World Mental Health Day: Preventing Depression in Developing Countries

By Charles F. Reynolds III, M.D.

Today is World Mental Health Day, when the World Health Organization works to raise awareness of mental health issues around the globe. Recent developments are helping us better understand how to treat depression and anxiety disorders in developing countries, but much work remains.

Depression and anxiety disorders are a significant public health concern in developing countries, also referred to as low and middle income countries (LMICs).  

Late-life depression and anxiety are of particular concern in LMICs. This is due to rapid demographic transition and aging in countries such as India, increased prevalence of social conditions that are recognized as risk factors - such as living alone or living with a chronic disabling condition - and the inability of health systems to address the physical and mental health needs of the elderly due to a lack of mental health resources.

Because of a lack of mental health specialists, there is a large need to focus on prevention interventions that can be delivered by non-specialists and lay health workers in non-health care or primary-care settings. In other words, mental health care services can be provided by caregivers other than mental health experts such as psychiatrists and psychologists.

By equipping lay and non-specialist workers with the skills needed to help individuals in countries with few mental health resources, we can work towards a long-term goal of scalable depression prevention in LMICs. These skills include the use of learning-based psychotherapies, such as problem-solving therapy for primary care and brief behavioral treatment for insomnia, which in the West have shown to reduce depressive and anxiety disorders by 25 percent over one to two years compared to usual care. Such therapies can help individuals cope with stressful relationships and situations that may trigger depressive episodes, and teach more constructive thought patterns to replace thinking habits that magnify feelings of worthlessness and hopelessness.

A recent study conducted in Goa, India, demonstrated that the use of lay health counselors increased recovery rates from common mental disorders - anxiety and depression - in a sample of patients of all ages.

Now, a new study funded by the National Institute of Mental Healthis working to investigate the use of non-specialists in an effort to prevent late-life depression and anxiety in LMICs, specifically in Goa, India.

Researchers  will develop best practices for depression and anxiety depression, and teach learning-based psychotherapies as well. Other tactics will include education about symptoms of depression and anxiety, instruction in breathing exercises and relaxation to manage symptoms of anxiety, and scheduling of activities to manage symptoms of depression.

Charles F. Reynolds III, M.D., is the UPMC Endowed Professor in Geriatric Psychiatry and Director of the Aging Institute of UPMC and the University of Pittsburgh.

Smartphone App for Child Anxiety Wins National Recognition

By Cristina Mestre

A smartphone app to help children with anxiety disorders that was developed by University of Pittsburgh researchers has been recognized at a national conference for its ability to empower consumers.

The SmartCAT, short for smartphone-enhanced child anxiety treatment, is a mobile health platform that was developed by Jennifer Silk, Ph.D., and Bambang Parmanto, Ph.D., along with Dr. Parmanto’s graduate student Gede Pramana, all from the University of Pittsburgh Schools of the Health Sciences. It was recognized as one of three winners of the Behavioral Health Patient Empowerment Challenge earlier this week at the Technology Innovations for Substance Abuse and Mental Health Disorders Conference at the White House.

The Office of the National Coordinator for Health Information Technology (ONC), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), the Office of National Drug Control Policy (ONDCP), and National Institutes of Health (NIH) held the conference to highlight how technology can be used to improve mental health.  For example, University of Pittsburgh School of Medicine professor Bruce Rollman, MD, presented his research on using the Internet to treat mood and anxiety disorders.

Each year, approximately 13 percent of adolescents experience mental illness, and between 10 to 20 percent of school-aged youth are diagnosed with an anxiety disorder. Yet according to SAMHSA, only one-third of children with mental health issues receive treatment, and many children continue to struggle with symptoms even after treatment. Fortunately, technology can play a significant role in helping individuals with mental illness to self -manage their behavioral health and to foster treatment.  

The SmartCAT  is designed to improve cognitive behavioral treatments for children with anxiety disorders.  Cognitive behavioral therapy (CBT) involves teaching children skills for coping with their anxiety and practicing the skills with a therapist, and has been recognized as an effective treatment.  However, many children continue to have symptoms of anxiety even after weekly therapy sessions.

Silk and Parmanto believe that if children use technology to practice the skills they are learning in treatment on a daily basis, instead of just once a week in the clinic, they may get better faster, and stay better for longer.

For this reason, SmartCAT is designed to improve treatment for children by allowing them to practice CBT while they go about their daily lives, through the use of their smart phones. The app provides coaching to patients when and where they need it (not just in their therapist’s office), increases communications between therapists and patients, and helps therapists track progress and personalize treatment by focusing on patient-specific needs and strengths.  All communications in SmartCAT are also secure, says Dr. Silk. 

