Is Distance Treatment the Wave of the Future?

With advances in technology, distance learning on college campuses has exploded over the last decade.  And as time passes, the mental health community is taking note.

Students want to study when they want and how they want.  Distance learning makes education available to those who wouldn’t otherwise be able to get off of work, travel to class or spend hours in lectures.  

That same increase in convenience and availability could have a real impact for people seeking psychological treatment. Is distance treatment ready to take off?

People who must maintain jobs, care for children or aging parents, don’t have cars or access to public transportation or want to learn material that is not offered where they live can all benefit from distance learning. These are often the same reasons people struggle to access mental health services.

And there is a large body of research that suggests distance learning and traditional classroom learning provide the same quality of education. Distance learning is no longer considered a sub-standard educational option.

So, how can these benefits apply to receiving psychological treatment?

Treatment available online or at a distance could certainly help people with difficulties in getting to therapy sessions and incorporating treatment into a busy lifestyle. It would also enable people to access specific treatment modalities not otherwise available to them.

And, according to the American Psychological Association, psychologists have begun using electronic communication such as email, Skype and various forms of videoconferencing to augment treatment. But, while technology surges ahead, licensing laws and guidelines for providing safe and ethical distance treatment are still catching up.

A recent article reporting on the use of phone therapy in Monitor on Psychology suggests that talking on the phone with a therapist can provide the same, or even better, results for some.

In this study, conducted by University of Cambridge researchers, British adults with mild and moderate depression and anxiety disorders who received cognitive behavioral-based therapy via the phone benefited as much, if not more, than those who received face-to-face therapy. Those with severe symptoms did not see the same results.

This study also found that telephone therapy was less expensive than traditional therapy and was conducted as part of a national initiative in Britain aimed at increasing people’s access to therapy.

The telephone is only one of many options for providing distance treatment. The number of mental health tools available is rapidly increasing. And many in the field agree that it’s time for practitioners to embrace technology and what it has to offer in delivering interventions.

One-on-one treatment cannot be replaced.  Nor should it.  However, the need for treatment providers to meet the changing and growing mental health needs of the population has caused the ΑΡΑ Insurance Trust and the Association of State and Provincial Psychology Boards to launch a task force to develop guidelines for tele-psychology practice.

So what are some of the alternatives to one-on-one therapy?  According to a cover story in the APA Monitor they include the following:

  • Behavioral intervention technologies, such as those that deliver care via the Internet or mobile phones
  • Computer programs for depression and other disorders, which typically teach principles of cognitιve-behavioral therapy or some other evidence-based treatment

Although these treatment options are appealing and there is a growing body of research to suggest that many are effective, it is important to proceed with caution.  It is essential to ensure that individuals get the right treatment and that treatments offered have been studied and found effective.

We Underestimate Our Changes: The End of History Illusion

We Underestimate Our Changes: The End of History IllusionIt’s like déjà vu all over again. ~Yogi Berra

Yep. That’s me in my fabulous Nehru tux getting ready for my prom date. I was about as spiffy then as spiffy could be. The tux was rented, but I had my regular Nehrus in the closet. They were next to my bell-bottoms, tie-dyes and 8-tracks.

What happened?

The Nehru went out of style around 11:55 p.m. the night of the prom and I had to hang on to my bell-bottoms and tie-dyes for about 30 years for them to come back around into fashion. The 8-tracks? They gave way to those newfangled cassettes.

How could I have been so wrong about the future of Nehrus and 8-tracks? Actually, when I think about it, I was wrong about a lot of things: The Afro perm I thought would look spectacular on me forever, the Beatles never breaking up, my best friend Kevin and I being pals for life, the Osborn 55-pound “portable” computer, and the 8-track tape player (which cost me a week’s salary) I had installed in my car. Naturally I thought my prom date would never change.

But in spite of my convictions at the time I was about as wrong as wrong could be. The good news is I am not alone.

Research recently reported on in the New York Times about a study on self-perception published in Science shows that individuals at every age and demographic make this kind of error: They call it the End of History Illusion because at each age we tend to underestimate the changes we will go through in the coming decade — even when we can point to all the changes we’ve been through in the last 10 years.

We think — somehow — that we have arrived at a more evolved plateau of being. We tend to think we are in a good enough place, perhaps even somewhat satisfied, and that things are not going to change that much. This builds on research that shows we do better at remembering who we were than predicting how much we will change. That brings us to the bad news.

