Title: TACKling chronic depression - adapting and testing a technology supported patient-centred and solution-focused intervention (DIALOG+) for people with chronic depression (TACK)
Funder: Department of Health and Social Care

Abstract: AIMS AND OBJECTIVES The overall aim is improve quality of life and clinical outcomes for people with chronic depression. We will adapt and comprehensively evaluate a person-centred solution-focused intervention (DIALOG+) for the treatment of chronic depression, and develop an online training package for use by different mental health professionals to aid implementation. BACKGROUND AND RATIONALE Depression affects one in four people during their lifetime. It is a leading cause of disability worldwide and a priority within the NHS. Despite a range of treatment options, between 20-30% of patients go on to develop a chronic disorder and are often termed treatment resistant". Outcomes remain poor, with chronic depression associated with an increased suicide risk, poor quality of life, physical comorbidity and functional impairment. From a societal perspective, chronic depression is estimated to cost the UK economy over &pound;7.5bn per year. There is a lack of evidence-based interventions and research specifically focused on chronic depression. Current treatment options lack effectiveness, or require referrals to specialist services. Consequently, there is need to develop interventions which are effective, cost-effective and can be routinely implemented within different clinical settings to improve patient outcomes. One potential solution is DIALOG+. It is based on quality of life research, patient-centred communication and solution-focused approaches. Unlike existing treatments, the intervention does not require additional referrals, but is instead implemented within routine appointments between patients and clinicians. The intervention has been shown to be effective in improving the quality of life and mental health outcomes of individuals with schizophrenia. If properly adapted and evaluated, it has the potential to improve outcomes for individuals with chronic depression. RESEARCH PLAN The research includes seven work packages (WPs) and will be led by a multidisciplinary team with expertise in the development of complex interventions and the treatment of chronic depression. To support the research, a Lived Experience Advisory Panel (LEAP) including eight individuals will be set up at the beginning of the study and provide expertise throughout. We will work with the LEAP to develop research materials, analyse qualitative findings, interpret results and ensure dissemination materials are accessible to patients and the public. In WP1 we will conduct a systematic review to identify recruitment and retention strategies used in previous psychosocial intervention trials with people with depression. This will help develop recruitment and retention strategies for the later stages of the programme. WP2 will iteratively adapt the intervention (DIALOG+) and online training materials for use with people with chronic depression. Initial adaptations will be based on two patient workshops and interviews with clinicians (n=10). Five clinicians and fifteen patients will then test the adapted intervention over a three-month period, with individual interviews used to help further modify the intervention. In WP3, a feasibility study will be conducted over 6 months, where nine clinicians and 45 patients will be randomised on a 2:1 basis to the intervention or an active control. This will inform the design of the full-randomised controlled trial (RCT) and will further refine the intervention and online training. In WP4, a multi-site cluster RCT with internal pilot will assess effectiveness and cost-effectiveness. Data will be collected from inner city, semi-urban and rural areas (East London, Sheffield, Oxford and Gloucestershire). A total of 448 patients and 112 clinicians will be recruited, with patients assessed at baseline, 6 and 12 months post-randomisation. A qualitative process evaluation (WP5) will explore the mechanisms of action and intervention processes. To maximise impact, twenty staff members from different professional backgrounds (primary care nurses, assistant psychologists, occupational therapists and inpatient staff) will test the feasibility of the online training across clinical settings (WP6). The study findings, intervention and online training will then be disseminated to different stakeholders in WP7. PROJECTED OUTPUT AND DISSEMINATION An intervention (including an intervention app) and online training package will be developed. Findings will be widely disseminated through publications in peer-reviewed journals, user magazines and conference presentations. An interactive project-specific website will provide regular updates about the research throughout and will be used alongside social media to increase dissemination to a wider audience. The online materials will be further disseminated through workshops, which will be co-produced and facilitated by the LEAP and delivered to different NHS Trusts. BENEFIT TO PATIENTS AND THE NHS The treatment and management of long-term conditions, including chronic depression, is a key NHS priority. If properly developed and evaluated, the intervention has the potential to improve the quality of life and mental health outcomes for thousands of patients with chronic depression currently being treated within the NHS. Unlike current treatment approaches, the intervention will neither require setting up new services, nor reorganising existing ones, and can be used within routine meetings. With only minimal online training, the intervention can be delivered by different professionals across service settings, thus maximising implementation and the potential immediate benefit for patients and the NHS."

Lay abstract: This research aims to develop a new approach to help people with depression. Depression is a common mental health problem affecting one in four people at some point in their life. It can result in high levels of distress, increased suicide risk and a loss of interest in daily activities. Most people with depression find treatment helpful. However for some people (one in five), depression continues for more than two years, despite receiving mental health treatment. This is called &ldquo;chronic depression&rdquo;. Approaches for chronic depression are limited, and people often continue to have a poor quality of life. In previous research we developed an intervention called &ldquo;DIALOG+&rdquo; which helped patients with another serious mental illness called schizophrenia. DIALOG+ involved mental health staff using a tablet computer to ask patients about their satisfaction with different areas of life. Patients and staff then worked together to find solutions to concerns raised. This process was repeated several times. After using DIALOG+, patients were more satisfied with life and had fewer symptoms. Patients and staff found the approach helpful and it saved the NHS money. As it helped patients to find practical solutions to their concerns, we think DIALOG+ might also work for people with depression. To find this out, we need a programme of research. Firstly, we will see if DIALOG+ is acceptable by asking people with depression their opinions on the approach so we can adapt it to their needs. We will then do a small study with nine staff members and 45 patients with depression to gain further experience with DIALOG+ and check whether a larger study testing it would be possible. We will then carry out a larger study in four different areas in the UK to test whether DIALOG+ really helps patients with chronic depression. This will include 112 care coordinators and 448 patients, half of whom will use DIALOG+. The other half will not use DIALOG+, and will act as a comparison group. We will ask all participants to fill out questionnaires at the start of the study and after six and 12 months. We will then compare the two groups using these questionnaires to see if patients receiving DIALOG+ show improvements. If the approach is successful, we will develop an internet training programme for different health professionals and test it with nurses, people working in General Practice surgeries, and assistant psychologists. To make sure we get the opinions of those who have experienced depression, we will set up a &ldquo;lived experience advisory panel&rdquo;. They will support the research throughout the five years. They will help us choose which questionnaires to use, and help ensure that all the research information is accessible and meaningful to other patients.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH