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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Douglas Adams Effect
- stephen brealey (25 November 2005)
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Goodbye and thanks for all the fish
- Mats Reimer (26 November 2005)
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Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression
- Biju Basil, Maju Mathews (27 November 2005)
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Further research in animal assisted therapy (AAT)
- Daniel J. Benor, MD (28 November 2005)
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Dolphins against depression
- Anna Conway Morris (28 November 2005)
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Cuddling with Koalas
- Michael R Forster (29 November 2005)
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Caring
- NANCY K O'CONNOR (29 November 2005)
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Dolphin?
- Theodore RW Floyd (29 November 2005)
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Poor dolphins!
- Mokhtar G E K N Isaac (30 November 2005)
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Should we be expert swimmers to receive this treatment
- Charles N Antwi (30 November 2005)
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What about the dolphins?
- Martin D Ferry (30 November 2005)
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Re: Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression
- Alok Kumar Jha, Indranil Chakravorty (1 December 2005)
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Clarification
- Christian Antonioli (1 December 2005)
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Turning point
- Niamh E Lynch (2 December 2005)
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What we are trying to do.
- Michael A Reveley (2 December 2005)
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How do the dolphins accomplish this?
- ABDULKADR MUSA/Dr. (8 December 2005)
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Swimming with dolphins? We might as well all be farmers
- Haroon Y. Raja, Twana Faraj (Trust grade), Graham Hill (locum consultant) (8 December 2005)
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Excellent Contribution to the Field of DAT
- Scott Taylor (9 December 2005)
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stephen brealey, Research Fellow York Trials Unit, University of York, YO10 5DD
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Fascinating study - it is great to see that Douglas Adams hypotheis has been proved correct! Douglas Adams ...Man had always assumed that he was more intelligent than dolphins because he had achieved so much... the wheel, New York, wars, and so on, whilst all the dolphins had ever done was muck about in the water having a good time. But conversely the dolphins believed themselves to be more intelligent than man for precisely the same reasons Competing interests: None declared |
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Mats Reimer, Community Pediatrician Child Clinic Molnlycke SWEDEN
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Christmas comes early this year, because BMJ usually reserve the unprobable and hilarious papers for its x-mas edition. This paper shows that single depressed women who want to try swimming with dolphins as therapy, actually feel less depressed if they are allowed to do this than if they are disapointed by being allocated to a control group. Hello? I must agree with the fist published rapid response - Douglas Adams was right. Competing interests: I'm allergic to cats and dogs, and usure if I might be allergic to dolphins also. Still I don't think i suffer from biophobia. |
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Biju Basil, Resident Physician Philadlephia, PA 19067, USA, Maju Mathews
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Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression We read with interest the article tilted ‘Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression’. The conclusions of the study made interesting reading. But we have the following concerns with this study: • The study had a very small sample of 30 patients and of that only 13 people from the animal care program and 12 people from the outdoor nature program completed the study. The authors of this study used an extremely conservative measure (on the basis of 0.8 power to detect a significant difference with P=0.05; two sided) to estimate the number of patients required for this study, and even then fell short by 17%. • There was predominance of single females in both arms of this study. 14/15 of the participants in the animal care program and 13/15 in the outdoor nature program belonged to female sex. 23 of these 27 were single women. • The authors say that clinical raters were blinded to treatment assignments and to the hypothesis under testing. It is difficult to fathom how that it is possible to be blind to the treatment hypothesis. • Only people who could go to Honduras were able to take part in this study. Most people with mild depression won’t be able to take a three week seaside vacation. • The authors have not mentioned the ethnic breakup of the people who took part in this study. • Swimming and snorkeling with fishes in a Latin American location are not the favorite past time of most people in the world and most people would not be able to afford it. So it is not possible to generalize the findings of this study. • It is not mentioned whether the study group sponsored the three week trip to Honduras. We suspect that, a free three week trip to a seaside location in Latin America would in itself be a powerful antidepressant. We would term this ‘vacation bias’. The authors of this study tried to control for this by having a control group at the same location. But a ‘disappointment bias’, as we outline next could have negated this. • It is not mentioned whether the control group were aware of the potential to be in a group, where they could interact with Dolphins for two week duration, before they reached Honduras. If so, the disappointment in missing out could lead to what we would term ‘disappointment bias’. It is well known that people with depression perceive disappointment more intensely. • A hypothesis of ‘boiphilia’ is a much tested hypotheses. For studying this hypothesis, a choice of dolphins in an exotic location is a classic case of wasting research dollars on non plausible treatment options. This could have been done in a more natural and plausible settings with common pets like dogs or cats for a fraction of the cost of this study. It is extremely disappointing that a high impact journal like British Medical Journal decided to publish this study. References: 1. Christian Antonioli and Michael A Reveley. Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression. BMJ 2005; 331: 1231 Competing interests: None declared |
