While it is predicted that depression will achieve the status of the biggest disease burden in the Western World before too long, providing access to evidence-based clinical interventions (medicines and talking treatments) for this growing number of people is a source of concern.

Supporting people to take steps to actively self-manage their symptoms and condition is one way to promote better outcomes for a larger number of people. If this sounds promising, but you’re not sure which path to take through the woodland – fear not, as a new study aims to provide us with a self-management ‘map’.

The study from the Netherlands (van Grieken et al, 2013), published last year in Health Expectations, focuses on people who have experienced an episode of major depressive disorder and have since recovered (or at least did not have symptoms at the time of the study). The authors were interested in how these people defined the actions and behaviours they can undertake themselves – self management strategies – to help in the recovery from depression. The aims of the research were to determine:

• What strategies do patients believe they can use themselves to recover from depression?
• Which main themes of self-management strategies can be detected?
• Which of these strategies patients perceive as being most helpful?

Methods

The authors have taken a novel approach to this research: concept mapping, which is a structured process that involves quantitative analysis of qualitative data. It was developed in the US and has been primarily used for service development and evaluation type projects (Johnson et al, 2000), although they do draw on examples of where this approach has been used to plan and evaluate a number of mental health programs.

The three stage process involved:

1. Generating self-management strategies in focus groups with participants
2. These data went through a structuring phase, where participants sorted and prioritised the identified strategies
3. Finally, a hierarchical cluster analysis process was used by the researchers to ‘map’ the strategies onto a two-dimensional diagram.

The 20 people recruited to the study had experienced an episode of major depressive disorder within the last 12 months, had received treatment, and were in remission at the time of the study. People were recruited through two routes – via a specialist clinic and through internet adverts. The treatment participants had received for depression included medication, outpatient care, group therapy and various forms of psychotherapy. The sample comprised eleven women and nine men, with a mean age of 42.6 years.

The participants took part in one of three focus groups where self management strategies were identified through group discussion. By the third session, only four new strategies were identified, suggesting data had reached saturation.

Results

The study identified 50 different strategies for self-management which were clustered into seven main themes (with a few ‘others’ in a final category).

1. Proactive attitude towards depression and treatment: emphasis on an active attitude towards depression by seeking good information and treatment.
2. Daily life strategies and rules: practical strategies to set goals and structure for day to day life.
3. Explanation of the disease to others: aiming to increase others’ understanding of depression to enable them to better support the person.
4. Remaining socially engaged: with people not necessarily associated with their depression.
5. Engaging in activities: sociable and fun activities, including sport and other hobbies.
6. Structured attention to oneself: strategies focused on the person to maintain a fixed routine and regular contemplation.
7. Contact with fellow sufferers (sic): sharing experiences with peers.
8. Other: three specific strategies that didn’t fit into the other themes!

These eight themes were mapped onto two dimensions creating four quadrants on a graph. The vertical axis shows whether the strategies were deemed to be ‘general’ or ‘depression-related’ and the horizontal axis shows whether strategies are ‘focused on the self’ or ‘focused on others’. The least populated quadrant was the top left, defined by general strategies focused on others.

The top 15 strategies prioritised by patients (mean score of 3.5 and above on a five point scale) were in four of the themes:

• Six in ‘Engaging in activities’
• Four in ‘Proactive attitude towards depression’
• Four in ‘Daily life strategies’
• One in ‘Structured attention to oneself’

On the map, these four clusters more likely to be positioned closer to ‘focused on the self’, but were widely spread across ‘general – depression-related’ dimension.

Conclusions

The authors concluded:

Our results suggest that from the patients’ perspective there are a substantial number of different self-management strategies enabling patients to contribute to their recovery.

While this is a helpful study highlighting the value of self-management for people with mental health problems, it is worth noting that it was led by clinicians (psychiatrists and psychologists) and I was left wondering how much these strategies would be news to people who live with depression and are already actively self-managing. For example, how common are these strategies adopted and shared by people in depression peer support groups? The authors do compare their results with a study exploring self-management strategies identified by people with sub-threshold depression and found considerable overlap. It may be useful to have these self-identified strategies discussed in the research literature aimed at clinicians as this helps to highlight the value of active self-management as part and parcel of a treatment package.

The authors acknowledge that these strategies are based on the views of a small number of people and they may have missed specific sub-groups within depression. Also they do not describe their sample in much detail (number of episodes of depression, socio-economic status etc), so it’s difficult to know how typical this group is of the wide range of people experiencing depression. Further research would be helpful to test out the value of these strategies with wider groups of people (which the authors state they are beginning to do) and also to assess what impact adopting these strategies has on people’s outcomes.

The authors do identify some useful practice implications. By highlighting these strategies to clinicians, they provide ways to offer specific ideas to patients to take an active role in their recovery from a major depressive disorder and note that patients with this level of depressive illness may not have the motivation or confidence to instigate these strategies without the support of clinicians or therapists. They also acknowledge that investment in training may be required to enable health professionals to adopt a more supportive and enabling role effectively.

So if we find ourselves lost in the self-management woodland, this study begins to map out the territory for us.

Links

van Grieken RA, Kirkenier AC, Koeter MW, Nabitz UW, Schene AH. Patients’ perspective on self-management in the recovery from depression. Health Expect. 2013 Aug 2. doi: 10.1111/hex.12112. [Epub ahead of print] [PubMed abstract]

Johnson JA, Biegel DE, Shafran R. Concept mapping in mental health: uses and adaptations. Evaluation and Program Planning Volume 23, Issue 1, February 2000, Pages 67–75. [Abstract]