Brief report
Self-help strategies that are helpful for sub-threshold depression: A Delphi consensus study

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Abstract

Background

Sub-threshold depressive symptoms cause substantial disability in the population and are often managed with self-help strategies. However, it is unclear which self-help strategies are likely to be helpful and should be encouraged.

Methods

The Delphi method was used to assess expert consensus on helpful self-help strategies. An international sample of 63 depression consumers and 34 professionals participated. A literature search found 282 self-help strategies that have been proposed as helpful for depressive symptoms. A systematic review of the evidence was carried out and given to panellists to assist their judgments. Panellists rated the likely helpfulness of each strategy in reducing sub-threshold depressive symptoms. Helpful strategies were then assessed for feasibility of implementation.

Results

Forty-eight strategies were endorsed by at least 80% of both consumers and professionals as likely to be helpful. Consumers and professionals rated a few strategies quite differently, but overall there was considerable agreement about the types of strategies most likely to be helpful, which were typically lifestyle or psychosocial in nature. Strategies rated helpful but difficult to implement were eliminated from the final list.

Limitations

Panellists found rating feasibility difficult and there was limited evidence from trials on which panellists could base their helpfulness ratings.

Conclusions

We identified a list of self-help strategies which are likely to be helpful and are feasible to implement by people with sub-threshold depression. The promotion of these strategies to the public needs to be evaluated to see if it could reduce the disability burden of sub-threshold depression.

Introduction

Although having diagnostic categories for depression is useful in a clinical setting, epidemiological evidence suggests that depressive disorders exist on a fluid continuum, rather than as discrete syndromes. Depressive symptoms that fall short of meeting diagnostic criteria (variously termed sub-threshold, sub-clinical, sub-syndromal, mild, or minor depression) are prevalent (Rowe and Rapaport, 2006), cause significant functional disability (Cuijpers et al., 2004), increase the risk of developing major depressive disorder (Cuijpers and Smit, 2004), and have considerable economic costs (Cuijpers et al., 2007).

Although several trials have investigated treatments for sub-threshold depression, they involve intervention by health professionals, and an approach that does not further burden clinical resources is preferable. Self-help methods that can be carried out without the need for professional guidance is an alternative, as they are commonly used, particularly for milder forms of depression (Jorm et al., 2004) and are perceived as helpful by the public (Jorm et al., 2005). However, some self-help methods may be less effective than others or even harmful (e.g. substance use).

Many self-help strategies are not amenable to evaluation by randomised controlled trials, e.g. taking time off work or seeking support from friends. Therefore, other approaches to evaluating evidence are required. One approach is to gather the consensus of consumer and professional experts on which self-help strategies are most likely to be helpful. The expert consensus approach has become standard in the development of practice guidelines for clinicians and may be similarly applied to guide the public in what actions they can take.

Once a set of effective self-help strategies is established, they could be promoted to the public in a similar way to other health promotion campaigns that encourage action to reduce risk of heart disease and cancer (Jorm and Griffiths, 2006).

In this paper we report a Delphi consensus study on self-help strategies for sub-threshold depressive symptoms. The aim was to identify strategies that are likely to be both helpful and feasible, and which could be used in a future health promotional campaign.

Section snippets

Delphi method

The Delphi method (Jones and Hunter, 1995) was chosen to assess expert consensus on helpful and feasible self-help strategies for depressive symptoms. Clinicians and researchers with depression expertise formed one panel, while consumers who had experience of depression and were in an advocacy role formed a second panel.

Panel formation

Experts in depression were recruited from Australia, New Zealand, Canada, the USA, the UK, Ireland, and the Netherlands. The professional experts approached were international

Panel members

Ninety-seven panel members (34 professionals, 63 consumers) participated in Round 1. Overall, 49 (50.5%) were male (70.6% of professionals, 39.7% of consumers). Of the 34 professionals, there were 19 psychiatrists, 5 general medical practitioners, 5 clinical psychologists, 3 occupational therapists, 1 mental health resource worker, and 1 psychiatric nurse. The Round 1 questionnaire response rate was 89.5% for professionals and 92.6% for consumers; nine individuals who agreed to participate in

Discussion

This study aimed to determine through expert consensus which self-help strategies for sub-threshold depressive symptoms are likely to be helpful and feasible to implement, and might therefore be good candidates for promotion to the public. Forty-eight strategies were thought likely to be helpful. Of these, the top fourteen were selected, excluding any that were difficult to implement. Rather than selecting a few strategies that everyone should carry out, we chose to select a larger number of

Role of funding source

Funding was provided by the National Health and Medical Research Council and the Colonial Foundation. These funding sources had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

The authors gratefully acknowledge the time and effort of the panel members, without whom this project would not have been possible. Thanks also to the members of the research team, Laura Hart, Claire Kelly, Anna Kingston, and Betty Kitchener, for their assistance with the questionnaire development.

References (12)

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