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Join us on this episode as we delve into the fascinating world of cognitive neuroscience with our guest, Moshe Bar. Discover how simple word associations and cognitive activities can transform mental health and address mood disorders like anxiety and depression. We’ll explore his groundbreaking research on the power of progressive thinking and the development of Facilitating Thought Progression (FTP). Find out how mobile apps and gaming are becoming exciting channels for promoting mental well-being.

Moshe Bar is a cognitive neuroscientist.

He discusses the KevinMD article, “A new approach shifts thought patterns to improve mood.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Moshe Bar. He’s a cognitive neuroscientist. His KevinMD article is titled “A new approach shifts thought patterns to improve mood.” Moshe, welcome to the show.

Moshe Bar: Thank you very much for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit. First off, just briefly share your story and journey.

Moshe Bar: I’ll talk about my professional journey. I grew up in Israel. My bachelor’s degree was actually in electrical engineering, and my master’s was in computer science and math, but then I decided I was mostly interested in the human mind. So I moved to the U.S. and did a PhD in psychology and neuroscience, then moved to Harvard University, where I did my postdoc, and then I joined the faculty. I served on the faculty at Harvard Medical School for 13 years, and then came back to Israel about 10 years ago, where I directed a big, young and vibrant neuroscience center for eight years. Two years ago I stepped down as director. I’m still an active scientist with a funded lab, I finished writing a book called Mindwandering last year, and I’m happy to be talking about the startup we established based on my research on mood and depression.

Kevin Pho: So I’m an internal medicine physician, and this audience is primarily clinicians, practicing physicians. Tell us about that intersection between what we see in medicine every day in the exam room and cognitive neuroscience.

Moshe Bar: Yes. My expertise now is specifically mental disorders, especially depression and anxiety. And of course, for clinicians, independently of what part of the body you care about, if depression is not the primary diagnosis, it will be secondary. Many, many sick individuals are worried or sad, and at the end of the day we have depression and anxiety in realms we didn’t expect. So we should be mindful of the state of mind of others regardless of their physiological problem, I would say.

Kevin Pho: All right, so your KevinMD article is titled “A new approach shifts thought patterns to improve mood.” Tell us, how did your article come together?

Moshe Bar: It’s more than an article; it’s really the main activity of my group these days. As you said before, I’m a cognitive neuroscientist, and for many years I really cared about what we call basic research, or basic science. I was selfish, just a kid playing in a sandbox, interested only in how the brain works, without thinking about practicalities or clinical issues. It’s not that I didn’t care about them personally, but in terms of the science, what fascinated me was really the brain and the mind. Cognitive neuroscience is the intersection of psychology, cognitive psychology and neuroscience.

But at some point, maybe after 10 years of being a young professor, I stumbled across a few observations about the depressed mind, specifically that people with depression don’t take the global context into account. Back then, we were the first ones to really characterize the network in the brain that analyzes context, broad perspective and associative thinking. So it kind of bugged me, and really almost annoyed me, that I couldn’t explain the relationship between your perception of the world and your mood. Mood is this mysterious pixie dust thrown at you, making you feel good or bad. So that’s the quest I’m really happy about, and I have to say also proud of: trying to connect the way we think with the way we feel.

The more you look at people with depression and mental disorders by and large, the more you realize that every mental disorder actually also involves a thought disorder. We usually think about mental disorders as some kind of chemical imbalance, something very biological, chemical, but there are also cognitive aspects, and by cognitive I mean the way people think. People with depression tend to think in a very characteristic way. If I phrase it informally, the thinking pattern of people with depression and anxiety is stuck.

Unless you’re a cognitive neuroscientist thinking about thinking, the subjective feeling is that we think in a singular way, that it’s a monolithic process: We just go from one thought to another. But the proverbial train of thought can move in different ways, and the way the train of thought of depressed individuals moves is that it gets stuck. People with depression think more slowly, they think more narrowly and they think more repetitively. In a way, you can compare it to their physical demeanor. They really are stuck in their living room, they don’t want to get out of bed, they think more slowly, and they keep repeating. We call it rumination: They keep thinking about the same things that make them feel bad.

