Study shows WhatsApp messages effective for elderly depression treatment

WhatsApp can be a highly effective tool to help older people overcome loneliness and depression, according to the findings of a study conducted in Guarulhos, the second-largest city in São Paulo state, Brazil.

An article on the study is published in the journal Nature Medicine. The co-corresponding author is Marcia Scazufca, a scientific researcher at Hospital das Clínicas (HC), the hospital complex run by the University of São Paulo's Medical School (FM-USP), and a professor at the school.

"This was a randomized controlled trial involving 603 participants aged more than 60 and registered with 24 primary care clinics belonging to the SUS [Sistema Único de Saúde, Brazil's national public health network]. They were positively screened for depression and displayed significant symptoms of the disorder. They were randomly divided into two groups," Scazufca explained.

"The intervention group, with 298 participants, received WhatsApp messages via the Viva Vida program twice a day, four days a week, for six weeks, with educational content on depression and behavioral activation. The control group, with 305 participants, received a single message with educational content. Neither group received support from health care professionals."

The name of the program, Viva Vida, means "Long Live Life."

The average age of the participants was 65.1. Women were a large majority (74.8%). Although 603 people were initially recruited, only 527 (87.4%) completed the follow-up assessment. Symptoms of depression improved in 42.4% of the intervention group, compared with 32.2% in the control group.

"This suggests that intervention in the form of mobile phone messages was an effective short-term treatment of depression for older people in areas with limited health services," Scazufca said.

Selection of participants was based on answers to Patient Health Questionnaire-9 (PHQ-9), a widely validated screening tool used to assess the presence and severity of depression based on a scale from 0 to 27, with 0–4 indicating absence of depression, and 5–9, 10–14, 15–19, and 20–27 indicating mild, moderate, moderately severe and severe depression respectively.

"We invited everyone with a score of 10 or more in the initial assessment to participate, so that our sample included people with moderate as well as severe depression," Scazufca noted.

Because many low-income elderly Brazilians are semi-literate or illiterate, the intervention group received three-minute audio messages or images but no text messages. The researchers took care to use simple language inspired by popular radio programs. Two actors, pseudonymously Ana and Léo, read the messages, which evolved from educational phrases about depression to guidance on behavioral activation and advice on avoiding a relapse.

"The difference of ten percentage points between the intervention and control groups in terms of improvement may seem small, but considering the very low cost of Viva Vida and the very large proportion of the population it could potentially reach, these ten percentage points could represent millions of people. Moreover, Viva Vida should be seen as a first step, which can be combined with other forms of intervention. It's important to note that that vast majority of the participants had never received treatment of any kind for depression, and hadn't even been diagnosed as depressed," Scazufca said.

The result is especially relevant in a middle-income country like Brazil, where the number of older people is rising fast and mental health services are scant, she added. The low cost of the program and the ease with which it can be implemented means it can be replicated in other countries with similar or worse socioeconomic conditions and where conventional treatment is unavailable or unaffordable for many.

"As we continue this type of research, we may find even stronger evidence of the benefits of digital mental health intervention and of extending the coverage of psychosocial treatment globally," she said.