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Daniel J. Benor, MD, Editor, International J Healing and Caring www.ijhc.org Medford, NJ 08055
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Lovely to see this randomized controlled study of dolphin-assisted therapy, confirming anecdotal reports over the past 20 years. See further references on Animal Assisted Therapy (AAT) at http:// wholisticHealingResearch.com/References/AAT.asp Competing interests: None declared |
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Anna Conway Morris, Senior House Officer Psychiatry Borders General Hospital, Melrose, Roxburghshire, TD6 9BS
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Dear editor, I wish to express considerable reservations regarding the conduct of Antonioli and Reveley’s study of dolphin facilitated treatment of depression. I am surprised that an ethical committee would consider approving a trial where patients in the control arm are being denied standard therapy which is of proven efficacy. It would be hard to envisage an randomised controlled trial of a novel therapy in coronary artery disease where the control group were denied aspirin. My second reservation regards the lack of follow up. We do not know whether the perceived improvement in symptoms was maintained following the withdrawal of dolphins. Consequently clinicians will be unable to advise their patients as to whether this would be a useful therapy and worth its considerable cost. Were this to be a study of a psychological or pharmacological intervention this deficit would have been regarded as a fatal flaw. Patients and relatives are often sceptical about conventional psychiatric interventions and deserve research of the highest quality when comparing alternatives. Leaving aside the methodological flaws, the lack of applicability to the great majority of depressed patients should have prevented the publication of this study in a high profile journal. Competing interests: None declared |
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Michael R Forster, Consultant in Anaesthesia and Intensive Care Perth Royal Infirmary, Perth, PH1 1NX
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Realising that the BMJ has resorted to publishing studies(1)for their ability to impact on the news, rather than their impact on real patient welfare, has made me feel a bit depressed. If anyone is planning a further study along the lines of "cuddling with koalas," I would be happy to take part, especially if it involves a couple weeks down under. I am sure it would make me feel better. I believe there may be health risks associated with close koala contact- we might need a follow-up study to quantify those, preferably next winter. References: 1. Christian Antonioli and Michael A Reveley. Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression. BMJ 2005; 331: 1231 Competing interests: None declared |
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NANCY K O'CONNOR, retired Gapan City Philippines 3105
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I am sure swimming with dolphins will help depression... Heck, simple "tincture of time" will help mild to moderate depressions, as will vacations at exotic resorts... I have no doubt hugs by grandchildren and having a pet will help depression...why not do a double blind study using a kitten as placebo? Call it "Garfield Therapy". Competing interests: None declared |
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Theodore RW Floyd, Student Imperial College London
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After reading this article I find myself deeply unimpressed by the work. The methods used in this research and hence the conclusions drawn are not very rigorous. It seems obvious to me that a group of totally random people irrespective of suffering from depression would find playing with a dolphin more stimulating and "fun" than being told about barrier reefs. I think that the authors are correct in their conclusion that the dolphins helped to treat the patients depression, however it seems a rather over exotic form of treatment. The point being that yes, animal therapies work, but to conclude that the fact that the therapy worked was due to the presence specifically of a dolphin, I believe not to be true. Any activity with a suitable stimulating animal is shown to help patients and finally the test also only involved, in the end, less than 30 patients, far more surely should be required to draw any such conclusions. Competing interests: None declared |
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Mokhtar G E K N Isaac, Specialist Registrar Old Age andGeneral Adult Psychiatry East Sussex County Healthcare, Eastbourne DGH, BN21 2UD
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I am amazed that such a study with a very small sample size, and many other methodological flaws, is published by a respectable journal like the BMJ. It is will known that interaction with the nature and exercise has a therapeutic effect on mild depression. It would have been more amusing and interesting to study the effects of the therapy on the dolphins. I think most likely that the dolphins’ behaviour following the therapy might show evidence of stress and depression. Of course the dolphins could be successfully treated by having some treatment sessions with healthy dolphins or other kind of fishes, whom in turn might get depressed and so on. I sympathise with the poor dolphins, as they had to entertain and "treat" depression but no one seems to think about them. Christian Antonioli and Michael A Reveley Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression BMJ 2005; 331: 1231 Competing interests: None declared |
