Comparative Study of the Ecacy of BiofeedbackAssisted Jacobsons Progressive Muscle Relaxation (Jpmr) for Managingmild/Moderate Depression

Biofeedback is the way of gaining greater awareness of physiological functions with a goal of self-regulation. JPMR (Jacobsons progressive muscle relaxation) causes release of tension in the skeletal muscles, neuro-muscular system is thus seen as a mediator in the relief of depressive symptoms. This study aimed to see the Comparative ecacy of Biofeedback assisted JPMR, Escitalopram and Bimodal use of both in management in mild/moderate depression. The study was conducted at Mental hospital, Indore, with a Sample Size of 30 [Group A 10 ; biofeedback ,Group B 10 ; Escitalopram ,Group C 10;both]. 8 sessions of biofeedback assisted JPMR was given to group A and C .Escitalopram was given group B and C. HAM-D and BDI was applied at baseline , 4 weeks and 8 weeks. As per BDI scale scores, Biofeedback assisted JPMR combined with escitalopram has signicantly better response than only biofeedback or only Escitalopram in patients of mild to moderate depression. As per HAM-D scale scores, Biofeedback assisted JPMR combined with escitalopram has signicantly better response than only biofeedback or only Escitalopram in patients of mild to moderate depression. Thus Biofeedback appears to be a useful adjunctive treatment for mild to moderate depressive episode.


Introduction
Biofeedback is the process of gaining greater awareness of many physiological functions by using instruments that provide information on the activity of those same systems((EEG, EMG, GSR, PR, TEMP, RESP), with a goal of being able to change them at will (Barlow et al.,2016). A growing body of research indicates that autonomic nervous systemdysfunction in depression (Veith et al., 1994;Carney et al., 2005).The Bio-feedback method aims to counteract the effects of SympatheticNervous System by promoting the action of the Parasympathetic Nervous System (Benson et al.,1974).
Before Biofeedback: Sympathetic arousal,Beta activity in EEG, Muscular constriction in EMG, Shallow and rapid respiratory curves in Pneumograph, Increased resistance in GSR, Vasoconstriction in thermal feedback, Increased Noradrenalin secretion After Biofeedback: Parasympathetic dominance, Alpha activity in EEG, Muscular relaxation in EMG,Deep and regular respiratory curves in Pneumograph, Decreased skin resistance in GSR ,Vasodilatation in Thermal feedback,Acetylcholine secretion.
Most patients are trained to relax and modify their behaviour in biofeedback. Stressful events produce strong emotions, which arouse certain physiological responses. Many experts believe that these individual responses to stress can become habitual.When the body is repeatedly aroused, one or more functions may become permanently overactive. Actual damage to bodily tissues may eventually result (Lazarus and Folkman,1984). Biofeedback is often aimed at changing the habitual reactions to stress that can cause pain or disease. Many clinicians believe that some of their patients have forgotten how to relax. Feedback of physical responses such as skin temperature and muscle tension provides information to help patients recognize a relaxed state. The feedback signal may also act as a kind of reward for reducing tension.
In a health care environment that where cost containment and evidence-based practice are important, biofeedback provides an effective way of non-pharmacological management in neurotic disorders like mild-moderate depression that comprises of maximum percentage of depressive disorders. Moreover it is not associated with any side effects or pain and has long term effect. Yucha and Montgomery's (2008) ratings are listed for the ve levels of e cacy recommended by a joint task force and adopted by the Subjects were recruited from mental hospital indore, ful lling the inclusion and exclusion criteria. Written informed consent was taken after explaining the objectives and procedure of study in detail. Detailed physical examination was done to rule out any medical or neurological abnormality. The diagnosis of depression was made using the ICD -10. 1 st session wasintroductory session which involved explaining the patients details of the study procedure. Group B and C patients were given escitalopram in optimum dosage. For group A and C, Next Sessions involved 20-25 minutes of abdominal breathing and biofeedback guided JPMR and parameters (alpha-EEG, EMG, GSR, PR ,RR, TEMPERATURE) were recorded using the biofeedback machine. Recorded audio was used for guided JPMR. Sessions were repeated once a week and continued upto two months. Rest 6 days of the week patients had to practice the techniques at home without biofeedback. Records of changes of all the parameters of all patients (all the 3 groups) through subsequent weeks was maintained in biofeedback computer. HAM-D was applied to all patients at baseline, 4weeks and 8weeks.

