Date Published: May 30, 2019
Publisher: Public Library of Science
Author(s): Patricia Moreno-Peral, Sonia Conejo-Cerón, Anna Fernández, Carlos Martín-Pérez, Carmen Fernández-Alonso, Antonina Rodríguez-Bayón, María Isabel Ballesta-Rodríguez, José María Aiarzagüena, Carmen Montón-Franco, Michael King, Irwin Nazareth, Juan Ángel Bellón, Adam Todd.
The predictD intervention, a multicomponent intervention delivered by family physicians (FPs), reduced the incidence of major depression by 21% versus the control group and was cost-effective. A qualitative methodology was proposed to identify the mechanisms of action of these complex interventions.
To seek the opinions of these FPs on the potential successful components of the predictD intervention for the primary prevention of depression in primary care and to identify areas for improvement.
Qualitative study with FPs who delivered the predictD intervention at 35 urban primary care centres in seven Spanish cities. Face-to-face semi-structured interviews adopting a phenomenological approach. The data was triangulated by three investigators using thematic analysis and respondent validation was carried out.
Sixty-seven FPs were interviewed and they indicated strategies used to perform the predictD intervention, including specific communication skills such as empathy and the activation of patient resources. They perceived barriers such as lack of time and facilitators such as prior acquaintance with patients. FPs recognized the positive consequences of the intervention for FPs, patients and the doctor-patient relationship. They also identified strategies for future versions and implementations of the predictD intervention.
The FPs who carried out the predictD intervention identified factors potentially associated with successful prevention using this program and others that could be improved. Their opinions about the predictD intervention will enable development of a more effective and acceptable version and its implementation in different primary health care settings.
Interventions to prevent depression are effective but their effect sizes are small to moderate [1–2]. These interventions are primarily psychological or educational and are provided by mental health professionals . Several randomized controlled trials of primary prevention of depression in primary care have been undertaken , although in only two the intervention was implemented by family physicians (FPs). In a third trial, (the “CATCH-IT” study)  the effectiveness in adolescents of brief counseling was compared with a motivational interview administered by FPs. While both interventions seemed effective, there was no evidence either way for superiority. Our research team carried out the predictD-CCRT study to compare a bio-psycho-social intervention implemented by FPs (the predictD intervention) versus usual care . The predictD intervention is based on a risk algorithm to predict the onset of major depression at 12 months in primary care attendees . This intervention was tailored to each patient based on his/her risk profile for depression (risk factors present) and his/her risk level (likelihood of becoming depressed at 12 months), and it was developed as five a priori active components [5–7]: a training workshop for FPs; communicating the level and profile of risk of depression to patients every six months in a 10- to 15-minute interview; constructing a personalized bio-psycho-social intervention to prevent depression; offering a brochure; and activating and empowering patients. This intervention reduced the incidence of major depression at 18 months follow-up by 21% versus the control group (usual care)  and it was also cost-effective . Qualitative methodology is the best way to elucidate the active ingredients/mechanisms of action of these complex interventions in order to promote them and to adapt the interventions for application in different settings . Therefore, the aim of our study was to assesss FPs’ opinions about the potential successful components of the predictD intervention for the primary prevention of depression in primary care and to identify areas for improvement.
All participants gave written informed consent and participant anonymity was maintained using personal codes in the transcripts. This study was approved by the ethic committee: Ethics and Research Committee of Primary Health District of Málaga.
The 70 FPs participating in the intervention arm of the predictD-CCRT study were invited to take part in the predictD-EVAL study. Of these, 67 (95.7%) agreed to participate. The remaining three did not participate because they did not complete the predictD-CCRT study: two due to sick leave and the third due to relocation to another health centre. The characteristics of the FPs are shown in Table 2.
The FPs suggested ways to adapt the predictD intervention to other settings and make its implementation more efficient. Some proposed prioritizing the ’constructing a tailored bio-psycho-family-social intervention by FPs to prevent depression’ component of the predictD intervention in patients at higher risk of depression. This is relevant to whether or the predictD intervention was more clinically and cost-effective in high or low-moderate risk patients. Other FPs suggested involving other primary care professionals (e.g. nurses) and minimizing the time to obtain information on the level and profile of the risk of depression. Our research team launched a free website (http://www.predictplusprevent.com/index.php?idioma=en) that anyone can access to calculate their risk of depression, anxiety or hazardous/harmful alcohol consumption. The website also provides information and resources on how to reduce risk. Some FPs, in addition to stepped care depending on the level of risk, also suggested specific interventions for patients with particular risk factors for depression (e.g. for sedentary or insomnia patients).