Does ‘The Depression Fix’ online programme help depression?
Results of clinical trials 2017
Mental heath is a growing concern globally with conditions such as depression rapidly increasing in the UK. Numerous credible medical sources advise that depression can be cured effectively using a combination of self-help, therapy and antidepressant medication. However suitable resources are limited and inaccessible for some either due to availability or cost and the alarming growth in reliance on antidepressants, which has more than doubled over the last decade (NHS Digital, 2017), is not slowing the increase of depression.
Modern technology has the potential to make effective cures widely available and accessible, but there are very few systems that address mental health conditions effectively. For people with depression the information currently available is overwhelming, confusing and inconsistent and due to the nature of the illness, therapist intervention is often essential.
The Depression Fix is the first in a series of online programmes that combine self help with therapist intervention in one simple step by step programme that addresses the multidimensional nature of depression using clinically proven techniques, video tutorials and therapist support in a way that people suffering from the illness can follow.
The three month programme was trialled with a group of volunteer participants between October 2017 and January 2018 to test the theory that clinical therapy can be effectively emulated in a self help online programme combined with suitably qualified therapist support. The results of the trials support this theory with all participants who completed the programme showing significant improvements in their condition.
“Depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease” (The World Health Organisation, 2017). In England one in three adults aged 16-74 (37 per cent) were accessing mental with conditions including anxiety and depression in 2014, a 13 per cent increase in seven years (NHS Digital, 2014) but this latest research that over a third of people in England are accessing services does not account for others that do not have access to adequate suitable and effective care.
There are numerous reports citing the lengthy waiting times for access to evidence-based psychological therapies and although self-help information is readily available, for someone with depression motivating themselves to effectively evaluate the confusing assortment of information is overwhelming. What’s more depression is an illness that has multidimensional causes, therefore one single strategy does not necessarily help everyone, so people with depression often become disillusioned and lose hope. Exacerbating this problem is the tide of pseudo-support groups emerging on social media platforms that, rather than help people to overcome depression, indulge sufferers in their hopelessness embedding the false belief that ‘nothing cures depression’ making them unwilling to invest the time and energy needed to work through solutions.
The programme ‘The Depression Fix’ was developed to serve those people who are unable to access the resources, mentally, physically or financially to help them out of depression. As increasing numbers of people turn to the Internet for solutions, The Depression Fix aims to leverage that comfort in using technology and online resources.
The Depression Fix addresses the top ten known causes of depression giving detailed explanations as to why they affect people in this way in weekly video tutorials and provides strategies of how to effectively address them. Each week there are exercises for the participant to complete with feedback and support from a therapist by email. The programme uses evidence based therapies and complementary therapies. The participants are monitored using period questionnaires to assess their level of depression and video diaries.
This trial was conducted to test the theory that The Depression Fix, an online self-help programme combined with therapist support is an effective way to treat depression.
Participants were invited to take part in a free trial of a new programme to help depression (Appendix 1 video invitation), they were then given access to the online programme and asked to follow the course on a weekly basis for three months. Each week a new part of the course was delivered that included video training on a subject, followed by exercises that were submitted to a therapist for feedback.
At the start of the course, periodically throughout the course and finally at the end participants were asked to complete a self assessment questionnaire and submit a video diary entry as evaluation of their progress.
The detailed methodology follows:
Volunteer participants invited to take part in the trials were sourced from a database of people who had previously requested a free self hypnosis track to help depression or a video advert publicised to people who had an interest in depression on Facebook using their advertising algorithms.
58 of those people confirmed they knew of no reason why they should not take part and they were not on antipsychotic medication. The participants were screen for risk of psychosis because the course contains self hypnosis and guided relaxation recordings and psychosis is a contra-indication for hypnosis. However it is recognized that antipsychotic medication is prescribed for anxiety and not necessarily an indicator of psychosis, but for the trial purpose it was felt important to eliminate this group of people.
30 people started the course of which 19 people (63%) went on to complete
37% (11) of those took the first Madrs assessment and then dropped off the course immediately with no explanation given. Those people were invited to take the final Madrs test at the same time the participants who completed the course did as the control group. The same source of people during the same time period to compare those who completed The Depression Fix Course with those who did not take the course.
Analysis of the effectiveness of the course is made using the 19 people who completed the full course against the 11 people who started but did not complete.
The analysis of the demographics below is of the 58 people who completed the application process.
The course is split into three modules which contain four weekly units.
