tag:theconversation.com,2011:/au/topics/online-treatment-5251/articlesonline treatment – The Conversation2017-05-11T19:21:54Ztag:theconversation.com,2011:article/761452017-05-11T19:21:54Z2017-05-11T19:21:54ZThere’s a strong link between anxiety and depression, and sleep problems, and it goes both ways<figure><img src="https://images.theconversation.com/files/164981/original/image-20170412-26751-10wvhni.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Treating sleep problems first will help in treating anxiety and depression.
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/bergie/2708590344/">Henri Bergius/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Good sleep is essential for our mental well-being. Just one night of disturbed sleep can leave us feeling cranky, flat, worried, or sad the next day. So it’s no surprise sleeping problems, like <a href="https://theconversation.com/explainer-whats-the-link-between-insomnia-and-mental-illness-49597">difficulty falling asleep</a>, <a href="https://theconversation.com/why-a-lack-of-sleep-makes-us-depressed-and-what-we-can-do-about-it-66446">not getting enough sleep</a>, or regularly disrupted sleep patterns, are associated with anxiety and depression.</p>
<p>Anxiety and depression, which can range from persistent worry and sadness to a diagnosed mental illness, are <a href="https://mhsa.aihw.gov.au/background/prevalance/">common and harmful</a>. </p>
<p>Understanding the many interacting factors likely to cause and maintain these experiences is important, especially for developing effective prevention and treatment interventions. And there is <a href="https://theconversation.com/why-sleep-could-be-the-key-to-tackling-mental-illness-50102">growing recognition</a> sleep problems may be a key factor.</p>
<h2>Which problem comes first?</h2>
<p>The majority of <a href="https://www.researchgate.net/profile/Pasquale_Alvaro/publication/243970419_A_Systematic_Review_Assessing_Bidirectionality_between_Sleep_Disturbances_Anxiety_and_Depression/links/00b7d52c1e76b94ef4000000.pdf">evidence</a> suggests the relationship between sleep problems and anxiety and depression is strong and goes both ways.</p>
<p>This means sleep problems can lead to anxiety and depression, and vice versa. For example, worrying and feeling tense during bedtime can make it difficult to fall asleep, but having trouble falling asleep, and in turn not getting enough sleep, can also result in more anxiety. </p>
<p>Sleep disturbance, particularly insomnia, has been shown to <a href="http://www.sciencedirect.com/science/article/pii/S0022395606001440">follow anxiety and precede depression</a> in some people, but it is also a common symptom of both disorders.</p>
<p>Trying to tease apart which problem comes first, in whom, and under what circumstances, is difficult. It may depend on when in life the problems occur. Emerging evidence shows sleep problems in adolescence might <a href="http://www.sciencedirect.com/science/article/pii/S1087079214000392">predict depression</a> (and not the other way around). However, this pattern is not as strong in adults. </p>
<p>The specific type of sleep problem occurring may be of importance. For example, anxiety but not depression <a href="https://www.ncbi.nlm.nih.gov/pubmed/15816796">has been shown</a> to predict excessive daytime sleepiness. Depression and anxiety also commonly occur together, which complicates the relationship. </p>
<p>Although the exact mechanisms that govern the sleep, anxiety and depression link are unclear, there is overlap in some of the underlying processes that are more generally related to <a href="http://www.sciencedirect.com/science/article/pii/S0167876013001475">sleep and emotions</a>.</p>
<p>Some aspects of sleep, like the <a href="http://www.smrv-journal.com/article/S1087-0792%2815%2900090-8/abstract">variability</a> of a person’s sleep patterns and their impact on functioning and health, are still relatively unexplored. More research could help further our understanding of these mechanisms.</p>
<h2>Sleep interventions</h2>
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<img alt="" src="https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=306&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=306&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=306&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=384&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=384&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165012/original/image-20170412-25865-11rubq6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=384&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Disentangling which problems come first, and under what circumstances, is difficult.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/masha_k_sh/2265926543/">masha krasnova shabaeva/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>The good news is we have effective interventions for many sleep problems, like <a href="https://www.mja.com.au/journal/2013/199/8/insomnia-prevalence-consequences-and-effective-treatment?inline=true">cognitive behaviour therapy for insomnia (CBT-I)</a>. </p>
