Overview

According to the American Psychological Association (APA), animal-assisted therapy involves animals in the therapy session, improving outcomes in various areas. Major depressive disorder, commonly known as depression, is the most frequent mental health condition. It’s part of life to feel sad once in a while, but depression is a deep sadness accompanied by feeling low, tired, empty, hopeless, anxious, guilty, and unable to focus, lasting over a longer period. The World Health Organization (WHO) states that about 3.8% of people worldwide suffer from depression, with people assigned female at birth being more affected than people assigned male at birth. Rates are higher in older adults (5.7%), especially in people suffering from other illnesses, and also significant in pregnancy, or after giving birth.¹ Depression can be treated with psychotherapy and medication, depending on the severity. This article aims to unveil animal-assisted therapy in depression, its benefits, scientific research, practical aspects, safety, and ethics. 

Understanding animal-assisted therapy (AAT)

Definition and history of AAT

Animal-assisted therapy, also known as pet therapy, is defined as a “goal-directed intervention” that aims to improve various aspects of a person. It involves a previously trained and certified animal. Improvements can be seen in social interactions, emotional responses, and even physical and cognitive functioning. Usually, as part of psychotherapy, AAT is delivered or monitored by a health, or human service professional, who has a licence to practice within the scope of their profession and is also further certified and specialised in animal therapy. This form of treatment must be monitored and evaluated throughout, but it can be provided in various settings. Therapy animals can be dogs, cats, horses, or even zoo animals but the most used are domesticated animals.^2,3,4

In 1964, Dr. Boris Levinson, known as one of the “fathers” of animal-assisted therapy, introduced the term “pet therapy” in his article focusing on the human-animal bond.⁵ This moment is considered the beginning of scientific research around AAT, but its history traces as far as ancient Greece when people used horses to cheer up the ill, showing the positive influence animals have on people’s physical and mental well-being. Even Dr. Sigmund Freud contributed to defining AAT in the “early days''. He noted the calming effect his dog, Jofi, had on children with anxiety, showing the impact of the human-animal bond.^5,6 

Animals commonly used in AAT 

Farm animals were the first ones used to improve people’s health. Studies analysing AAT with farm animals in patients with psychiatric disorders showed a reduction in anxiety and depression and an increase in self-efficacy.⁴ Dogs are the most used and studied animals in AAT. Besides naturally being “the man’s best friend”, dogs are easily trained and also accepted in various settings. AAT can be provided even in hospitals, or long-term care centres. “Pet therapy” can also include horses, cats, fish, birds, and even guinea pigs or reptiles. Recently, science has shown an interest in animal-like robots. Who knows what the future holds?^4,6,7

Mechanisms of action to alleviate depression

Studies reported that the presence of a companion animal in the room lowers the blood pressure of patients while doing a stressful activity. Also, cortisol, a stress-response hormone, is elevated in people suffering from depression and anxiety. Data shows that spending thirty minutes with a therapy dog has a positive influence on patients with depression. As a mechanism against the symptoms of depression, the presence of therapy animals calms the patient by lowering blood cortisol levels and reducing anxiety and arousal.⁵ 

Animals also reduce stress and anxiety related to social interactions, facilitating an easier human-to-human connection. For example the therapist-patient relationship: the presence of a therapy dog can bring out a “personal side” of the therapist, helping to better connect with the patient. Additionally, through this “social support” animals offer during therapy, they make the patients feel that they are “cared for, esteemed and valued”, helping people further engage in social interactions. Therapy with farm animals can also help people overcome mental health problems by improving the sense of what psychotherapists call “self-efficacy” which is the ability to complete a task that can also contribute to one's perception of personal value, self-esteem, and self-confidence. This can be obtained through farm animal-assisted therapy, by completing different work tasks adjusted to the patient’s characteristics. Additionally, caring for animals helps depressed people feel like they are the caregivers, not just the care-receiver like how they usually feel when they interact with healthcare professionals. This also has a positive effect on their recovery.^4,8 

Research supporting AAT for depression

Studies and findings on AAT benefits 

A therapy animal offers unconditional emotional support and companionship. The animal’s presence during therapy resembles the experience of owning a pet and brings various health benefits for patients suffering from depression, including improvements in social interactions, improving the feeling of loneliness, offering a calming effect when stressed, and decreasing anxiety and arousal.⁹ 

Reducing stress and anxiety helps patients in their struggle with depression. Research shows improvements in depressive symptoms for hospitalised patients, including patients with risk pregnancies, psychiatric disorders, and older patients with many comorbidities who are institutionalised.⁷ 

A recent study analysing AAT in older adults with depression suggested that the effectiveness of the therapy might be due to social interaction. Connecting with the therapy animal, people feel “loved and needed”, and this improves their mood and emotional well-being, giving them a sense of positivity. Through joy and laughter, patients might also experience improvements in pain management, considering that often older patients suffer from depression caused by chronic pain or loss of functionality.¹⁰