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Charles N Antwi, Senior House Officer, Psychiatry Wonford House Hospital, Dryden Road, Exeter EX2 5AF
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EDITOR-I applaud Antonioli C and Reveley MA on this novel therapy. It is certainly very sensational and quite unusual. Presumably, all patients undertaking this therapy must be expert swimmers. I am currently feeling depressed, but unfortunately I may not be eligibile for this treatment as I always sink whenever I try to swim. Hopefully this is treatment may prove to be beneficial and perhaps it is worth developing larger studies to establish efficacy. Competing interests: None declared |
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Martin D Ferry, Student G11
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The authors of this paper have not commented upon a significant aspect of this paper: did swimming with depressed people make the dolphins miserable? Competing interests: None declared |
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Alok Kumar Jha, Senior House Officer 1st Floor, Wessex House, Falcon Court, Preston Farm Estate, Stockton, TS18 3tx, Indranil Chakravorty
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This article did make interesting reading however we were left with a feeling of dissatisfaction on account of lack of explanation of why the therapy had to take place in this particular setting and with this set of animals. In our opinion if an experiment was to be conducted, regarding the therapeutic effects that the company of animals or even water has, why could it not be done in a far less expensive setting with trained domestic animals, like a cat or a dog. This would have saved unnecessary expenses of finding trained dolphins, along with their trainers or a visit to the sea side, with a supposed lengthy stay there. Again for the point of view of cost, the saving would have been considerable if the whole thing could have been carried out in an out patients setting with good results. We would then have been in the position of saying it has been recently proven in America that play with animals is useful, so why don’t you get yourself a pet. This is much more realistic then telling people to go and swim with dolphins. The study would have been far more useful if carried out in realistic surroundings as it is difficult to duplicate unless one is located at sea side and dolphins are accessible. Though implications could be huge in terms of saving of medical resources and economy, it needs to be more realistic in terms of environment, Again a lot of depressed people do have pets or the loss of a pet can be like a grief reaction. This is a well known fact already and the question does certainly arise do we need to relearn all this through a costly experiment. However I would not be averse to going out and swimming with the dolphins in Hawaii, it looks like a better option compared spending the Christmas in United Kingdom. Yours Sincerely Alok Jha Indranil Chakravorty Competing interests: None declared |
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Christian Antonioli, President Tursiops Society Onlus
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Dear Editor, It appears, from the responses we read, a misunderstanding of our work. In 1995 Roger Montenegro wrote: "Mankind is now at a turning point. The continuous damage of the ecosystems on which we depend to survive in our planet has led us to the urgency of planning some sort of joint action to achieve better conditions of living for everybody. The preservation and improvement of the ecosystems is closely bound to the improvement of quality of life and health.[...]." In 1995 the Executive Committee of the World Psychiatric Association accepted Roger Montenegro’s request of founding the WPA Section "Ecology, Psychiatry and Mental Health". We are not trying to advocate the utilization of dolphins versus other animals, but simply to put in evidence the biophilic method of intervention, which is based on a holistic approach, through interaction with animals in nature and the stimulation of the nervous systems through the senses. This, represents a new emphasis in psychiatry and has the potential to bring alternative clinical strategies to the treatment of emotional disorders. We encourage further research in the field of integrative medicine. Competing interests: None declared |
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Niamh E Lynch, Paediatric neurology fellow Vancouver V6P 1T4
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Mankind is at another turning point in 2005. It is no longer widely considered acceptable to keep wild creatures, particularly marine mammals, in captivity. I looked up the Roatan Institute for Marine Science website and they refer to bottle-nosed dolphins that they 'house' at their facility. Does 'housed' mean captive? And was it the 'housed' dolphins that were used in the study? Competing interests: None declared |
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Michael A Reveley, Professor of Psychiatry Department of Health Sciences, University of Leicester LE5 4PW
