When Ricardo Muñoz was 10 years old, his mother sat him down for a talk. Their family was leaving Chosica, Peru, for better educational opportunities in the United States. Later, she said, they would return so that Muñoz could share what he learned. “She taught me two things that day,” Muñoz says. “One was that knowledge is worth traveling halfway around the world to get. And the second was that once you get it, you share it.”
Muñoz, ’72, has made it his mission to share. The former chief psychologist at San Francisco General Hospital has been a pioneer in preventing people with some symptoms of depression from developing a clinical disorder, and in finding novel ways to share therapeutic tools with the world. The need for his work has never been greater: Before the COVID-19 pandemic, the Centers for Disease Control and Prevention estimated that about 11 percent of U.S. adults had symptoms of a depressive disorder or an anxiety disorder. In 2020, that rose to 40 percent.
“There’s clear evidence that we can prevent clinical diagnoses of major depression,” says Muñoz, now a distinguished professor of clinical psychology at Palo Alto University and the founder of the Institute for International Internet Interventions for Health (i4Health). His work demonstrates the power of teaching people how to manage their mood early, while depression is perhaps still a storm on the horizon. “We now have the knowledge to do it, and it’s time to put that into practice and to make it available to anybody in the world,” he says. Preferably for free, and in as many languages as possible.
Ounces of Prevention
Muñoz recommends getting a “minimum daily requirement” of pleasurable or meaningful activities to boost or maintain your mood.
Call a friend
Get enough sleep
Listen to a few favorite songs
As a child in Peru and in the Mission District of San Francisco, Muñoz wanted to be a priest, and then a scientist. But in the spring of his sophomore year, he took Introduction to Psychology, and he was hooked. “Psychology tests things. So you don’t have to take things on faith,” Muñoz says. “And of course psychology was focused on helping people, which is why I wanted to become a priest in the first place. It was a beautiful combination of science and helping people live good lives.”
But just a few weeks into Muñoz’s doctoral program at the University of Oregon, a remark by a lecturer made him question his path. “[He said] we should be going out into the community and sharing what we’ve learned as mental health professionals so that we can prevent the suffering that brings people to our offices,” Muñoz says. “Here I was about to start five years of doctoral work to become a therapist, and this guy is saying that that won’t be enough!”
Muñoz decided then and there that he would dedicate his professional life to prevention in addition to treatment. Our modern understanding of depression was in a nascent stage. Cognitive behavioral therapy, which teaches people how to alter their thoughts and actions to improve their mood, was only just starting to gain traction. And preventing depression? That just wasn’t a thing. Even by 1984, a National Institute of Mental Health pamphlet contained the statement, “In general, the onset of a clinical depression cannot be prevented.”
When we start to feel low and lack energy, we often stop doing activities we previously enjoyed—waiting, perhaps, until we feel better. But, Muñoz says, it is exactly those activities (talking with a friend, being out in nature, having a special event to look forward to) that elevate our mood and can buffer us against developing clinical depression.
‘As a therapist, what I want to do is first begin turning the gears myself and then have the patient grab ahold of the gear and turn it herself.’
In graduate school, he worked on a study that showed that when people resumed pleasurable activities even though they didn’t feel like it, their moods improved, which in turn made them able to do more activity. “As a therapist,” Muñoz says, “what I want to do is first begin turning the gears myself and then have the patient grab ahold of the gear and turn it herself.” He did similar studies focusing on “self talk”—how people think about the events in their lives—while another team looked at improving interpersonal skills. All three methods reduced symptoms of depression.
Muñoz began dreaming. If clinicians could use these techniques to help people who were clinically depressed, he thought, why not teach them to people before they got to that point. “Most of this stuff is common sense,” he says. “The key is to do it systematically.”
He returned to San Francisco in 1977 in hopes of finding an academic position close to his parents. (He still translates during medical appointments for his mother, who is 93.) Instead, the UCSF department of psychiatry at San Francisco General came calling. The public hospital is the city’s largest acute inpatient and rehabilitation facility for psychiatric patients. In 1985, Muñoz opened its depression clinic—the first cognitive behavioral service at UCSF. “I was working with very-low-income people,” he says. “Many of them didn’t speak English, and I began working on how to prevent depression in people who have very few resources.” Muñoz trained new clinicians to turn psychological principles into actionable steps for their patients—“things that they could do to make their complicated lives a bit better,” says James Gross, a professor of psychology at Stanford who trained in the UCSF program as a postdoc. “So this is not just a dreamer, right? This is somebody who takes those dreams and finds very concrete ways of turning them into reality.”