I am (we are) about to do it all over again. Right now the chances are we are thinking the same thing about our future — we believe we are going to live, love and long for where, who, and what we are thinking about right now. But the research says it just ain’t so. This too is a transient state.

Professor Daniel Gilbert and postdoctoral fellow Jordi Quoidbach of Harvard and Timothy D. Wilson of the University of Virginia studied over 19,000 participants ranging in age from 18 to 68 in an online questionnaire. Each phase of life group underestimates how much they are likely to change in the coming decade. In other words, the research demonstrated that at every age we describe more changes in the past 10 years than we would have predicted a decade ago.

According to Gilbert, “What these data suggest, and what scads of other data from our lab and others suggest, is that people really aren’t very good at knowing who they’re going to be and hence what they’re going to want a decade from now.”

How could this be? Mounting evidence indicates that we are influenced by what is happening to us now to the point that it creates a distortion of what we want and what will make us happy in the future. These findings were made popular by Daniel Gilbert’s bestselling book Stumbling on Happiness . He noted that there is a cognitive bias as to what makes us happy. This bias makes us predict very poorly what will make us happy in the future.

It is a hard pill to swallow. But the fact remains that we tend to make systematic mistakes about what is going to make us happy downstream. The advice? Don’t imagine your future. Use others’ experience to chart your course. We have lots of data about what people experience in different life stages. This is a more realistic guide to how you are going to feel once you have those experiences – not your own imagination of what it will be like. (In other words, hold off on that tattoo you were thinking of getting until you talk to someone who has had one for a while.)

Or you can simply remember the words of Yogi Berra: The future ain’t what it used to be.

Additional Reading

Quoidbach J., Gilbert, D.T., and Wilson, T.D. The End of History Illusion. Science 4 January 2013: 96-98. [DOI:10.1126/science.1229294]

Kaiser Permanente’s eCare for Moods Racks up Another ‘Win’

Kaiser Permanente's eCare for Moods Racks up Another 'Win'In the last decade, Kaiser Permanente launched a web-based service known as eCare for Moods, meant to help support patients within their health care system with bipolar disorder. Over the years, there’s been some research to support the use of this online tool to help improve patient outcomes.

In the November 2012 issue of Psychiatric Services, another study was published demonstrating the effectiveness of this free online tool for Kaiser Permanente customers. The study, by Hunkeler et al. (2012), found that depressed patients who had access to and used the eCare system had better outcomes — reduced depression and better overall health.

But although the research team clearly believes this is a “win” for eCare for Moods, after examining their data, I’m not so sure. If it’s a win, it’s more of a statistical win than a win for reducing a patient’s depression symptoms.

First, let’s get out of the way the fact that more than half of the study authors (out of 12) are affiliated with Kaiser, the publishers of the eCare system (parts of which Kaiser has also applied for patents, suggesting a potential revenue motive underlying some of this1 ). Obviously, when you work for an organization and are researching that organization’s tool for effectiveness — and possible later license or such — there might be some… ahem… incentives for a positive finding.

The study was designed to measure depression symptomology of participants who were divided into two groups. One group would have access to Kaiser’s proprietary eCare for Moods online web-based support and messaging system, in addition to their usual mental health care. The other would have just the usual mental health care provided by Kaiser. This design helps ensure that the primary difference between the two groups is the eCare for Moods program.

The program itself is comprised of a secure, password-protected website that provides personalized self-monitoring tools, secure messaging with the patient’s eCare manager — a trained psychiatric nurse — 8 depression psychoeducational modules, an appointment calendar, and a monitored discussion group (which you could only access after completing all 8 modules). eCare was only offered during the first year of the study. The second year of the study was just ongoing assessment of how the two groups were still doing, to see if the effects of eCare — if any — wore off over time.

How participants were doing was measured in telephone interviews after the initial interview was conducted in-person. The interviews included a number of different health surveys and questions designed to measure progress.

Which brings me to the second nitpick — why didn’t the study authors use a standardized and recognized measure for depression symptoms? Instead, these 12 researchers decided to make up their own, with no rationale for doing so (and no psychometrics provided on their made-up depression scale):

All interviews included an assessment of depressive symptoms experienced over the previous two weeks with questions adapted from the SCID. This provided a psychiatric status rating of the severity of current depression on a 6-point scale derived from the research diagnostic criteria2

Worse, the interviewers then had the subjects recreate a week-by-week blow of their mood for the previous 6 months. By memory. Could most people accurately recall how they were feeling three weeks ago — much less 3 months ago?