So once we started developing some kind of understanding of the mechanisms, we decided to start playing, if you will, with the thinking pattern. Can we take somebody with depression and just change the way they think? And I’m not talking about the content of their thoughts. There’s a whole field of positive psychology that really considers what you are thinking about and whether I can make you think about more positive things. That is not what we do. What we say is, let’s look at this train and make it drive in a way that’s healthier. By healthy thinking, I mean a broader, faster, more original, more flexible and more global way of thinking.

So with cognitive paradigms, which is what I know how to do, we started playing, initially with healthy individuals, because it’s not that easy to recruit patients to studies, especially if you’re not sure what you’re doing and you’re just examining ideas. We didn’t want to bother patients before we knew what we were doing. So we took healthy individuals into the lab, and in the first study we had them read chains of words that either expanded in a broad manner or repeated in a more ruminative fashion around the same topic. Somebody with depression might be ruminating on some bad comment he made last night over dinner, and keep thinking over and over about the implications, the content, the feelings of other people and what will happen to him now, whereas a person with a broader, more flexible pattern of thinking will just move on to other things.

Similarly, in these experiments we used chains of words. I’ll give you a very basic example, and it’s important to emphasize that these words were emotionally neutral. Again, it’s not positive or negative content, just neutral. Let’s say I give you a chain that starts with the word “table.” For people with rumination, or people who think more narrowly, all the associations will be related to table: table, chair, tablecloth, dinner, plate, fork, knife. It’s all neutral in terms of the valence, in terms of the emotions, but it all stays within the same topic. Compare this with a more expansive way of thinking, where I say “table,” and then you think about “tree,” and then you think about “forest,” and then you think about “camping,” and then you think about “bear,” and then you think about “Winnie the Pooh.” You see how you start from the same point, but somebody with an expansive way of thinking just goes further and further and further.

We’ve shown repeatedly that such expansive thinking is associated with positive mood. Initially we showed this with healthy individuals: a significant improvement in mood just from reading these chains of words that expanded more broadly. We published this and went beyond it. The idea was really to look at different ways of facilitating the progression of thought, so it’s not only broad associations but also making it faster. If you make people read text faster and faster and faster, it kind of emulates the state of exhilaration that’s typical of a manic state, and we know that is associated with elevated mood. We make people think more broadly, think about the broad aspects, look at the forest rather than the trees. We make people think more creatively. So it’s interesting that you can change the way people think with these little games, as we call them, which have now been translated into games.

We have this app that’s based on this research. The app looks like any other game on the App Store, but it is based on paradigms from my lab at Harvard back then, translated into fun games so that people can rework this system. When I was still there, we showed with MRI scans that people who think in a depressive manner, in a very narrow and ruminative way, if they do this chronically, if they ruminate for a few years, actually lose neuronal volume. A key structure in the brain, the hippocampus, loses neuronal volume over the years. So you realize that there is damage to structure here, and the idea is that if you now engage in a thinking pattern that is more expansive and practice this better type of thinking, you actually reconstruct this lost infrastructure and regain lost neuronal volume.

Kevin Pho: How long does it normally take to shift someone from a narrower range of thinking into something more expansive? You mentioned the chain of words. How long does it typically take to break that narrow band of thinking?

Moshe Bar: It’s an excellent question. We didn’t go looking for the record of how quickly we can do it. People in the lab played for 10 or 15 minutes, I mean read their chains, and it was already enough for them to think more broadly. Now, the follow-up to your great question is: How long would the effect last? When they leave the lab and go home, will they still be thinking broadly? Here I have to refer to SSRIs, like Prozac or other antidepressants. People take them, and for the first four weeks they don’t even notice the effect. It starts to kick in only after three or four weeks, and even then they don’t just stop the SSRIs the moment they feel good. You actually have to maintain this regimen.

