R U OK? Texting to Treat Depression

A New Connections grantee explores the use of mobile technology in group therapy for disadvantaged populations.

Text messaging has been blamed for all manner of calamity, from car crashes to sex scandals. But what if its powers could be used for good—say, to treat depression?

Adrian Aguilera, PhD, thinks it can. Aguilera works in cognitive behavioral therapy (CBT), a form of psychotherapy that aims to modify dysfunctional emotions and behaviors by teaching patients to recognize and challenge negative thoughts that influence mood.

In addition to regular therapy sessions, clients are asked to do “homework” by tracking their thoughts and moods using paper-and-pencil questionnaires. It was here that Aguilera saw room for improvement: the response to written questionnaires hovered around 20 percent.

“Practicing CBT skills is analogous to taking the right dosage of medicine,” he says. “If you don’t take the dosage, it’s not going to have an effect.” 

The texting method he devised is both simple and ingenious: rather than asking participants in group therapy to monitor their moods via the typical questionnaires, automated text messages pose questions like, “What’s your mood on a scale of 1 to 9?” and “How many negative thoughts have you noticed today?” In their responses, clients can offer additional context as to what they are experiencing at that moment. Therapists then ask follow-up questions, such as “Have you noticed any thoughts that improved your mood?”

Participants also get reminders of weekly group meetings, and those on medication can opt to receive reminders to take their medicine.

Although research on the effectiveness of Aguilera’s approach is still in the initial testing stages, the early feedback is promising.

“Overall, clients responded to 55 percent of the messages they received,” he says. “That’s a big improvement over the response to paper-and-pencil questionnaires.” 

CUL8R*

Another preliminary finding is that English and Spanish speakers perceive the text interventions differently. According to Aguilera, Spanish speakers say the messages make them feel cared for and supported. English speakers conversely state that messages asking about their mood prompt them to be more introspective.

The role that culture and socioeconomic status play in mental health, particularly within Latino communities, has been an enduring focus for Aguilera as a child of Mexican immigrants. 

The majority of his clients at San Francisco General Hospital, a public-sector facility, are from low-income and underrepresented populations. Depression and anxiety disorder are the most common mental health issues in this community. The problem is compounded by a dearth of culturally competent providers.

“There’s a severe shortage of mental health providers or researchers who speak Spanish. Many have to communicate through interpreters, which makes it difficult to build a connection and trust with the patient,” Aguilera explains. “Consequently, I’ve always worked with Spanish-speaking clients.”

In addition, there is a surprisingly high incidence of PTSD in the population he serves. “A lot of mental health issues are caused by social problems—economic inequality, for example, or exposure to violence in the community,” says Aguilera. “Those things can be the source of trauma.” Many of the immigrants he works with have also confronted traumatic events in the process of emigrating from their home country.

He further sees these challenges within a broader context—specifically that low-income, high-need patient populations have elevated rates of co-occurring illnesses such as diabetes, cardiovascular disease, and other chronic health problems that can affect mood.

Despite the multiplicity of interconnecting factors, profound stigma is attached to psychotherapy among underrepresented communities that prevents many people—particularly men—from seeking help. “People often talk about not wanting others to think they’re ‘crazy,’” Aguilera says, adding that there are far more women than men in the groups he runs. 

“I’d say probably 75 percent to 80 percent of our patient population is female, which would indicate that there’s some gender difference in the stigma accorded to mental health problems.”

He is quick to note, however, that once patients overcome their concerns about stigma, they find tremendous benefit in therapy. “One thing I can say unequivocally is that when people go to group therapy and are consistent about it, they tend to get better.”

YMMV*

Aguilera, an assistant professor at the University of California, Berkeley, School of Social Welfare, first began to look at text-message interventions in 2010 when it became clear from his clinical work that the completion rate for the standard written questionnaires was extremely low.

“It was frustrating,” he says. “The interventions we were delivering didn’t seem to be penetrating the way they were intended to.”

A conversation with a mentor providing interventions online got him thinking. “The idea of online interventions was exciting to me, but I saw the limitations of reaching an underserved, low-income population who might not be able to afford a computer or a smartphone to get Internet access.” 

The discussion turned to cell phones and text messaging—an idea that crystallized once they looked at the data and saw that the rates of basic cell phone ownership were high regardless of income status. “That made it an attractive vehicle for delivering interventions,” Aguilera says.

He was able to fully explore the practical applications of his idea through a 2011 grant from New Connections, a Robert Wood Johnson Foundation (RWJF) initiative that works to expand the diversity of perspectives informing RWJF program strategy. 

“New Connections was instrumental in my developing this project,” he says. “It not only helped me do the initial testing, but it also provided a community and mentorship, which is extremely valuable in the early stages of an academic career—especially for an ethnic minority.”

mHealth FTW*

As the second phase of his research hits full stride, Aguilera says he and his colleagues are seeing more receptiveness to mood tracking, which is central to CBT. “To us, that’s an indication that people are engaging more with what we’re trying to do.”

Looking ahead to the future of mobile health technology (known as “mHealth”), Aguilera is excited about the possibilities. “Really, we’re just at the beginning of this wave of utilizing technology,” he says. “As more and more people get smartphones, interventions will become more sophisticated.”

In the interim, he sees hope in the current shift toward connecting mental health more closely with primary care. 

“One of the disservices we’ve done to patients over the years is to separate mental health from physical health,” Aguilera observes. “Depression and other mental health issues occur with a variety of physical ailments. If one’s mental health is overlooked, doing things like exercise to improve physical wellness is much harder.”

“Obviously I’m biased,” he adds, “But I think mental health is absolutely central to building a culture of health.”

*Texting abbreviations:
CUL8R =  see you later
YMMV =  your mileage may vary
FTW =  for the win

 

R U OK? Texting to treat depression
R U OK? Texting to treat depression

Texting to Treat Depression

Can text messaging powers be used for good—say, to treat depression?

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