Module 1 – Introduction to Depression Brain
The first module introduces the client to the effect negative thinking is having on their psychological and physiological mind and body. It explains how the flight/fight response is engaged which then encourages them to think in terms of the worst possible scenario, obsess and negatively introspect even more. It also explains about sleep patterns in a depressed person and the importance of regulating sleep before going on to step by step practical instructions of how to come out of depression.
Before the course starts participants are asked to take an self evaluation assessment to register their starting point and also record their first video diary. Then they get straight into the week’s content which explains how depression develops and introduces them to the concept of the intellection brain and primitive brain – aka depression brain.
Week 2 builds on the knowledge of how depression develops by explaining what needs to happen for depression brain to relax its control over their life. Participants also learn more about the influence they have on the neurotransmitters and hormones in your body and mind that affect their moods, energy and motivation. Finally they will understand exactly what anti-depressants do and how to benefit from them effectively.
Week 3 explains why people need to stop fighting depression. Although it seems counterintuitive, fighting depression becomes counterproductive and keeps people trapped in a vicious cycle. Participants learn tools and strategies to adopt instead of directly fighting depression and begin to understand why fighting is having a negative effect.
In week 4 the course get deeper into the chemical makeup of humans focusing on what’s missing when someone has depression, what there is too much of if with anxiety. People don’t realise that every action and thought has a direct impact on the hormones and neurotransmitters they produce, so it is vital that they learn what they are currently doing to causing the imbalance and what they need to do to rebalance them.
Module 2 – What causes depression
The four weeks of module two cover the top ten known causes of depression and what to do about each one. It examines lifestyle, diet and nutrition, technology and genetics, dispelling the many myths surrounding depression, provides scientific information with solutions of how to address these issues.
Week 5 kicks off Module 2 which examines the known causes of depression, how these might be affecting the participant and, most importantly, what they can change or do to reduce or eliminate them from their life. Week 5 focuses specifically on new research that is gaining ground scientifically suggesting depression could be an allergic reaction.
In week 6 looks at how our primitive ancestors lived and compare that with a modern western lifestyle to understand how people are evolving into depression. With some tweaks and lifestyle adjustments everyone can learn to emulate elements of the primitive way of life and fuse them with modern lifestyles to maintain a healthy and balanced life.
Week 7 continues with modern life by focusing on how technology is influencing mental health. There is no doubt that the rapid developments in technology have enhanced lives in many ways, but is it a double edged sword? Week 7 explains how the subconscious is affected by unfiltered input from the world around us and helps people to resurrect healthy boundaries.
In Week 8 participants understand the truth about the hereditary factor of depression. They will learn exactly how families are effect by depression and will gain the tools to halt the tide in future generations, but perhaps most importantly they will understand that they can and must let go of the guilt of depression because hanging onto the guilt is adding to the depression. They will learn that depression is not their fault, but it is their responsibility to fix.
Module 3 – Perception
The final module starts the clients looking forwards at what needs to change in their life and their own perception of themselves and the world around them in order to maintain a mentally healthy lifestyle in the future. It also addresses relapse and how to avoid a reoccurrence of depression in the future.
Week 9 commences the third module of the course, Perception. How we view the world around us, including everything in it and ourselves will determine how individuals ease through life. Starting off with people and personality types participants will be exposed to the reality that everyone is different and no one can read anyone else’s mind and in trying to do so, they cause themselves emotional pain. It then goes on to look at the different personality types and how they interact with each other. Participants will discover their personality type and that of the problem people in your life learning strategies of how to deal with them more effectively.
In Week 10 participants learn the importance of focusing their mind on the positive things in life and the detrimental effect focusing on their problems has on their mental health. They will also do an exercise to discover how balanced their life is, what life balance actually means and how to put it right before going on to understand that pain shows up in life when something needs to change using examples from past clients about how making big or even just the smallest of change can have a powerful positive beneficial impact.
In Week 11 participants learn about basic human needs using theories from the Human Givens. Often problems occur because these needs are not met, as life circumstances change so must we adapt and change to readdress these needs which are essential to being mentally healthy. Understanding these needs will help participants to identify the areas of their life that might need development.
The final week of the course starts with an exercise in goal setting and a positive look forwards then wraps up with a self reflection on how participants are going to avoid falling into the depression relapse cycle and stay happy and healthy into the future. The depression cycle can be easily broken with practice and adopting a mentally healthy lifestyle and a new self awareness.
Each weekly unit follows the same structure
- Introduction video that sets the lesson for the week and addresses anything arising from previous weeks.
- Clients are asked to list ‘the good things’ that have happened to them during the previous week, this is sent to the therapist for feedback.
- A video tutorial which addresses the main topic that week which is sometimes supported by additional video information and scientific evidence.