So the researchers were reliant on accurate memory recall to fill in the blanks every 6 months. It’s not clear why they didn’t simply have participants keep paper-and-pencil journal logs or use some other more frequent data recording method if they wanted weekly data tallies.3

Weird.

Depression Scores Decrease — for Everyone

The third problem is that the average depression score at the baseline of the study was 3.88 (eCare group) or 3.65 (usual care group). According to the researchers, depression is scored as: “3, moderate impairment; 4, marked impairment but below DSM-IV criteria for [a depression] episode.” In other words, the average of the participants was somewhere below the threshold to actually diagnose anything but the mildest of depression.

But if you think that’s bad, wait — it gets worse.

After a full year of treatment, the eCare group still averages a 3.00 — moderate impairment (technically, still depressed). They’ve dropped nearly a full point on the scale, but that’s it. According to the criteria, they’re still pretty much as depressed as they were when they started (as a group). The usual care group after one year looks pretty darned similar — a 3.10. While they’ve only dropped a half point (since the group wasn’t as severely depressed as the eCare group), their improvement is less impressive. But again, as a group, still depressed.

At the end of 2 years, no statistically significant change occurred in the eCare group — now it’s at a 2.95 average score. Same with the usual care group — now at a 3.11.4

Now, unfortunately, the clinical trials record doesn’t note what specific primary outcome measure they had planned to use. So we can’t know if they decided to change the primary outcome measure because it was even less impressive than what we’re seeing here.5

That’s okay — the researchers had another way to make these results look more impressive than they are. They also measured the “presence of depression” (as though depression was like an off/on switch). Any score less than 3 on the PSR means depression isn’t “present” any longer. Score 3 or higher and you’ve still got depression.

If this sounds arbitrary, that’s because it is. It is one of the ways researchers today get around the fact that a treatment isn’t really as effective as they hoped it would be. (Of course, the eCare group came out on top in this measure.)

Summary

The upshot? Here’s a study demonstrating the statistical effectiveness of a treatment intervention supplement — eCare for Moods — that likely had very little real world benefit for the patients who were using it. One of the areas that stand out in the data with a difference between the two groups — learning new coping skills — could be attributed to the psychoeducational modules the program offered.

These modules, of course, could be offered to the general public today and help potentially thousands learn new coping skills.

The eCare system itself has problems with keeping its audience. While 90 percent of patients logged into the system during the first 6 months, that dropped to under 50 percent in the next 6 months. Only 4.6 (on average) of the 8 educational modules were completed by participants — less than half of participants completed the full 8 (a problem common among virtually all online psychoeducational interactive learning modules).

While I appreciate that eCare for Moods can be a helpful supplement to people with mood disorders — such as depression or bipolar disorder — I feel like this research team may have overreached in extolling the benefits of the program. I’m not so sure that weekly depression severity was significantly different from the usual care group, given the data presented in this article alone.

 

References

Hunkeler, E.M. et al. (2012). A web-delivered care management and patient self-management program for recurrent depression: A randomized trial. Psychiatric Services, 63, 1063-1071.

 

Footnotes:

  1. Yes, even non-profits can have a revenue, if not profit, motive.
  2. Criteria, I should note, that were first proposed back in 1978 — long before the DSM-III-R made the scene. The researchers list no rationale for using this depression scoring method — as opposed to one of the well-researched and regularly-used depression measures. The researchers also fail to acknowledge this as a limitation in the article.
  3. The researchers make no note of this methodology concern in their limitations discussion. Ideally, the study would be designed to incorporate data directly from patients themselves, without retrospective memory coming into play, or the potential bias of the interviewer.
  4. p = 0.047 in a time-by-treatment repeated-measures design
  5. This study took a really long time — more so than usual — to make it into publication. This study was begun in 2002 (and was supposed to include bipolar patients too) with data collected primarily in 2003 and 2004. Its results were first presented at a conference in 2009, and it finally appeared in a journal in late 2012. Draw your own conclusions.

