It’s 11:03pm and I’m at a fashionable dinner party that has reached the Époisses cheese course. I apologise and say that I need to go home to stimulate myself. There’s an awkward silence, and the person next to me mutters “Punchy.” I quickly clarify that I need to stimulate my brain, not anything else. However, my explanation doesn’t go over well after three and a half hours of pretentious conversation. The hostess scowls and says, “Well, go stimulate whatever parts we haven’t reached yet.” My #socialfail is now complete.
Contemporary mental maintenance can be quite a challenge. One solution that has emerged is Flow, a treatment that uses a brain-exercising headset to target the physical causes of depression, along with a therapy app that addresses behavioural factors such as sleep, diet, and exercise. Flow is a non-chemical, waitlist-free, and side-effect-free treatment that costs £299 for a headset, with a monthly rental option of £79. There’s also a 30-day money-back guarantee for those who don’t see improvements in their mood after three weeks of using the device. According to Flow, 83% of users experience improvements within this period, and 4 out of 5 strongly recommend it.
Last week, it was announced that patients with depression or anxiety will be prescribed self-help apps that deliver cognitive behavioural therapy (CBT) online, according to NHS treatment guidelines. An initial trial will offer web-based courses to about 40,000 people, providing a non-drug-based first-line treatment option that could replace antidepressants. The ultimate goal is to reduce the 8.3 million people in England who were prescribed antidepressants last year. Some experts even suggest replacing pills with art, music, or gardening classes, anything that can alleviate the growing reliance on medication for mental health issues.
At a time when the NHS is actively looking into ways of steering patients off medication, Flow might provide one of these means, offering options both as an accompaniment to happy pills and as a lone, non-drug-based treatment. It is available in Europe, the United Kingdom, Norway and Hong Kong, with plans to launch in the US this year. It arrived here in 2019, after receiving approval from the British Standards Institution. More than 50,000 people have deployed the Flow app (it’s free, so some use this alone), while more than 8,000 have stimulated using the headset, a tenfold growth during the past two years.
Devised by a psychologist and neuroscientist, based on 20 years of research, Flow boasts users aged from 18 to 81. Last year, after demands from British doctors, the company launched a service for professionals. Within four months more than 50 clinics were offering Flow as a therapy, with up to five joining every week. They included psychiatry units, specialist facilities for severe depression, hospitals and primary care practices. Earlier this year it was announced that it is to be trialled at an NHS clinic, the Centre for Neuromodulation, near Northampton. The medical establishment is thus increasingly on board.
Meanwhile, transcranial direct current stimulation (tDCS) – the activation provided by the headset – is gaining a cult following among athletes, musicians and health-hacking tech-bro types persuaded that it can promote focus and mental endurance. Devices are available to buy online, while there’s an amateur community attempting to construct their own.
At this point, allow me to say how sceptical I was, am and will always be of anything promising to treat depression. My mood has not been a problem, even before I learnt that this wasn’t merely the human condition. When I was a child, my psychiatrist father referred to me as “mercurial”. When I was 29, around the time I experimented with St John’s Wort, a boyfriend told me I had “no gift for happiness”. At 39, I went on Citalopram, an SSRI (selective serotonin reuptake inhibitor), one of an estimated 83.4 million antidepressant drugs prescribed in England between 2021 and 2022, an increase of 5 per cent on the previous year.
While I haven’t gone back and forth with my antidepressant medication, many people with depression do, as they often dislike being on them. Even for those of us who consider our antidepressant use successful, managing our moods can still be a challenge. Personally, my sadness tends to follow a hormonal pattern, with two difficult periods during my menstrual cycle. However, I’m one of the fortunate ones. There are individuals for whom medication does not work, and over 1.4 million people in the UK are currently waiting to see a therapist.
We gloom merchants grow tired of amateurs advising that we clutch crystals, try rock climbing or eat moonbeams to alleviate our woes. On the other hand, we’ll also try anything to abate our symptoms. This includes what my partner refers to as “conker cures” after the custom of using conkers to repel spiders. Flow sounds a good deal more promising than smoky quartz to combat suicidal urges. Besides, a placebo effect is still an effect. And so, I sally forth. (I also continue with my regular dose of antidepressants because I may be sad but I’m not a complete maniac.)
Alas, I am not merely an apathetic depressive but a tech-resistant apathetic depressive, meaning it takes days of painful procrastination to get stuck in. Happily, Flow is a cinch. You download the app, and then there’s a spot of cheery, but not utterly maddening, guff about this wonderful new adventure, plus sundry smiling animal images. It assesses your levels of dejection using the widely used Montgomery-Asberg Depression Rating Scale (MADRS-s), then guides you through your first stimulation. (I do wonder about this terminology.)