- The client is then asked to rate themselves of the ‘happiness scale’ which is recorded in their main record
- The first exercise is based around the topic for that week – Sent to therapist
- The second exercise asks the client to set their intention for that week – sent to therapist
- The client goes on to play a guided relaxation track.
In addition to the week’s activities the client is asked to perform two daily activities
- List three things they are grateful for in their life that day
- When they are ready to sleep at night, play a guided relaxation/self hypnosis track as they fall asleep.
- At the start of each week the client is asked to list their ‘good things’ this is to encourage positive thinking and retaining their mind to notice the positive things in their life and then recalling positive incidents to help them learn that their life is not just about negatives.
- Daily gratitude list follows a similar principal in that it encourages the client to focus more on the positives they have in their life on a daily basis.
- The video tutorials are aimed at teaching the client how to regain control of the different aspects of their life and tackle depression in a way that is easy with practical advice that goes beyond, eat healthy, exercise and think positively. When in the grips of a depressive episode people find it difficult to conceptualise what to do, they need more practical help.
- The exercises are generally CBT principals whereby they encourage the client to examine certain aspects of their life or of depression and reflect on how this can be addressed in a positive way.
- The second exercise is always for the client to set their intention that week of what steps they are going to take that will help themselves out of depression.
- Finally, the guided relaxation/self hypnosis track is played directly after a session when the client is in a positive frame of mind and every night when they are ready to sleep. Apart from the hypnosis theories about retraining the mind, the guided relaxation does help the client to sleep. Many people with depression have irregular sleep patterns, many experience insomnia and disturbed sleep, the deep relaxation of the tracks helps to regulate their sleep and have a better quality of sleep.
Therapist Support and Intervention
There are three pieces of work each week that are sent to the therapist via email from the client:-
- What’s been good this week
- Exercise 1
- Exercise 2, setting the weekly intention
The therapists role is to review the content and then feedback to the client specifically:-
- Encourage and congratulate the client for what they have done and achieved, helping them to notice what they have been able to do and why that is significant
- Helping the client to reflect on why things have been good or better and what they have done that has contributed to the positive things in their life
- Help the client reflect on any language or actions that are not helpful for their depression, reassess how it could be thought of positively or changed in such at way to lead to a positive outcome.
Throughout the course the client is encourage to use the ‘get support’ link if they are struggling with a particular problem or something is on their mind.
An important part of the therapist’s role is to build rapport with the client.
Throughout the course a variety of therapeutic techniques are used:-
- CBT (Cognitive Behavioural Therapy)
- SFBT (Solutions Focused Brief Therapy)
- Guided Relaxation / Self hypnosis
Participants were asked to complete a diagnostic questionnaire, the Montgomery–Åsberg Depression Rating Scale (MADRS) four times during the course.
- Prior to commencement of the course
- At the start of Module 2 (Week 5)
- At the start of Module 3 (Week 9)
- At the end of the course (Week 12)
Participants were asked to submit a period video diary addressing a specific question each time.
- Prior to the commencement of the course – “How is depression affecting your life?”
- At the start of Module 2 (Week 5) – “In the first month, what is the most significant thing you have learnt and why?”
- At the start of Module 3 (Week 9) – “How has your perception of depression changed?”
- At the end of the course (Week 12) – “Has this course has helped you with depression and if so, how?”
All 15 participants in the trial shows significant improvements in their condition. The quantitive data shows an average improvement of 19 points from the start to the end of the course.
Of the eleven participants in the control group who started but did not continue past the two weeks, five responded to the request to complete a final Madrs assessment and showed little or no improvement, with the average improvement score of 1.
Table 1 blow reports mean and standard deviation by conditions for 15 subjects. The mean of change over the twelve week course shown in the MADRS assessment was 19, compared to 1 for the control group. This difference is statistically significant (t=2.2, p< 0.05). Results of the trial revealed that participants completing the twelve week Depression Fix course did significantly improve their condition compared to the control group.
Participants that finished the course – MADRS Assessments
Participants that left after the first week
Control Group – results
Qualitative Video Diary Results
Qualitative evidence from Video Diaries
13 of the participants who completed the course submitted video diaries at the start of the course, at the beginning of weeks 5 and 9 and finally at the end of the course. The participants were asked to answer given questions in their video diary:
Before they started the course – “How has depression affected your life?’
Week 5 – “What significant changes have you noticed in the last month?”
Week 9 – “What has improved or changed since the start of the course?”
Week 12 at the end of the course – “Has this course helped your depression?”
