Project objectives 

Two core research questions will guide the project:

1. What structure for the intervention content would be perceived by patients as most acceptable, usable and potentially helpful when attempting to reduce distress?
2. What are the barriers to use of a distress reduction internet intervention provided and endorsed by a GP?                                         

The project is designed to lead to future trials with distressed patients, and trials in health symptoms where effective stress-management is likely to be beneficial.

Changes to Project proposal

Research plan and methodology

The main change to the research plan was the timeline for this project. With hindsight, 10 months was extremely ambitious in order to develop a new form of psychotherapeutic approach, write intervention content, build an internet-based programme and conduct a full qualitative study with primary care patients. We are grateful for the no-cost extensions from the SPCR that enabled the PI (AG) to complete the project after the RA’s contract ended after 10 months.

Brief summary

Background:

Computerised/Internet-based Cognitive Behavioural Therapy (cCBT) is often suggested as providing a means to increase access to evidence-based psychological therapy. This is particularly the case in primary care, where access to face-to-face CBT is limited. Despite evidence cCBT can be effective for depression and anxiety, the majority of studies have been conducted with community samples rather than in primary care patients. In primary care trials, where therapeutic human contact is reduced cCBT interventions are often not more effective than usual primary care, and use is very low. These findings lead to suggestions that cCBT interventions need to delivered with therapist support, consequently increasing their cost and limiting access. An issue that is rarely considered is changing the content and format of the digital interventions themselves. In addition, development papers for commonly used cCBT interventions suggest that patients or users have not been included in the development process in a systematic and in-depth way.

 Aims:

The aim of this project was to develop an internet-based intervention for emotional distress in primary care patients. We aimed to work with primary care patients from the outset and throughout development. An additional aim of the project was to qualitatively explore with patients how they perceived or conceptualised their own emotional experience in relation to their primary care consultation. Many of these patients may not identify with notions of depression as a psychiatric condition, and therefore not identify with the content of existing cCBT interventions for depression. 

Methods:

Our team included leading clinical and health psychologists, academic GPs who specialised in primary care mental health, and lay patient and public involvement representatives. Initially we held regular meetings to consider the nature of content for and intervention that was designed to be used without guidance. We drew techniques from behavioural activation and mindfulness-based therapies and placed them within an overarching framework based on Professor Ricardo Muñoz’s ‘Healthy management of reality’ approach. Here, the focus is placed on using evidence-based strategies to manage negative emotions in the presence of life stressors.  In designing the intervention specifically for unguided use, techniques were chosen that were likely to be reinforcing at the time of use, or very simple. Many techniques such as challenging negative thoughts can be difficult, which may lead to disengagement without the presence of supportive human guidance.

As the framework was put together and initial content drafted, we worked closely with ourPPI reps to check the framework could be easily understood. When we had an 

online prototype, we recruited 20 primary care patients who had consulted with their GP regarding emotional distress, but had not been diagnosed with major depressive disorder for in-depth interviews. We conducted these interviews iteratively in blocks of 3 or 4 over the development period. Patients were first asked about their emotional experience and their understanding of it. Following this open-ended section of the interview, 13 patients went through the prototype intervention providing detailed feedback on the content, and its likely relation to their lives/experience.

Key findings/conclusions:

Our process lead to the development of ‘Healthy Paths through Stress’ (short name: Healthy Paths), an interactive, internet-based intervention specifically targeting severe emotional distress in the context of social/environmental stressors. A demo version can be found here:

https://www.lifeguideonline.org/player/play/August2014HealthyPaths-NEW-Images

Additionally, the initial open-ended interviews were transcribed verbatim and explored using thematic analysis. Consistent patterns in the data were categorised into four overarching themes: Difficulties Coping; The Stress Experience; Considering Depression; Having Anxiety. The majority of patients described how multiple life events had become ‘too much’, and they could no longer cope. Patients’ descriptions of what they often referred to as ‘stress’, were severe. Metaphors included feeling ‘pulled apart’, ‘worlds falling in’ or references to ‘nervous breakdown’. A number of patients actively considered whether their symptoms might be ‘depression’, with a range of conclusions. Some patients worked to conceptualise their symptoms as severe, but distinct from depression. Some patients were unsure and were seeking guidance; others had taken depression as the most appropriate descriptor. Patients’ descriptions of their emotional distress reflected a severe affective experience. The complexity in patient narratives around depression, reflects complexity in the theoretical literature on disorder. These issues regarding what depression is, represents and is caused by are often overlooked in primary care research on ‘common mental health problems’. 

Plain English summary

General practitioners often see patients who are experiencing psychological distress, but are not clinically depressed or anxious. Although within the ‘normal’ range of emotional experiences, distress can have a number of negative effects on health, and can place patients at risk for major depression or anxiety. Interventions to help patients deal effectively with distress may reduce the number of new cases of stress-related health complaints or psychological problems and increase patient well-being. However, GPs may not have time or resources to offer face-to-face support for the promoting mental health. The proposed project will develop and research an internet intervention to be offered by GPs and designed to help patients effectively manage distress. Working closely with patients who have experienced distress our team will develop a brief intervention drawing from the most up-to-date psychological research on the most effective ways to deal with stress. Free software that allows non-programmers to build internet interventions will be used. As the intervention is built, patients will be interviewed and asked for their opinions about our intervention, and how they might use, or not use internet interventions in general. This information will be used to improve the intervention, and will be published in order to allow other researchers to draw from our experience. As well as publishing in academic journals, this project will produce an internet intervention that can be immediately evaluated for feasibility and effectiveness in groups of primary care patients. The intervention may also be helpful for patients with a range of stress/distress related health complaints. The team has extensive experience developing and evaluating internet interventions for primary care. The team includes GPs working in research as well as in practice, and psychologists with expertise in how to manage mental health and how to use the internet most effectively to provide engaging interventions. The aim of this project is develop and qualitatively research an internet intervention for distress in primary care. 

Dissemination

This project led to the development of an internet intervention that will be trialled and implemented in a broad range of contexts, if future studies deem it to be effective.

This intervention and research around it, will form the basis of an NIHR Career Development Application that AG will submit in early 2017. This will feature a trial and an examination of a stratification method of for patients presenting to primary care with psychological symptoms.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 161 )

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.