<p>So there is the possibility that targeting sleep problems in people who are at risk of experiencing them – like teenagers, new mothers and people at risk for anxiety – will not only improve sleep but also lower their risk of developing anxiety and depression. </p>
<p>Online interventions have the potential to increase cost-effectiveness and accessibility of sleep programs. A <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2815%2900536-2/abstract">recent study</a> found a <a href="http://www.myshuti.com/">six-week online CBT-I program</a> significantly improved both insomnia and depression symptoms. The program included sleep education and improving sleep thoughts and behaviours, and participants kept sleep diaries so they could receive feedback specific to their sleep patterns. </p>
<p><a href="http://psychologicalsciences.unimelb.edu.au/research/msps-research-groups/adpt">We’re conducting some research</a> to improve and even prevent physical and mental health problems early in life by <a href="https://www.ncbi.nlm.nih.gov/pubmed/27775416">targeting sleep problems</a>. Using smart phone and activity tracker <a href="https://adaptlab.uoregon.edu/projects/">technology</a> will also help tailor mental health interventions in the future.</p>
<p>General improvements to sleep might be beneficial for a person with anxiety, depression, or both. Targeting one or more features common to two or more mental disorders, like <a href="http://www.sciencedirect.com/science/article/pii/S0272735810000668">sleep disturbance</a>, is known as a <a href="http://www.tandfonline.com/doi/abs/10.1080/16506070903033825">“transdiagnostic”</a> approach. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0272735815000914">Interventions</a> that target transdiagnostic risk factors for anxiety and depression, <a href="http://www.sciencedirect.com/science/article/pii/S0005796716302352">like excessive rumination</a>, have already shown some success. </p>
<h2>A good foundation</h2>
<p>For many people, treating sleep problems before treating symptoms of anxiety and depression is less stigmatising and might encourage people to seek further help. Addressing sleep first can develop a <a href="https://www.researchgate.net/profile/Jenna_Gress-Smith/publication/5396138_Manber_R_Edinger_JD_Gress_JL_San_Pedro-Salcedo_MG_Kuo_TF_Kalista_T_Cognitive_behavioral_therapy_for_insomnia_enhances_depression_outcome_in_patients_with_comorbid_major_depressive_disorder_and_insomni/links/004635335d66965b40000000.pdf">good foundation</a> for further treatment. </p>
<p>For example, people with a depressive disorder are <a href="http://www.psychiatrist.com/JCP/article/Pages/2012/v73n04/v73n0412.aspx">less likely to respond</a> to treatment and more likely to <a href="http://www.journalofpsychiatricresearch.com/article/S0022-3956%2802%2900052-3/fulltext?refuid=S0033-3182%2813%2900219-3&refissn=0033-3182&mobileUi=0">relapse</a> if they have a sleep problem like insomnia. </p>
<p>Many of the skills learned in a sleep intervention, such as techniques for relaxation and reducing worry, can also be used to help with daytime symptoms of both anxiety and depression. And this is not to mention the <a href="https://theconversation.com/health-check-three-reasons-why-sleep-is-important-for-your-health-41176">physical benefits</a> of getting a good night’s sleep! </p>
<p>If you’re concerned about your <a href="https://www.sleephealthfoundation.org.au/">sleep</a> or <a href="https://www.beyondblue.org.au/">mental health</a>, speak to a health care professional such as your GP. There are already a number of effective treatments for sleeping problems, depression and anxiety, and when one is treated, the other is likely to improve. </p>
<p>And with research in this area expanding, it’s only a matter of time before we find more ways to use sleep improvement interventions as a key tool to enhance our mental health.</p>