All the thirteen participants who submitted the video diary said that the course had helped their depression with the most frequent way in which it had help was in their change of attitude or perspective with comments such as ‘it has given me back a positive can do attitude’, ‘thinking differently’ and ‘changed the way I’m thinking’. Ten participants said they were worrying less about things and nine people expressed a more positive attitude towards themselves, participant B went on to say that he was ‘happier with me’ and ‘I value myself and feel a useful member of society’.
In the first video diary where participants were asked how depression had affected their life, many were having difficulties with other people and their relationships, felt isolated and had withdrawn from social situations, however, during or at the end of the course eight people said their relationships with other people, in particular family, had improved as a result of the course and they were now socialising more. When explaining what part of the course had helped them most, seven participants cited the new knowledge and understanding of depression as the most important part of the course for them. After confirming the course had helped them, five participants went on to explain that they were not completely cured yet, they understood that it would take time, but the course had given them the knowledge and tools to get better and that they were on their way.
At the end of the course, participants were asked to complete voluntary feedback surveys. Five participants completed these surveys.
The surveys asked how helpful they considered each week of the course followed by some of the other features of the course and finally they were asked to cite just one or two elements of the whole course they felt had helped them most.
Motivation to recover
It was made clear before volunteers signed up to the programme that video diaries would be required. Approximately half the people who had expressed an interest in taking part opted out of completing the the full application form on learning this information. Those people were contacted to ask if the only reason they didn’t go forwards was an objection to submitting a video and if that was the case, they were given an option to complete the course giving written diaries instead of video diaries. Approximately half of those people then opted back in. However, interestingly, only one of the people who took part in the trial in to the trial after opting out of the video diaries completed the course. This leads me to interpret this as people with depression need to be sufficiently motivated to recover before they are able to receive any help and specifically start online programmes. A measure of that motivation in this case was their willingness and co-operation in submitting videos, perhaps other adequate motivators or a measure of motivation can also be found. Perhaps the others were not yet at a stage where they were willing to do ‘whatever it takes’.
Although the primary focus of the programme is depression, most participants also reported anxiety symptoms, therefore, anxiety needs to be addressed alongside the main thread. Anxiety was present with most of the client on the trial, but other conditions and symptoms were also apparent such as weight gain and weight loss, insomnia, IBS, OCD, pain and dealing with illnesses, so short bite video tutorials will be developed to address some of these other conditions and their relation to depression alongside the course that clients can choose to watch in addition.
Staying on the Course
The symptoms of depression such as negative thinking and lack of motivation and energy make it particularly difficult for clients to stay on a self help programme.. This is evident from the trials with the high drop off before the course started and then a second drop off in the first couple of weeks, but those who stayed on the course past week 3 subsequently stayed for the duration, finished the course and made significant improvements in their depression. Therefore, a step will be introduced whereby the therapist will make personal contact with the client by telephone within a week of joining the course to start the process of building rapport. The method they will use will be to conduct a telephone initial consultation (see form), this will also help the therapist to understand more about co-existing conditions that might be present and will be able to address them during the course. It will also help the client to feel understood, supported and included.
Long term results
Feedback from clients suggests need to feel they can continue to access the course and therapist support after the final week. This reflects feelings that clients finishing in person therapy sessions express at the final session, they take comfort in knowing the door is open as a way back if needed, but in practice, from experience they rarely return to therapy.
Trial participants and then subsequent clients will be contacted after 6 months and asked to complete a Madrs questionnaire to evaluate the long term and sustainable success of the programme.
The World Health Organisation, ‘Depression’ [online], available at http://www.who.int/mediacentre/factsheets/fs369/en/ (Accessed 6th January 2018)
NHS Digital, ‘Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014’ [online], available at http://digital.nhs.uk/catalogue/PUB21748 (Accessed 6th January 2018)
NHS Digital, ‘Antidepressants were the area with largest increase in prescription items in 2016, [online], available at http://content.digital.nhs.uk/article/7756/Antidepressants-were-the-area-with-largest-increase-in-prescription-items-in-2016 (Accessed 9th January 2018)
The appendices are all in the body of the report as hyperlinks. However, a complete list is as below.
The video invitation to take part in the trials can be found at: https://vimeo.com/236404054
The first expression of interest form can be found at: http://emmajtriplett.com/online-programme-trials/
The application form to take part in the trials can be found at: http://emmajtriplett.com/depression-fixer-trial-sign-up/
The final form to confirm eligibility to take part can be found at : http://emmajtriplett.com/depression-fixer-trials-final-stage/
The MADRS Assessment can be found at: https://thedepressionfix.com/madrs-assessment/