You unseal a pair of saline-soaked sponges, attach them to the (charged) headset’s electrodes, and then your phone’s selfie mirror guides you in, positioning them over your frontal lobes. A single click, four notes of what sounds like the Addams Family theme, and away you go. Zapping comes via this aforementioned non-invasive brain stimulation technique called transcranial direct current stimulation (tDCS), used as a treatment for psychological disorders for more than a decade in-clinic, activating areas of the brain that experience fewer electrical impulses during the depression.
Full disclosure: it stings. I have extremely sensitive skin, and one gets used to it. However, my first half-hour session isn’t without a degree of swearing and I am left with sponge-induced pockmarks in its aftermath. I sleep extremely well but have a spot of head and neck ache the next morning, possibly because I’ve been clenching. Still, anything short of a One Flew Over the Cuckoo’s Nest meltdown I consider a win.
A week in, an acquaintance inquires whether the point of the device is “to cause you pain, thus making you realise that your life is actually quite good when you remove it”. I reply that depression is a tad more complicated than this, otherwise, I could simply get someone to punch me.
Unrelatedly, my day seven MADRS-s check finds me still more wretched, devastated for no reason, desolate without cause. One of its questions concerns suicidal ideation. Fellow depressives will know that there is a vast difference between thinking about killing oneself and actually attempting it. However, the app does due diligence in advising me not to top myself, steering me to seek outside help via a Mr Happy cartoon. I press on.
Personally, I am not particularly fond of the app’s courses simply because, at nearly 52, I am already aware of the behavioural strategies necessary to prevent depression. However, for individuals who are new to the concepts, the courses might be life-changing. As time goes on, I tend to abandon the courses and instead opt for brain stimulation while flossing in front of Netflix’s Bling Empire. Still, during low points, I prioritise self-care by getting adequate sleep, staying well-fed and hydrated, spending time in natural light, and attempting to engage in enjoyable activities.
Flow recommends completing 15 sessions to ascertain whether one wants to stick with it. (That’s five a week for three weeks for this “activation phase”, and fewer thereafter.) After my regulation 15, I seek out its co-founder, 38-year-old Swedish clinical psychologist Daniel Mansson, with a list of questions; not least, what led him to go with the Flow, as it were?
“After graduation, I worked in an outpatient psychiatric unit in Norway,” he explains, “treating patients with different mental conditions – from moderate depression to severe psychosis. I was seeing day in and day out how traditional treatments were leaving behind so many people desperately in need. I started spending more time researching brain-stimulation technologies that I’d first seen in university and seemed to hold a lot of promise.
“There was no epiphany; it was more of a slow burn. The larger studies on tDCS were just being finalised in 2016, and it seemed obvious it was going to be significant. Even with efficacy that is slightly better or similar to antidepressants, the lack of side effects with tDCS was groundbreaking. More than 60 per cent of people suffer serious side effects from antidepressants that can be life-altering, lasting long after treatment stops. The potential in tDCS is remarkable.”
His clinical experience had made Mansson a believer in holistic treatment, so accessible behavioural therapy would also be key to the approach. He is prepared to take on board that some truculent types (me) will only keep up the zapping element. “Our internal data estimates that 65%–75% of Flow’s impact can be attributed to brain stimulation, with the remaining 25%–35% attributed to the behavioural content.” Greater personalisation of the app is to follow this year.
Continuing to take an SSRI is not unusual (“There are several large clinical studies which demonstrate that combining tDCS with an SSRI gives an enhanced effect”). As for my conclusion that using the device has led to consistently better sleep and fewer addictive tendencies, Mansson confirms that 50 per cent of patients report improved sleep during their first six weeks, with some evidence that it can help with stopping smoking. Flow is also able to provide a solution for demographics that are “typically less well served by existing depression treatments”, namely the 50-plus age group and men.
My mood plunges may still be with me, but I’m extremely impressed by my enhanced rest and decreased desire to spend myself happy via the shopping addiction (which sprang up in the place of my previous drinking). Will I keep stimulating? Hell, yes. Better sleep alone could lead to an increase in sanity.
And I am not alone. Half of Flow’s users have been zapping for more than six months, and 30% for more than a year, showing sustained benefits. Critics argue that we are yet to discover the long-term consequences of tDCS, but depression itself has long-term side effects.
I asked the creator of Flow if it was appropriate to refer to it as my “nightly at-home lobotomy”. He responded by saying that I could call it whatever I liked as long as it helped me. He also clarified that Flow is quite different from a lobotomy. The latter was a Bell Jar-type horror that created brain lesions to achieve certain effects by stopping brain activity. In contrast, Flow uses transcranial direct current stimulation (tDCS), which is more like a brain massage that promotes activity. For now, at least, Flow seems to be working for me.
Hannah Betts has always been sceptical about anything that promises to improve her mood.