At SF General, Muñoz also developed the Mothers and Babies program for pregnant women who are at risk of depression. The program uses social learning ideas—like a mother imagining the kind of relationship she wants to build with her child and how her thoughts and actions can influence that relationship. In a pilot study, 14 percent of women in the program experienced major depressive episodes in the first year after birth, as compared with 25 percent of the control group. Other researchers have gone on to use and test the program, with some reporting reductions as high as 53 percent.
In 2012, Muñoz co-authored “Major Depression Can Be Prevented,” an article in American Psychologist that analyzed existing research and showed that currently available techniques could prevent up to 38 percent of cases of clinical depression. He thinks the health field is moving—slowly—in the right direction, though he laments that most insurance companies won’t pay for treatment until a person has met the clinical criteria. He points to another preventive treatment, flu shots, which are generally 40 percent to 60 percent effective: “They still want us to get them because that’s a significant reduction.” Applying the same principle to depression, he says, “would reduce so much suffering.”
In the mid-’90s, Muñoz wanted to broaden the reach of his work, so he turned to a new thing called the World Wide Web. Initially, he studied the online efficacy of a smoking-cessation program he had previously run by mail. About 20 percent of the 9,000 online participants were able to quit smoking using the program’s behavioral techniques, which compares favorably with the nicotine patch’s 14 percent to 22 percent success rate. But to get the same number of people off cigarettes via the patch would have cost $2 million in patches alone. “Wow, right? We did it for $200,000,” Muñoz says. He kept the website open long after the formal study ended, which allowed another 34,500 people to embark on the free program. “I should have closed it, technically,” he says, “but . . . I mean, I can just keep on helping people.”
Muñoz joined Palo Alto University in 2012. That year, he also founded i4Health, the first step in creating what he has dubbed digital apothecaries—online repositories of free, self-help mental health content. Muñoz grows animated as he talks about his vision for such sites—seals of approval, clear information about the efficacy of each treatment, and, most of all, the sheer number of people who could find help there, not least for depression. “Now, it won’t work for everybody,” he says, “but nothing does.”
“A lot of accomplished researchers and academics develop really effective, cutting-edge interventions and treatments, but they’re not always accessible to the masses,” says Alinne Barrera, a professor at Palo Alto University and an associate director of i4Health. “That’s at the core of what he does. He always says he wants to give psychology away.”
‘The world has now caught up with where Ricardo has been for quite some time.’
Barrera, who has modeled her own large online studies on Muñoz’s, believes digital tools are key to how he reaches diverse—in particular, Spanish-speaking—communities, which “isn’t always the focus or mission of a lot of researchers and academics.” The offerings can also reduce the stigma around therapy. “If you’re logging in online, no one’s going to question that. It’s very different than ‘I’m going to this clinic’ or ‘I’m going to this hospital.’ That’s a huge barrier.”
Over the past two years, the pandemic has given medicine a firm technological shove into the future. Today, it’s commonplace to meet with a therapist online—provided you can find one. There aren’t enough mental health clinicians in the United States to handle the number of people who need them. Once a therapist’s 50-minute hour is used, it’s gone, and it likely helped only one person. Therapeutic interventions that can be used by anyone, anytime, anywhere, over and over again, Muñoz believes, are the way to help most of us.
The potential of online self-help therapy is backed up by research. A recent German study showed that among adults with depressive symptoms who didn’t yet meet the criteria for clinical depression, 41 percent developed depression within a year. With web intervention programs, that rate was cut to 27 percent. “The world has now caught up with where Ricardo has been for quite some time,” Gross says. Muñoz has long served on consensus committees, convened jointly by the National Academies of Science, Engineering and Medicine, on preventing mental health conditions. The latest committee report, from 2019, recommends disseminating the current knowledge on prevention to as many people as possible.
“Will we ever be able to get to a world without depression? I don’t know,” Muñoz says. “We have the knowledge now to get halfway there. [Depression] is a really painful experience that should be prevented, if possible. There’s an ethical obligation.”
At 71, Muñoz practices what he teaches in order to manage his own mood. He exercises; he spends time with his wife, children and new grandbaby; he looks forward to the future. And 50 years into his career, he marvels at the opportunities he has to share his knowledge all over the world. Recently, he got a message asking whether he was the Ricardo Muñoz from Chosica, Peru: His digital smoking-cessation program had made it back to his family’s hometown.