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Editor Depression is an important health problem worldwide. The lifetime prevalence of depressive disorders is 15%, and the cost in morbidity and economics is substantial. Despite advances in drug treatment and some forms of psychotherapy, the problem remains. At least 30% of patients do not significantly improve with antidepressants and many more do not have full remission. Many others cannot tolerate drug side effects. Despite limitations of current treatments, and the extent of the problem, there has heretofore been no serious attempt to validate an "alternative" treatment for which there has been anecdotal evidence of efficacy in some mental disorders and disabilities. The aim of our study was to begin to establish an evidence base for animal assisted therapy in depression. We used the "gold standard" of the randomised, controlled trial. It was necessarily single blind, as is the case in most, if not all, trials of a psychotherapy in which fully informed consent is obtained. To the best of our knowledge, this is the only randomised controlled trial of animal assisted therapy with any animal, using strictly defined diagnostic criteria, and rigorous inclusion and exclusion criteria, to be published in a refereed journal. We hope that we have shown that such studies can be done and that further RCTs with other animals will be done to establish evidence based efficacy not only for depression, but also for other psychiatric illnesses and disabilities. Basil and Mathews expressed several concerns to which we reply. We used an intent to treat, last observation carried forward, analysis, which means that all 30 subjects who were randomised to enter the study, including the dropouts, were included in the analysis. This provides a conservative measure, making it more difficult to show an effect. The results were highly significant statistically, reflecting the large differences in improvement between the groups, and the small variance, despite the modest sample size. Women outnumber men two to one in the prevalence of depression, and being unmarried without a close, confiding relationship is a risk factor for depression. This may explain the preponderance of unmarried women in the sample. We believe men would be as responsive as women to the therapy, but it may be that those without close human relationships would be more responsive. This is an issue for further research. It is self-evident that most people with depression will not be able to swim with dolphins. The purpose of the study was to establish a principle, not to develop a universal therapy with dolphins for everyone. Clearly, further RCTs with other animals are needed. Participants paid for their own travel expenses. It is true that going to a pleasant location, away from the stress of one's usual environment, would be expected to improve mood and reduce anxiety, even in depressed people. That is precisely why we had a control group, which had the same non-specific experiences as the experimental group. We think "disappointment bias" was not a significant factor, as the control group swam with dolphins after the study ended. The control group also improved slightly during the study, reflecting the "placebo" effect of the pleasant location. The controls did not become more depressed, as might be expected if depressed people had "perceived disappointment more intensely". The hypothesis of biophilia is not a "much tested hypothesis". In fact, the hypothesis of biophilia has never before been tested with a randomised, controlled trial. The study was supported by the voluntary contributions of those acknowledged. It was not supported by an external grant awarding body. Conway Morris has expressed reservations about ethics and follow-up. The study had full ethical approval by the local IRB. Fully informed consent was obtained from all participants after the study had been fully explained. Patients with severe depression, or in whom continued standard treatment was essential, were excluded. In fact many people with depression do not wish to receive medication or have intolerable side effects which lead them discontinue medication and seek an alternative therapy. We believe it is ethical, indeed a doctor's duty, to offer them that therapy when it has been validated by RCTs. If there are no RCTs of a potential therapy, it is ethical to carry out such trials. As regards follow-up, as we described in the paper, three months or more after the study, patients provided a self-report of their mental health status. Please read the paper for the results. We have fully discussed the limitations of the study in the paper. We do not propose that dolphin assisted therapy will be a common therapy for most people. More studies with other animals are needed. We believe we have shown that the biophilic principle can be used to devise effective therapies and that their validation by randomised, controlled trials is feasible. In the era of evidence based medicine, we need more controlled trials of alternative therapies. We hope our study will inspire others to develop and validate new therapies for the millions of people world wide who suffer from depression. Professor Michael Reveley
No competing interests Competing interests: None declared |
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ABDULKADR MUSA/Dr., postgrad student in mental Health studies,iop,,king's college ,London 9th Floor, Capital House,42 Weston street, London,SE13QD
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The perception that dolphins could have a healing capability is not a novelty; this has been known since ancient times. Communication skills of the dolphins are akin to or even superior to those of humans; they possess special chemicals in their melons which are not found in other mammals. As it is said 'they see with their ears, hearing reflected lights' because of their large acoustic nerve. Studies have been conducted about their effect in patients with spinal injury and learning disability. The authors imply that the mechanism involved in this healing effect of the dolphins is obscure, at best apriori. In 1947, Arthur Mcbride presented evidence that the atlantic bottlenose dolphin may detect objects underwater by echolocation(Mcbride 1956). The acoustic fields of the different species of dolphins differ and their ability to carry out different tasks depends on the characteristics of their sonar signals and, on how these are emitted; target detection varies across species ; when dolphins emit a signal, they wait until it is reflected before emitting a new one; the number of clicks and the click interval depends on the distance between the dolphin and the object amongst other things. When confronted with a