How Texting Might Ward Off Depression

Studies have shown that cognitive behavioral therapy is beneficial for depressed people. But a relatively new area of research involves using mobile phones to help patients stay engaged with their health.

Cognitive behavioral therapy or “CBT” treatment involves teaching patients to identify and modify negative thoughts or behaviors that are prone to exacerbate their depression, and by doing so, change their mood. One integral part of CBT is the “homework” patients do in between weekly sessions, which usually involve logging their moods throughout the day.

“It helps you monitor how you’re doing, identify thoughts that bring your mood down, and also when you’re engaging in activities that will improve your mood,” said Adrian Aguilera, a clinical psychologist at the University of California, Berkeley.

But many people find it hard to carry around a piece of paper or a notebook, and many simply forget to keep track. Not doing the homework limits the efficacy of CBT.

So Aguilera has been testing out using text messages to his patients at San Francisco General Hospital to stay on top of their out-of-session assignments. He’s developed an open source platform called HealthySMS that automates the process of tracking patient moods.

Many psychiatrists and psychotherapists have been considering ways to use technology to help their patients deal with mental health disorders. Some have used web-based interventions for many years. With the widespread adoption of smartphones, others are eyeing apps as a way to aid in-person therapy.

Keeping in touch with patients between in-person visits can be a powerful tool for mental health professionals, both as a way to remind patients of what they learned in sessions and as a way to track how well patients are doing in between sessions.

Although there are a few mobile phone apps to help people with their mood disorders, texting is a uniquely suited technology for staying in touch with a wide swath of mental health patients.

"Many [low-income patients] don’t have desktop computers at home. Mobile phones and smartphones are breaking down some of those barriers,” said Aguilera.

Moreover, most of his patients are Spanish-speaking elderly. Quite a few of them find the learning curve for a complicated smartphone app a lot steeper when compared with texting and Aguilera built HealthySMS to incorporate Spanish-language texting.

Aguilera has been working on texting his CBT patients since 2009. The earliest incarnations of texting apps were clunky and not particularly versatile. When it came time to upgrade, one of his graduate students pointed him in the direction of Twilio, a startup that specializes in software for cloud-based communications. On the heels of fellow technology companies Salesforce and Google, Twilio launched a philanthropic arm, Twilio.org, which provides the company’s technologies to nonprofits at a deep discount. Over 450 nonprofit groups are currently using Twilio.

Aguilera worked with researchers and developers at Northwestern University’s Center for Behavioral Intervention Technologies to create  HealthySMS and since its open sourced,  other mental health professionals can adapt it to their purposes.

HealthySMS automatically sends a daily text at random times of day to CBT patients asking them to rate their current mood. Besides making it easier for patients to track their moods, HealthySMS lets the treating psychotherapist track those responses. That information can then be used during therapy sessions.

Aguilera is currently in the middle of a clinical trial testing whether Spanish-speaking CBT patients who use HealthySMS improve more than patients who only attend in-person CBT sessions.

Patients tend to respond more at the beginning of the 16-week program, according to Aguilera, he says it tapers off after a few weeks. But he’s also noticed that when they become more depressed, they show up to in-person sessions less often, but interact with the texts more.

“We know in general that people who are depressed have a harder time showing up to sessions. It’s an illness of motivation,” he said. But if depressed patients are still texting, it’s one way to keep the line of communication open with them, even when their therapy attendance gets spotty.

“It could serve as a way to stay on the radar for someone thinking about getting treatment,” said Aguilera.

Results from the clinical trial will be available some time in 2016. In the meantime, Aguilera said it is challenging to disentangle depression from other problems. For example, many of his patients have diabetes. So personalizing the texts to address those multiple health problems is one area he is interested in pursuing. “One size fits all can be limiting,” he said.