The Strange & Surprising Science of Sleep

The Strange & Surprising Science of SleepIn his book Dreamland: Adventures in the Strange Science of Sleep, author David K. Randall calls sleep “one of the dirty little secrets of science.” That’s because despite spending almost a third of our lives sleeping, we don’t really know much about the process of sleep.

In fact, Randall, a senior reporter at Reuters, notes that sleep is one of the youngest fields in science. Until the 1950s, researchers believed that our brains remained quiet during slumber.

But the discovery of the stages of sleep shattered this perspective. For instance, our brains are just as active in REM sleep — aptly named rapid eye movement because our eyes shift rapidly against our lids — as they are when we’re awake.

In Dreamland, Randall shares a slew of these fascinating, surprising and eye-opening facts, anecdotes and research studies. These are a few curious tidbits from his book.

Our Normal Sleep Isn’t So Normal

Today, we think that sleeping through the night is a sign of normal and healthy slumber. In fact, people who wake up around the same time every night think their sleep is fractured — and that something is wrong, Randall writes. And when they complain about this concern to their doctors, they probably walk away with a sleeping pill, he says.

But segmented sleep has actually been the norm for thousands of years — that is, until the advent of artificial lighting. In the 1980s and ‘90s, history professor Roger Ekirch began seeing interesting patterns in his book collection, which included tales and medical texts: references to “first sleep” and “second sleep.”

Psychiatrist Thomas Wehr also began seeing strange results in his sleep experiment: After participants, who were deprived of artificial light for up to 14 hours, caught up on their sleep and felt more rested, they’d wake up around midnight and lie awake for about an hour, and then fall asleep.

In another study, Wehr found that during that hour awake the brains of participants were churning out higher levels of prolactin. This hormone reduces stress and relaxes the body after orgasm, according to Randall.

Before Thomas Edison invented the light bulb, people would fall asleep after sunset. Then they’d naturally wake up around midnight for about an hour. During that time individuals might do anything from praying to reading to having sex. Then they’d naturally fall back asleep until morning.

Randall notes that other studies have confirmed that people naturally experience segmented sleep. And in areas with no artificial light, people still experience first and second sleep.

Naps Get a Bad Rap

In our society, naps are viewed as luxurious activities only reserved for the privileged or the lazy. That’s a shame, because research continues to show the benefits of naps and discredit these beliefs.

One study found that astronauts who slept for just 15 minutes had better cognitive performance, even when there was no boost in their alertness or ability to pay attention.

Another study found that participants who napped and experienced the deeper stages of sleep had more flexible thinking. They were able to apply information they memorized to a new task much better than participants who watched a movie instead of napping.

Randall also notes that participants who take naps outperform their counterparts who aren’t allowed to doze off on other various tasks. For instance, research has found that they’re able to finish mazes faster and remember longer lists of words.

Big companies have even made naps part of their workday. According to Randall, Google and Nike are just some of the companies that have created specific spaces for their workers to sleep. “The idea is that naps may allow engineers and designers to arrive at creative solutions more quickly than they would by staying awake all day,” he writes.

In Dreamland Randall explores many more peculiar issues surrounding sleep, from the purpose of dreams to the bizarre world of sleepwalking and “sleep crime.”

While sleep research is in its infancy, one fact is undeniable: Sleep is vital for everything from our survival to our success.

When functioning optimally, sleep can sharpen our thinking and help us problem solve (like golfer Jack Nicklaus did when he figured out how to tweak his swing in his sleep). When gone wrong – as in cases of sleepwalking and sleep deprivation – it can distort our cognitive skills, sink our mood and even make us dangerous.

As Randall notes, “Sleep isn’t a break from our lives. It’s the missing third of the puzzle of what it means to be living.”

 

Woman sleeping photo available from Shutterstock

Are You a Hero in Waiting?

Are You a Hero in Waiting?This is a true story.

Imagine that you are at a Wal-Mart around midnight. Dark parking lot. Little security and yet a number of random people wandering around. A man with a little boy thrown over his shoulder passes you. The little boy is screaming and kicking and crying and yelling for his mama.

The man slaps and spanks the boy and is telling him to shut up. He never uses the boy’s name. There is no woman near them and the man is moving faster. Also, imagine the boy is blond and the man has dark hair. Onlookers shake their heads but do nothing.

What would you do? Would you watch and not do anything? Or would you intervene? Social psychologists tell us there is a very good likelihood we will do nothing.

But this is the story of a woman, Pam, who did.

