and behavioral disorders. ...

"The mapping of the human genome already is spurring the search for genes and gene variants that singly or in combination may confer risk for the onset of a mental disorder....

"Thus, mental disorders may well be shown to be emergent properties of multiple systems that have gone subtly awry. ...

"The lack of a laboratory-based diagnostic test for mental disorders does not diminish the irrefutable evidence that mental and behavioral disorders exact devastating emotional and financial tolls on individuals, families, communities, and our Nation. ... "

Said Oaks, "The APA statement uses words such as 'complex' and 'subtle.' There's little that is complex or subtle about today's psychiatric system. We are pro-choice, and many of our members choose to take psychiatric drugs. But the current psychiatric system is predominantly one thing: drugs, drugs, drugs, drugs, drugs, drugs, and drugs, often given coercively or even forcibly. Families deserve much more."

http://www.mindfreedom.org/mindfreedom/hungerstrikeapa2nd.shtml
------------------------------------

[HuckleB]

22. I'm not completely sure what your doubts are about.

Whether biochemistry and genetics play a part in mental illness or whether you think practitioners treat only with drugs?

No, we haven't yet been able to say that some specific brain scanning shows that someone has bipolar disorder or depression. There are many reasons for this. But the biggest reason is that the biochemistry of the brain is in constant flux. Mood fluctuates with everyone, but it fluctuates to a much greater degree in those facing such disorders, and this has been noted via brain scans. Further, damage via brain scan markers has been noted in studies of those who've had a number of manic and depressive episodes over time, meaning that a deterioriation of brain matter and function has been noted in untreated and undertreated patients over time.

Finally, I'm not sure that I would have much faith in an advocacy organization that makes the type of final statement offered by Oaks. I know of no psychiatric provider who focuses on drugs first or only. And I certainly know of no provider who coerces patients into taking drugs. I'm not saying that some don't exist. Like any profession, there are good and poor providers. But I can't sit and look at such a sweeping generalization without saying, "Hey, that's a sweeping generalization without any research to back it up." On the other hand, the biochemical side of the equation with mental health disorders has a great deal of research to back it up. Do we need to continue to do research in order to understand it further and further? Heck, yeah, we do, and we'll likely change our current view of it in time, as we learn more. That doesn't mean that a responsible practitioner isn't going to use what we do know in practice. And, yes, responsible practice includes assessing for the environment. Always has, and it always will.

Thanks for your post. Best to you.

[bobthedrummer]

17. Ever hear and/or see the novelty effect in action?

:+

[HuckleB]

25. NPR: (mostly audio) Clues to Depression Sought in Brain's Wiring

http://www.npr.org/features/feature.php?wfId=3866330