strange object, the dolphin emits a audible signal but emits none when in contact with a familiar one and, they can also increase the amplitude of their signals for enhancement. So, it was quite surprising why the authors in writing such a paper did not dwell on this; even, a cursory look at the internet will give a lot of information: David Cole wrote about the formation of cavitations in the brain that lead to the creation of regions of compressions and expansion forming bubbles in cell membranes that eventually facilitate the movemnt of molecules; an encounter with a dolphin is said to lead to pain reduction, increased ease of breathing, muscle relaxation, feeling of euphoria, etc As the efficacy of non-biological treatments for depression and other mental illness has been proven, this particular mode of treatment though, not going to be readily available, is a welcome addition to our armamentarium in psychiatry. The sonar of dolphins.Whitlow W L,Au .Spinger-Verlag.1993.pg 2- 4,115,137. Echolocation in Whales and Dolphins.PE Purves;GE Pilleri.Academic press1983.pg114,249. New Oxford Textbook of psychiatry,M G Gelder et al. vol.1 Oxford university press.2000 pg 14 Competing interests: None declared |
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Haroon Y. Raja, Educational Staff Grade Psychiatrist Fieldhead, Ouchthorpe Lane, Wakefield WF1 3SP, Twana Faraj (Trust grade), Graham Hill (locum consultant)
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We have appraised the paper by Antonioli and Reveley (1). This is of particular importance given the subsequent media reporting (2). Although we welcome alternative therapies, it is essential that proposed new treatments are robust. We are glad to see a randomised, controlled, single-blind study using validated outcome measures. The use of a power calculation and analysis by intention to treat with last observation carried forward is also to be applauded. However we are concerned about the following matters. This is a highly self-selected sample with its subsequent bias. The preponderance of female subjects (90%) confirms this. We also have grave concerns about the validity of saying that swimming with dolphins is a treatment for depression. We highly suspect that a group of normal mental health controls would have shown similar mood elevating results given the same intervention over a similar time course. The control group also had a biophyllic intervention and therefore should have had a similar positive effect. The intervention is really a positive life event and therefore any changes in mood are an adjustment reaction to this. Other positive life events (such as hot air ballooning) are likely to have the same effects. We suspect that pet therapy is much more likely to have an enduring effect on a chronic illness such as depression. It is also more pragmatic to the population in question. If we follow the biophyllic hypothesis, all those who work in nature (e.g. farmers) should not develop depression. Clinical experience tells us that this is far from the truth. References: 1. Christian Antonioli and Michael A Reveley. Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression. BMJ 2005; 331: 1231 2. Swimming with dolphins can beat depression. Daily Mail 25/11/2005 Competing interests: None declared |
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Scott Taylor, Director Cetacean Studies Institute, PO Box 2116, Byron Bay, NSW Australia 2481
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Thank you for doing this study and keeping it well within the scientific requirements for serious research. As a long-time student and researcher in the field of Dolphin- Assisted Therapy (DAT), I know all too well how few papers have been published in respectable journals on this topic. With literally thousands of families having had wonderful effects from DAT over the approximately 20 years since its beginnings, DAT must be considered as a worthwhile, and successful therapy. Depression is only one of the many conditions susceptible to DAT, and one of the rare adult conditions being addressed these days. Island Dolphin Care, in Key Largo Florida, has been successfully working with families of special-needs children for many years. They recently opened their $3 Million dollar (US) purpose-built facility to continue this work. Many families suffer from adult depression as a by-product of the difficulties of living with special-needs children. The results of DAT are frequently both transformative for the child as well as the affected adults. Dolphins are unique creatures, unlike any terrestrial animal. They can both see inside us, just as a medical ultrasound machine can (this technology was originally based, in part, on what dolphins can do), and can respond to percieved needs with their ultrasonic capabilities. A bottlenose dolphin can emit almost five times the ultrasonic power used in hospitals to shatter kidney stones...and it wields this power with its well- documented care and gentle regard for human's needs. In essence, we have, in the dolphin, an extraordinary diagnostician, capable of seeing abnormalities of both physical structure and behavioural actions, and a therapist with on-board capacity for direct therapeutic effect. No other animal comes close to these capabilities, including humans. To suggest that puppies or cats could do as well is simply misinformed opinion not based on fact. Dolphins are thriving in human-managed facilities around the world, many of whom are most correctly seen as no longer ocean creatures, having been born in human care. Their destiny as ambassadors and partners in building interspecies cooperation cannot be denied. Dolphins do not take on the depression of humans. They do not absorb the condition, instead they observe it, regard it as different, and continue to do as dolphins do--they live in extraordinary balance in both mind and body. Meet them yourself and you will see. And take the time to know them well, and you too will feel the depression so prevalent in our world lifting from your shoulders. Competing interests: None declared |
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