Besides social interaction, animal therapy also brings improvements in physical activity and self-efficacy. In the case of older adults with depression, walking, brushing, and caring for an animal makes them more active, and also activates a feeling of more autonomy, increasing their self-efficacy.¹⁰ This also happens, in AAT using farm animals, patients acquire new skills and new behaviours while completing adjusted tasks. In this way, AAT offers a new perspective about the world and themselves, paving the way to improvements with positive feelings.⁴ 

Discussion of limitations and areas for further research 

There is still room for further research focusing on animal-assisted therapy and its effectiveness. The scientific evidence about AAT is still adding up and data is still defining concepts and guidelines. Amongst others, one aspect of concern is the well-being and safety of the therapy animals. Researchers are looking for answers regarding the ideal use of the animal following the ethical principles, the right duration and how frequent the interventions should be, and when it’s the right time to retire an animal from working in therapy and how to do it properly. The Institutional Animal Care and Use Committee is responsible for overseeing the ethical use of animals in research in the US, and in the UK, this is done by the Animal Welfare and Ethical Review Body.⁶

Implementing AAT in depression treatment

Planning and preparations for psychotherapy sessions

Evidence shows that animal therapy can be effective for depression or social isolation when “administered” once or twice a week, during a period of six to twelve weeks.⁹ The provider of the AAT should plan before the therapy, including the assessment of the patient’s needs and characteristics, therapy goals, session plan, and the compatibility between the therapy animal and the patient.⁶

Training requirements for therapy animals and handlers

You may think that a service dog, for example, can “work” as a therapy animal, but there is a difference between service and therapy animals. Service dogs provide specific assistance to a person with disability, and are not part of a particular treatment, as therapy animals are.³ 

Therapy animals and their handlers undergo training, evaluation, and certification, and the therapist – who can be a mental health professional, psychotherapist, social worker, or occupational therapist – needs further specialisation in AAT, on top of their professional education. To ethically and safely integrate animals in this therapy, training and certification opportunities are provided by various organisations, such as the European Society for Animal-Assisted Therapy (ESAAT), or the Pet Partners Program by Delta Society, among many others. Therapy animals are required to pass an evaluation regarding their behaviour with a certified evaluator, and also a physical exam at the veterinarian. The handler evaluates and monitors the welfare of the animal and makes sure that therapy work is not stressful for them. There is currently no universal AAT guideline to follow, but getting trained, educated, and certified by an authority in the field, ensures the benefits of the therapy and limits the risks.⁶

Creating a safe environment for AAT sessions

Maybe the first thing you would think of is the risk of injury. But the key is planning. Selecting the right animal who is familiar with people, and clearly instructing patients on how to handle the animals, ensures the therapy’s safety and success.⁴ Animal allergies can be avoided by being aware of the patient’s health and characteristics, and carefully selecting the animal.⁷ The risk of getting a zoonosis, or an infection from a therapy animal can be minimised by following simple hygiene protocols, like hand washing. The risk of zoonosis is low because the animals used in therapy are closely monitored by veterinarians, but protecting the patients with vulnerable health, such as the immunosuppressed, further lowers health risks. When conducting AAT in healthcare settings, infections with Methicillin-resistant Staphylococcus Aureus (MRSA), or Clostridium difficile (C.diff) can occur, because animals can be a source of infection. This risk can be prevented by hand washing and following specific guidelines, such as the CDC guidelines for environmental infection control in healthcare facilities.^6,7

Ethical considerations 

AAT can be delivered in various settings, involving the therapist, the animal, the client, and sometimes the handler, but it must always be an ethical and safe process for everybody involved. By acquiring specific training and certification, following guidelines for incorporating animals in AAT, and guidelines for practising AAT, like the APA Ethical Standards Competencies in Animal-Assisted Interventions, the therapist ensures the welfare of the animal and the safety of the patient. The therapy animal is not “a tool”, but a “co-therapist”, working towards the patient’s goals and benefits, and deserves protection, respect, and care. Also, the process of planning ensures ethics and safety, which involve informed consent, inquiring about the patient’s health, allergies, certain phobias or fears, and cultural, religious, or other beliefs that could be incompatible with the selected animal.^6,11

Summary 

Depression is a serious mental health problem, but it can be treated with psychotherapy and medication. Animal-assisted therapy is a complementary form of psychotherapy that can be used in addition to the traditional treatment for depression, improving outcomes in social interactions, emotional responses, and even physical and mental functioning. Studies focused on the human-animal bond and its effects on depression. These studies showed that pet therapy lowers stress, and anxiety, and improves symptoms, but there is still room for scientific evidence regarding the effectiveness of this therapy. Further research is needed to refine guidelines and protocols for certification and practical implementation and address ethical and safety concerns. Whilst continuing to explore the potential of AAT for depression, we can’t deny the positive impact a therapy animal has on the patient, improving their therapy outcomes and helping the patient gain a new perspective about themselves and the world.