Results And Discussion
The mean age, in years, of patients in group A was 31.34±11.21 years. The mean age, in years, of patients in group B was 33.1±11.33 years. The mean age, in years, of patients in group C was 31.52±11.11 years.(table 2) Patients were more likely to have low socioeconomic status (table 2) , an urban background, and be educated up to primary school and mostly Hindu, married, and from joint family. There was no statistically signi cant difference among the groups in gender, habitat, education or marital status (table 1).
The mean age of onset of depression in patient group A was 28.64±8.76 years. The mean age of onset of depression in patient group B was 27.66±9.20 years. The mean age of onset of depression in patient group C was 29.66±9.44 years. The mean duration of illness in patient group A was45.48± 46.08 months. The mean duration of illness in patient group B was 53.64±45.49 months. The mean duration of illness in patient group C was 48.44± 40.55 months (table 3). Most patients had precipitating factors, had no past history, had no family history and had acute onset of illness (table 4).
For group A, the HAM-D score was 11 at baseline, 7 at 1 month, and 4 at 2 months. For group B, the mean HAM-D score was 11 at baseline, 8 at 1 month, and 4 at 2 months. For group C, the mean HAM-D score was 11 at baseline, 7 at 1 month, and 3at 2 months. (table 5) For group A, the mean BDI score was 15 at baseline, 12at 1 month, and 10 at 2 months. For group B, the mean BDI score was 15 at baseline, 12 at 1 month, and 10 at 2 months. For group C, the mean BDI score was 15 at baseline, 12at 1 month, and 8 at 2 months 8 (table 6).
Signi cant improvements were noted in the Hamilton Depression Scale (HAM-D) and the Beck Depression Inventory (BDI) by Session 4, and further signi cant improvement was noted between session 4 and session 8 in patients in all groups.
The difference in BDI score (baseline vs 8 th session) was signi cantly greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback)and B (only escitalopram).The difference in BDI score (baseline vs 8 th session) was equal for group A (only biofeedback) and group B (only escitalopram).The difference in BDI score (baseline vs 4th session) was signi cantly greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback)and B (only escitalopram).The difference in BDI score (baseline vs 4th session) was signi cantly greater for group B (only escitalopram) than for group A(only biofeedback).The difference in BDI score (4th session vs 8 th session) was signi cantly greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback) and B (only escitalopram). The difference in BDI score (4th session vs 8 th session) was equal for group A (only biofeedback) and group B (only escitalopram).
Therefore, according to BDI scale scores, biofeedback-assisted JPMR combined with escitalopram as a treatment modality producesa better response than biofeedback alone or SSRIs alone (escitalopram) in patients with mild to moderate depression.
Biofeedback-assisted JPMR produces an equal response compared to escitalopram in patients with mild to moderate depression.
The difference in HAM-D score (baseline vs 8 th session) was greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback) and B (only escitalopram).The difference in HAM-D score (baseline vs 8 th session) was greater for group B (only escitalopram) than for group A (only biofeedback). The difference in HAM-D score (baseline vs 4th session) was greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback) and B (only escitalopram). The difference in HAM-D score (baseline vs 4th session) was greater in group A (only biofeedback) than in group B (only escitalopram). The difference in HAM-D score (4th session vs 8 th session) was signi cantly greater in group C (biofeedback +escitalopram) than in groups A (only biofeedback) and B (only escitalopram). The difference in HAM-D score (4th session vs 8 th session) was signi cantly greater for group B (only escitalopram) than for group A (only biofeedback). Therefore, according toHAM-D scale scores, biofeedback-assisted JPMR combined with escitalopram as a treatment modality produces a better response than biofeedback alone or SSRIs alone (escitalopram) in patients with mild to moderate depression.
According toHAM-D scale scores,biofeedback-assisted JPMR produces more response than escitalopram in patients with mild to moderate depression after 1 month(4 th session), but produces less of a response than escitalopram between 1 to 2 months (between 4 th and 8 th session).
This nding can be explained by the fact that antidepressant action needs 2 to 3 weeks, but biofeedbackassisted JPMR acts immediately by inducing relaxation and reducing sympathetic tone.
Therefore,considering theoverall improvement in symptoms for patients assessed using both HAM-D and BDI, biofeedback-assisted JPMR combined with SSRIs (escitalopram) as a treatment modality produces a better response than biofeedback alone or SSRIs alone (escitalopram) in patients with mild to moderate depression.
Only biofeedback is also a successful treatment for mild-moderate depression.
Moreover, it is not associated with any side effects or pain and has long-term effects. It improves overall relaxation for all parameters (i.e., EEG, EMG, GSR, PR, TEMP, RESP) over subsequent sessions.
The ndings of this study are substantiated by the ndings of previous studies. 'Preliminary case studies (Kumano et al., 1996;Rosenfeld, 2000) and pilot studies (Waldkoetter & Sanders, 1997) show neurofeedback decreases depressive symptoms. One study compared biofeedback-assisted relaxation to a wait-list control on depression in chronic pain patients and improved scores on the Beck Depression Index was found (Corrado & Gottlieb, 1999).
Physiological arousal is governed by the ANS. When the organism is under threat the SNS (Sympathetic Nervous System) increases arousal on the other hand the PNS (Parasympathetic Nervous System) restores the body to a resting state. These actions are involuntary and enable the organism to survive. When the activity of SNS is prolonged and the organism is exposed to constant threat the organs concerned can become fatigued. The Bio-feedback method aims to counteract the effects of SNS by promoting the action of the PNS (Basmajian, 1979).

Conclusions
On the basis of the index study, which substantiate the earlier ndings of previous studies, it can be concluded that: Biofeedback is a useful adjunctive treatment for mild to moderate depressive episode.
Biofeedback assisted JPMR is a successful non-pharmacological modality for treatment of mildmoderate depression.
So, non-pharmocological methods like biofeedback should be added to pharmacological management of mild-moderate depression.

Advantages
This the only study of its kind that compared the response three groups (only biofeedback ,only escitalopram and both).
Previous studies had conducted fewer sessions of biofeedback.
LIMITATIONS Sample size could have been larger.

FUTURE DIRECTIONS
Further studies with larger sample size and more sessions of biofeedback assisted JPMR should be conducted in patients of depression as well as other psychosomatic illness.
Biofeedback is applicable not only for people suffering from any psychological or physiological disorders, but also applied on normal healthy individuals as Peak Achievement Training for improving attention and concentration. So further studies should be done in this regard.