RCGP/SAPC ELECTIVE PRIZE WINNER - Primary care patients’ knowledge, attitudes and beliefs around the use of self-help strategies in the management of subthreshold depressive symptoms: a qualitative study

The Problem 

Subthreshold depression is common among primary care patients. It has a significant functional impact and represents a considerable socioeconomic burden. Although there is a high spontaneous recovery rate, subthreshold depression is a strong predictor of major depression. GPs feel that subthreshold depression is clinically significant, typically offering low-intensity interventions such as active monitoring and lifestyle advice. The feasibility of implementing other interventions such as psychotherapy and collaborative care on a large scale is limited and many patients do not participate. There are high rates of antidepressant prescribing, contrary to the evidence base. In addition, patient preferences for the treatment of subthreshold depression are mixed. Therefore, exploring patient preferences for treatment and considering the role of GPs is important in developing efficacious and patient-acceptable management strategies.

The Approach

We recruited a sub-sample of patients from both arms of a randomized controlled trial (Target-D) testing different forms of depression care. We conducted telephone interviews with those scoring between 5 and 9 on the PHQ-9, using a semi-structured topic guide covering management of mood (focusing on self-help), perceptions of self-help as treatment, and the role of the GP in recommending such strategies. We used framework analysis to develop themes.

Findings

Interviews with fourteen participants yielded three themes with subthemes. Participants used self-help strategies, typically revolving around lifestyle choices including exercise, social connectedness, and immersive activities such as gardening and reading. All the participants were aware of the link between using self-help strategies and improved mood. However, not all participants engaged in deliberate use of that strategy to improve their mood. Those that noticed, but did not utilise, the link between self-help and improved mood were more likely to attribute their depressive symptoms to factors outside their control and to consider self-help strategies to be coping mechanisms rather than treatments. Participants were open to the idea of GPs promoting self-help strategies but stressed the importance of GPs personalizing it to the individual.

Consequences

Our findings suggest that participants utilize several strategies to improve their mental health. Self-help strategies are acceptable to patients and perceived to be efficacious. GPs should receive education into the acceptability of self-help strategies and how to incorporate discussion about self-help into consultations, potentially by utilising motivational interviewing. Encouraging the use of self-help, rather than antidepressants or resource-intensive interventions such as CBT, may reduce cost of care and empower patients to manage their symptoms, thereby easing the public health burden of subthreshold depression.