Some people have experienced very adverse experiences over their lives, leading to low self-esteem and other vulnerabilities which can make people susceptible to depression. Difficult life circumstances, such as financial problems, loneliness, stresses at work, among family or in relationships, poor physical health and genetic vulnerabilities also contribute. Even long-term depression can be treated, but the lifetime risk that the depression returns has been reported as about 50% for those experiencing one episode of major depression, with the likelihood increasing with further episodes.
Greater numbers of people experiencing mental health problems, and greater awareness of effective treatments, has increased demand for services. In recent years this has led to investment through the Improving Access to Psychological Therapies programme, but because of huge demand, waiting times can still be a problem and it’s important that we develop new ways of helping people manage and overcome their mental health problems – to prevent problems occurring in the first place, and to prevent them returning. A lot of this comes down to teaching people to help themselves more effectively.
To some extent this is already happening, for example with increases in self-help support within mental health services, and the use of self-help websites, online support and apps. Working with NHS staff, we have developed the Self-Management after Therapy intervention, or SMArT, designed to help people to stay well after they have recovered from an episode of depression.
Like other relapse-prevention approaches, it assumes that many people continue to remain vulnerable to depression. Recovery is seen as a process that continues after the end of therapy that has its ups and downs. This approach helps prevent someone from feeling they are back to square one if they have a setback, a frame of mind that can increase the likelihood of a return to more severe depression.
The approach, first developed by psychologist Peter Gollwitzer in the 1990s, has been found to support changes in behaviour, such as quitting smoking or doing more physical activity, through what are called implementation intentions. It is designed to help people turn an intention to act into a habitual behaviour. We know how hard it can be to make good intentions a reality (such as practically every New Year’s resolution), and when someone’s mood and motivation are low it can be even harder. As one mental health service user said during our research: “I know what to do, but when I’m down I just don’t do it.”
Implementation intentions work by linking a specific situation to a specific response. For example: “Every evening between 7pm and 9pm I will write down all the positive things that have happened that day,” or “Every Thursday evening I will go to the pub quiz with my friend Katy”. They often take the form of “if …, then …” statements, such as: “If I feel down, then I will talk to my partner about why this might be.”
When the situation comes up, the learned response is brought to mind, and is therefore more likely to be acted out. Using our SMArT intervention, people are encouraged to identify up to five of these implementation intentions. It’s important that they are realistic and that they will have an impact on the person’s wellbeing. The best way of thinking about them is to consider five things you do on a regular basis that are important to you. Then, imagine how you would feel if you didn’t do them. That is what tends to happen in depression, or when a person is at risk of a relapse.
The use of the SMArT intervention is supported in mental health services by psychological wellbeing practitioners, and patients are encouraged to share their intentions with friends or family who can support them.
SMArT is just one of a number of ways of helping people who are prone to depression to stay well and we’re carrying out more research to see how effective it is. It provides a bridge between the end of therapy and life without therapy and helps people see the importance of setting plans and having routine in their lives. It also emphasises that recovery is a process that includes learning about oneself and self-management strategies. It is something for the long-term – not just for all-too-soon-abandoned New Year’s resolutions.
Some of the work to develop the SMArT intervention was funded by NHS Research Capability Funding from the West Yorkshire Clinical Commissioning Groups.