Children are prompted to complete a series of questions about their emotions and a series of coping thoughts and problem solving steps used to deal with the situation. This information is sent to a therapist ‘portal’ where it can be monitored.  The therapist is therefore able to review patients’ real-world CBT skill use, monitor their progress, and send treatment materials (e.g. a relaxation video) and encouraging messages. 

Children can earn prizes for using the app, notes Dr. Parmanto.  This encourages them to use the app and keep them engaged. The team is also working on developing skill-building video games to the app, to make it even more engaging for patients.

“Initial results of the app’s use are promising, and feedback from both patients and therapists has been overwhelmingly positive,” added Silk.  “Technology is enabling us to explore a whole new world of treatment options for our patients.” 

Diane Nyad: 64 is the New… Amazing

By Cristina Mestre

Many of us have a list things we want to accomplish in our lifetimes.  These items might include running a marathon, seeing the bulls run in Spain or travelling the world.  For 64-year-old Diana Nyad, her life list included swimming 110 miles in the open ocean from Cuba to Florida, something she first tried unsuccessfully 35 years ago. This week, she accomplished this incredible feat, giving new meaning to the old adage that you’re never too old to live your dreams.

Here, we ask Charles F. Reynolds III, M.D., UPMC Endowed Professor in Geriatric Psychiatry and Director of the Aging Institute of UPMC and the University of Pittsburgh, about the importance of setting big life goals, and how Diane is an inspiration to older adults everywhere, both for her physical performance and her perseverance. 

Q: Diane’s story is certainly inspirational, especially at age 64!  What kinds of physical limitations did she have to overcome that she didn’t have to worry about on her first attempt, 35 years ago?

A: Endurance is the main obstacle and physical limitation. Whether or not she could sustain the kind of physical and mental effort required to swim that far was a key question.  As we age, we may not have the same reservoir of energy or degree of aerobic fitness that we did in our 20s.  But we do have the benefit of mental toughness – we know what our limitations are and we have learned from our experiences.

Charles F. Reynolds III, M.D.

It's evident that Nyad had built up and maintained her stamina and hardiness to the point where she could undertake and complete her 110 mile swim.  Many people who live to become centerarians make lifestyle choices that promote robust aging, via physical and mental activity, plant-heavy diets, social connectedness, and avoidance of deleterious activities like smoking.

Q: Nyad claimed she was in her physical peak, is this really possible in your 60s? Is it safe for all 60-somethings out there to sign up for an Ironman Triathlon?

A: I do think it’s possible to be in the shape of your life in your 60s and beyond.  People are living longer and remaining engaged and vital: about 76 million Americans are now in the “third chapter of life.”  Even in the 7^th and 8^thdecades of life and beyond, there is always room for improvement – we can tap into reservoirs of physical strength and improved mental acuity.  We don’t’ have to be on a downhill course – we CAN do things to improve our life, but it does take work and determination.  

Overall, exercise is important for all older adults in some cases endurance events or races may also be possible. It is however key to check with your doctor first, before starting or ramping up any exercise routine.  I advise my patients to pursue a medically supervised aerobic program that includes resistance training.

Q: Despite her previous failed attempts, Nyad came back time and again to attempt this swim.  Can you tell us about the importance of setting big life goals?

A: In a great book called The Third Chapter, author Sara Lawrence-Lightfoot states, “We want to find out what this penultimate chapter of our life is going to be about…We’re ready for something new…for a new adventure…All of us to some degree experience burnout.  Burnout is not about working too hard…Burnout is about boredom…This is about moving beyond the boredom to compose, to invent, and reinvent the path we’re on.”

The setting of life goals has to do with a person’s need for meaning.  It’s a question of finding a life of meaning, not finding the meaning of life.  Utility to oneself and utility to others are key facets to a fulfilling life.  Setting goals not only makes us more resilient to depression and helps us bounce back from adversity, but it also becomes a source of motivation and fulfillment.

Q: What smaller steps can older adults take to tackle their bucket lists?

A: Not everyone should (or wants to) jump up and swim across the ocean.  But finding small activities that you find fulfilling and tackling them day-by-day allows you to build your capacity to savor life and just be grateful to be alive.  Sometimes those activities are physical but sometimes they are more social in nature – the key point is to find pleasurable activities that allow you to savor life.   

Plus, technology allows us to access many resources for tips on healthy aging, including the National Institute on Aging, in the click of a mouse.