So given what I told you about the lost infrastructure, and the fact that persistent rumination has changed your brain, you would imagine that you really have to engage in this for an extended period of time for it to become a new mental habit. We know that when we do this with people for about 15 minutes a day, a few days a week, after four to eight weeks they already show a remarkable improvement in depression. To give you an exact answer on how quickly, it’s not a one-shot thing, but it definitely takes surprisingly little time to change it, at least temporarily.

Kevin Pho: So in terms of the data on how it affects depression, give us a sense of what kind of impact it has. Have there been double-blind studies where you gave one population this app and another population no app, and compared rates of depression and improvement? Give us a sense of some type of data on the link between facilitating thought progression and its impact on depression.

Moshe Bar: Funny you should mention it, because we just finished our clinical trial. We ran clinical trials at Massachusetts General Hospital that concluded a month or so ago. A blinded but very competent crew of psychologists and psychiatrists at MGH recruited patients for us and assigned them to control versus intervention. Those in the intervention had to play for 15 minutes a day, four times a week, for eight weeks, and the psychiatrists evaluated their state at the beginning, in the middle and at the end with a very extensive battery of questionnaires that are standard for depression, but also for other aspects of mental health, well-being and so on. We found that eight weeks were enough to reduce their main measures of depression. There’s a famous standard measure called the MADRS, which is filled out by the clinician, and there’s also the PHQ-9, which is filled out by the patient. Both of these were reduced by almost 50 percent. Almost 50 percent of depression seems to disappear with just playing this game for a total of eight hours, really, over the eight weeks.

Kevin Pho: What are these games like?

Moshe Bar: I’m not a gamer, so the people in my startup company were begging me and chastising me for not playing, but at the end of the day they are fun games. One thing I need to emphasize when I talk with people is that these are not meant to be feel-good games. The treatment here is not the fun from the game. The game is supposed to be fun because, just like when I was a kid and my mother wanted to give me a pill that was too bitter, she’d grind it and add sugar. The fun of the game is just the sugar; it’s not the pill. It’s the game itself that is supposed to imitate what we did in the lab with your thought pattern. The games themselves are a farm, where you do all these silly things that people do in games, but they are actually rooted in science: We make you see the big picture, we make you read chains of words like the table example I just gave, and we make you read text faster and faster all the time. So it’s everything that we know from the lab, and it’s not only my lab. I’m happy to say that it’s also been replicated and expanded in other colleagues’ labs. We really put it under one roof in FTP, facilitating thought progression. FTP is really the collection of all the paradigms that we know work to facilitate thought progression from different angles.

Kevin Pho: So you mentioned depression, of course, and a little bit about its effect on bipolar disorder and mania. What other mental health conditions are affected by facilitating thought progression?

Moshe Bar: Right. This is something where, as a newcomer to a field, you sometimes have an insight that was in front of people’s eyes all along. I consider myself still a newcomer to the world of psychiatry. I’m a PhD, and I do have extensive experience already, but I will say that even as a cognitive neuroscientist, or especially as a neuroscientist, it becomes almost an absurd observation. The idea here is that every mental disorder involves a thought disorder. On the one hand it sounds intuitive; on the other hand it sounds provocative. With every type of mental disorder, people think differently, and people with almost all mental disorders, I can’t say all of them, suffer from some type of ruminative or repetitive thoughts. Think about OCD, for example, or eating disorders or addiction, all these other problems that are not depression per se. They might have comorbidity with depression, but all of these other mental disorders are also characterized by some type of repetitive thinking.

It’s interesting, because again, we tend to think about mental disorders as a chemical thing. Think about the brain as a cascade of operations. At the very bottom of this cascade there are molecules and genes, but at the very top level there are cognitive processes and emotional processes. Pharma and most of the world have been attacking the lowest layer, the molecules, and then the effect goes all the way up to the way you feel. We just look at this cascade from the other direction and say, let’s modify the way they think, and this will trickle down to the molecules. I don’t have evidence that it actually changes concentrations of serotonin or dopamine, but I’m sure it does. So it’s really about thinking about thinking, and in all mental disorders it actually goes beyond just depression, bipolar disorder and the other clear mood disorders.

