Can we reduce the risk of relapse of depression in primary care? A mixed methods study
Problem
Most people with depression are treated in primary care. Relapse (a re-emergence of depressive symptoms) after improvement is common, contributing to the burden associated with depression. We lack evidence-based approaches for identifying people who are at higher risk of relapse. By identifying higher risk individuals, we could potentially target relapse prevention strategies with a view to improving patient outcomes and using limited healthcare resources more effectively.
Approach
This was a mixed methods study. We aimed to identify and critically appraise previous studies looking to predict relapse of depression across all settings. We then attempted to derive and validate a prognostic model to predict relapse within 6-8 months in a primary care setting. We used multilevel logistic regression analysis on individual participant data from 6 RCTs and a cohort study (n=1244) to develop a model and internal-external cross validation to assess generalisability. Concurrently, a qualitative work-stream explored the perspectives of General Practitioners (GPs) and people with lived experience of depression on relapse risk and prevention in practice. Data analysis used principles of constant comparison and ethics approval was granted by the Health Research Authority. A Patient Advisory Group contributed to all stages of the study.
Findings
Our Cochrane systematic review identified 12 studies looking to develop and/or validate prognostic models for predicting relapse. All were either at high risk of bias or developed models with poor predictive performance; none could be implemented in a primary care setting. Our model development work is ongoing; preliminary results suggest inadequate predictive performance. Twenty-two interviews with GPs and 23 with people with lived experience of depression.Thematic analysis of the qualitative data generated three over-arching themes: significance of social, personal and environmental factors in determining depression course; relationships and communication; recognition of importance of relapse, but limited discussion in practice. Continuity and an understanding, empathic approach from the GP was felt to be important by people with lived experience of depression. People with lived experience of depression and GPs reflected that a discussion around relapse would be useful but was not routinely offered. Both participant groups felt there would be benefits to relapse prevention for depression being embedded within primary care. GPs suggested that, while relapse prevention is appropriate work, additional resource would be needed to enable relapse prevention to be incorporated into routine primary care.
Consequences
Relapse is considered an important problem by GPs and people with lived experience of depression. The constructs of relapse, remission and recovery, widely used in the psychological literature, may not be applicable in primary care. Work is needed to ensure individuals at higher risk of relapse can be identified and target relapse prevention efficiently. Scalable brief interventions are needed and barriers to their implementation in primary care should be addressed.