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<p><em>Professor Emeritus John Trinder contributed to this article.</em></p><img src="https://counter.theconversation.com/content/76145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joanna Waloszek has received funding from the Australian Government Research Training Program Scholarship. </span></em></p><p class="fine-print"><em><span>Monika Raniti receives funding from the Australian Government Research Training Program Scholarship and is a member of the Australian Psychological Society and Sleep Research Society. </span></em></p>Sleep problems can lead to anxiety and depression, and vice versa. General improvements to sleep might be beneficial, whether a person has anxiety, depression, or both.Joanna Waloszek, Postdoctoral Research Fellow in Psychology, The University of MelbourneMonika Raniti, Master of Psychology (Clinical)/PhD Candidate, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/490212015-10-15T10:44:34Z2015-10-15T10:44:34ZThe problem with most NHS-recommended mental health apps? There’s no evidence they actually work<figure><img src="https://images.theconversation.com/files/98431/original/image-20151014-15162-114zxpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Easy to access, hard to prove</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The unmet need for mental health services is reaching an <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/thousands-attempt-suicide-while-on-nhs-waiting-list-for-psychological-help-9734284.html">unprecedented level</a> thanks to rising demand and continually falling NHS resources. <a href="http://www.mentalhealth.org.uk/content/assets/PDF/publications/manifesto-better-mental-health-manifesto.pdf">Monthly referrals</a> to community mental health teams increased by 13% in 2013, and 16% in the case of crisis services. Yet more than 200 full-time NHS mental health doctors and 3,600 nursing positions <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/cuts-leave-nhs-mental-health-services-dangerously-close-to-collapse-9667370.html">have been lost</a> over the same period.</p>
<p>As so many of us now have access to and rely on smartphones, one increasingly popular solution to this problem is the use of apps to provide automated forms of mental health treatment. Apps are relatively inexpensive, widely available and, unlike traditional NHS mental health services, can be used by more than one person at any specific time. Some apps, such as <a href="https://www.bigwhitewall.com/home/how-it-works.aspx#.Vh49G_lViko">Big White Wall</a>, offer a community support service with access to trained healthcare professionals at any time of the day. Others provide automated <a href="http://thriveport.com/products/moodkit/">cognitive behavioural therapy</a>(CBT) and methods for <a href="https://www.moodscope.com/">mood tracking</a> or <a href="http://www.happyhealthyapp.com/">self-reflection</a>.</p>
<p>Only a half of people <a href="http://www.mind.org.uk/media/280583/We-Need-to-Talk-getting-the-right-therapy-at-the-right-time.pdf">have a choice</a> about when they receive conventional mental health therapy and just 13% can choose where. Using mental health apps would allow people to access a form of treatment on their terms and could even extend therapy to people who are currently unable to engage with it. This could include the teenager who is too anxious or stigmatised to discuss his condition face-to-face, the armed forces serviceman who needs anonymity, or the single mother who struggles to schedule an appointment around her childcare and work commitments. </p>
<h2>No hard evidence</h2>
<p>The reality is that there is a large gap between the theoretical benefits of mental health apps and what they are likely to deliver in practice. Of the 27 mental health apps endorsed and recommended through the NHS health apps library, 14 are designed to treat or manage the symptoms of depression and anxiety. They are frequently described as helping users to do things like <a href="https://itunes.apple.com/gb/app/the-mindfulness-app/id417071430?mt=8">control stress</a>, <a href="http://mentalhealthpartnerships.com/resource/five-ways-to-wellbeing-app/">improve well-being</a> and <a href="http://www.blackrainbow.org.uk/">beat depression</a>.</p>
<p>Yet <a href="http://ebmh.bmj.com/content/early/2015/09/16/eb-2015-102203">only four</a> of these apps currently provide any hard evidence of results reported by <a href="https://www.bigwhitewall.com/home/how-it-works.aspx#.Vh49G_lViko">real-world users</a>. And <a href="https://www.moodscope.com/">just two</a> make use of NHS-accredited ways of measuring the effectiveness of mental health treatments, such as the <a href="http://archinte.jamanetwork.com/article.aspx?articleid=410326">Generalised Anxiety Disorder 7</a> questionnaire. This leaves a question over the effectiveness of the remaining 12 out of 14 (85%) of NHS-accredited mental health apps.</p>