Kevin Pho: So do you envision a world someday where a clinician like myself, tackling this huge population with behavioral health disorders, can prescribe an app, a cognitive-based app that can facilitate thought progression, and hopefully that can make an impact?

Moshe Bar: Yes, I actually do, because we also talk about resilience. Even if you don’t have depression, you do want to feel better, and you do want to not fall into depression in the future, right? We actually have an app that you can try. For some reason I thought you had it already, but feel free to play with it. It’s called Mood Bloom, and it’s on the App Store, and you can see for yourself how it looks. The idea is that if people play games anyway, it’s a no-brainer: Instead of Angry Birds, why don’t you play Mood Bloom and see what it does to your brain?

I joke with my friend and chief executive officer, who is one of the founders of Waze, if you’re familiar with it, that even one item in our game, making the thought process more flexible and more creative, could be a startup company in itself, because it emphasizes creativity. It makes you think more creatively, and we know that is associated with improved mood. But imagine I told you, have your kids play this game and they’ll be more creative. That’s already something people would be happy to do. So now, when you talk about your patients, even if they suffer from their liver or pancreas or lungs or have a broken leg, why not make them feel better by playing a game that can actually take their mind off rumination about their pain or their condition?

Kevin Pho: We’re talking to Moshe Bar. He’s a cognitive neuroscientist. Today’s KevinMD article is titled “A new approach shifts thought patterns to improve mood.” Moshe, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Moshe Bar: OK. I don’t know about the scale of these messages, but I will just freestyle it, and take whatever you want from it. I approach depression with a lot of compassion. I think about the patient the whole time and their suffering. Other than mood, you probably know about the other criterion for depression, which is anhedonia: They’re not able to enjoy the pleasures of everyday life, biting into a mango, listening to a story or enjoying a song. You think about their state, and it’s really sad, and you think about how society accepts them. I’ve been seeing a lot of people who deny that depression is even an illness, and I also see that stigma is still very prominent in our society. I have a distorted vision, because I’m surrounded by young students most of my working hours, and this generation talks about their therapist and their Prozac without blinking. But my peers, people around my age, almost hide the fact that they go to a psychologist, and it shouldn’t be like this. That’s one thing.

The second thing I learned: Even though I’m not a clinician myself, I have many clinician friends, and clinicians who worked in my lab and did their postdocs, psychiatrists and so on. In return, I go to their departments in the hospitals where they work, and I talk with patients. What really stunned me, especially given what I just said about the stigma, is that you would think these people would prefer to preserve their privacy and not open up. Initially I was excited about it, but then I became sad about the extent to which they want to open up and tell you about their symptoms and their innermost thoughts, things you would think are too private to share. They’re not shy to talk about their pain, and I think we should listen. I’m sure that caregivers in the mental health world are listening, but even in our game, there’s a little grandpa in a little shack who asks the players, “Tell us how you feel,” and you talk into a little phone. Nobody’s listening on the other end, and people still pour out all their inner feelings. That’s the extent to which your patients want to talk about their pain.

My last take-home might actually be a little too cold, but I’m new to the world of commercialization and making things global. The moment we finished the clinical trials, which were a big success, I thought to myself, we found, well, you can’t say a cure. This problem is too complex to fix with one approach; that’s why there are so many good approaches out there, and still there’s no solution. But as a scientist, you would think that if you have something so significant, everybody would use it immediately. Now we have to get into, “Let’s spread the word, let’s do some PR, let’s convince people that it’s important to reduce symptoms by half,” because it brings people back to the workforce, back to society, to their family, to the gym. To change people’s lifestyle, I guess it’s not enough to show the results; you also have to spread the word. That’s a new challenge for me, and I embrace it.

Kevin Pho: Moshe, thank you so much for sharing your perspective, time, and insight, and thanks again for coming on the show.

Moshe Bar: Thank you very much, Kevin. I appreciate it.