Pam asked the security to go check on the boy. The security man did, and then turned away. Pam asked the security guard what transpired. As she does the man screams at her: “The little shit is crying for his mother like a pansy-ass.”

“At that moment,” said Pam as she recalled her ordeal, “I forgot to be scared.”

The man shoved the boy into the back set of the car all the while cursing and screaming at him. He got in the car and backed up. Pam stood behind the car and blocked the man from going. She walked over to the driver, told him to roll down his window and then asked the boy if the man was his dad. The boy said nothing.

The man pushed Pam back from the window and threw open the door. He swore at her, stumbled and fell onto the car next to his. He was drunk. Very drunk. As this was happening Pam went over to the boy and asked again if the man was his dad. She tells him she knows he is very good at telling the truth, and that she is just there to see what is the matter for all those tears. The man is quiet and never moves but mutters something and then laughs.

Pam faces the man, apologizes for inconveniencing him and tells him she knows how unpredictable children who are tired can be. But given the circumstances she was pretty sure a good dad like him would want people to care that no child was being abducted in their presence. She said she hopes she is wrong in her suspicion.

Pam’s powerful display of courage, acting to help a victim while others are not responding is a correction for one of the most replicable effects in social psychology. The bystander effect, or Genovese syndrome, is the name given to the phenomenon where the presence of bystanders decreases the likelihood that someone will intervene. In fact, there is an inverse relationship between the number of witnesses and the likelihood someone will help: The greater the number of bystanders, the less likely someone is to respond.

Researchers John Darley and Bibb Latene were interested in the 1964 murder of Kitty Genovese in New York City where witnesses to the murder did not respond. While there is controversy about the reports on the number of witnesses and their reasons for not responding, the newspaper reports of the murder and apathy inspired the researchers to conduct experiments to demonstrate the effect.

But there is more to Pam’s story than just speaking up.

Pam introduces herself to the boy and asks him again if the man is his dad. He nods and is able to tell her his daddy’s name. She then asks the man to show her his driver’s license. By then the security guard has returned to check the license, which is expired. The security guard hands the license back to the man and walks away.

He walks away.

Pam says in a very loud voice that she will be happy to wait until the police arrive so this little boy doesn’t have to drive in a car with a drunk driver who has an expired license. She then dials 911, asks the security guard to stay with her and she talks to the boy. The father is furious. He curses and kicks a can at Pam. It hits her in the shoulder and Pam is unmoved as she continues to talk to the boy, asking him about his mama. He tells Pam about her, his sister, and his grandpa.

When the police arrived Pam gave a statement and they arrested the man for public intoxication. Pam waited with the little boy, another policeman, and the security guard until the boy’s grandpa came to get him.

Pam has done more than challenge the bystander effect. She is an everyday hero. Research on the Genovese syndrome has resulted in three processes that are important for people to respond to others in distress. The first is to actually notice the situation. When there are many other people around we may narrow our awareness – so the first thing Pam did was realize something was happening with the man and the boy. In other words, she paid attention to her surroundings.

Second, those who respond interpret the situation as an emergency. Pam did this the moment she saw the boy being hit. The best response I have ever heard for an intervention came from a woman who witnessed another woman hit her child several times at a park. The witness told her to stop and the abusive parent said, “It is none of your business.” The woman who intervened said: “If you do this in public it makes it my business.”

Pam made it her business, which is the final point the researchers formulated. Once you notice, and interpret the situation as an emergency, then you finally take responsibility for helping.

This is an area Phil Zimbardo, another leading social psychologist, is studying: What it takes to be a hero. His latest endeavor involves fostering heroic imagination. He has noted that heroes are never going to conform to group norms and highlights the two core principles of heroism:

  1. Heroes act when others are passive.
  2. Heroes act sociocentrically, not egocentrically.

They act alone, and for the good of others. It also seems they don’t like to boast about their deeds. That is why we need to honor their stories and retell them when we hear about them. That is why Pam’s story appears here.

Dr. Zimbardo calls it Heroes in Waiting, and we need to be prepared. In his own words, we need to be “waiting for the right situation to come along, to put heroic imagination into action. Because it may only happen once in your life, and when you pass it by you’ll always know, I could have been a hero and I let it pass me by. So the point is thinking it and then doing it.”

Pam is an inspiration because she didn’t let her opportunity pass her by. I hope we can all do the same when it is our turn.