<p>In 2013, there were 1,536 depression-related apps available for download but just 32 published research articles studying <a href="http://www.jmir.org/2013/6/e120/">their effectiveness</a>. This pattern of high availability and a low evidence base can also be seen in apps for treating <a href="http://www.jmir.org/2015/8/e198/">bipolar disorder</a>, <a href="http://www.sciencedirect.com/science/article/pii/S0005796714001624">bulimia nervosa</a> and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439418/">post-traumatic stress disorder</a> (PTSD).</p>
<p>But the real problem is with the apps that come with a seal of approval from a world-leading healthcare system. Accreditation by the NHS gives apps an appearance of quality, and the reputation and legitimacy of an app <a href="http://www.jmir.org/2013/4/e86/">correlates with</a> how many people are likely to download it. </p>
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<img alt="" src="https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98432/original/image-20151014-15137-684rs6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Therapy on the go.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p><a href="http://www.%0Amind.org.uk/media/280583/We-Need-to-Talk-getting-the-right-therapy-at-the-righttime.pdf">Three in ten</a> people with an untreated mental health issue choose to pay for private treatments, and apps that have yet to demonstrate any measurable benefits are a potential waste of their money. But they could also compound levels of anxiety in those with the greatest need and the least access to effective NHS-led mental health services. Unsuccessful attempts to resolve any mental health issues are only likely to make sufferers feel that no solution is possible.</p>
<p>The NHS usually provides a regulatory framework that is second to none, and winning over its guidance body, NICE, is usually seen as a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391507/">major hurdle</a> for developers of new medical products. Unfortunately, it seems as though the same level of evidence-based decision making has not been applied to the apps that the NHS has been recommending to mental health patients. </p>
<p>Luckily, it would appear that this subject is now being taken more seriously. As of October 16, the NHS health apps library will officially cease to exist and the organisation is looking for new ways to assess and regulate such products. A framework to help app developers understand what level of clinical quality and evidence they need to reach would be highly beneficial.</p>
<h2>Spotting the good ones</h2>
<p>In the meantime, there are some clear signs of quality that users can look out for to ensure mental health apps do not do more harm than good. Firstly, apps that are supported by a mental-health practitioner are on average more than <a href="http://www.sciencedirect.com/science/article/pii/S027273581200027X">twice as effective</a> as those developed without professional expertise.</p>
<p>While the NHS itself may not have enforced such rigour, well-established regulatory bodies such as NICE and the US Food and Drug Administration can help highlight apps that offer real solutions. It is also worth checking how much information the app developers provide about their products. Is there any proof that their claims of “beating depression” are anything more than marketing?</p>
<p>Finally, it is worth remembering that some mental health apps are designed with clinical quality and effectiveness in mind and provide real support to their users. For example, <a href="https://www.bigwhitewall.com/landing-pages/landingv3.aspx?ReturnUrl=%2f#.Vh5I2flViko">Big White Wall</a> boasts a recovery rate of 58%, better than the 44% recorded by the NHS’s flagship initiative to increase access to traditional mental health therapies <a href="http://www.hscic.gov.uk/catalogue/PUB14899/psyc-ther-ann-rep-2013-14.pdf">over the same period.</a>. So apps can improve people’s mental health, at a low cost and from the comfort of their own home, but only if done properly.</p><img src="https://counter.theconversation.com/content/49021/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Leigh consults to MINeD ACCESS Ltd, a a technology company delivering solution-focused brief therapy (SFBT). </span></em></p>If apps aren’t proven to make users’ mental health better they could end up making it worse.Simon Leigh, Health economist, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.