Title: Accessibility and implementation in UK services of an effective depression relapse prevention programme: Mindfulness based cognitive therapy
Funder: Division for Social Care and Health Research (Wales)

Abstract: BackgroundMindfulness-based cognitive therapy (MBCT) is a cost effective psychosocial prevention programme to help people with recurrent depression stay well in the long term. It was singled out in the 2009 National Institute for Health and Clinical Excellence (NICE) Depression Guideline as a key priority for implementation. However its accessibility across the UK is limited.Depression is a major public health problem that like other chronic conditions typically runs a relapsing and recurrent course producing substantial decrements in health. In terms of disability-adjusted life years the World Health Organization consistently lists depression in the top five disabling conditions and forecasts that this will worsen over time. A recent health economic analysis of the cost of anxiety and depression in the UK suggested a cost of £17billion or 1.5% of the UK gross domestic product. Without effective treatment people suffering recurrent depression have a high risk of repeated lifetime depressive episodes. Major inroads into the substantial health burden attributable to depression could be offset through evidence-based interventions that prevent depressive relapse among people at high risk of recurrent episodes.To stay well NICE recommends that people with a history of recurrent depression continue antidepressants for at least two years. However many patients experience side-effects and express a preference for psychosocial interventions that provide long-term protection against relapse. There is significant interest in an effective and promising psychosocial intervention: mindfulness-based cognitive therapy which was developed to teach people with a history of depression the skills to stay well in the long term (Williams & Kuyken 2012).Even if a psychosocial intervention has compelling aims has been shown to work is cost-effective and is recommended by a government advisory body its value is determined by how widely available it is in the health service. Feasibility work for this application shows that service provision on the ground falls well short of that envisaged in the UK national guidance for MBCT implementation. Research aimsThe proposed research will first scope the current state of MBCT implementation across the UK (phase 1). It will then develop an explanatory account of facilitators and barriers to implementation that will be used to develop an implementation plan (phase 2). Specifically we will:•Scope existing provision of MBCT across the four countries.•Develop an understanding of the perceived benefits and costs of embedding MBCT in mental health services.•Explore facilitators that have enabled services to deliver MBCT.•Explore barriers that have prevented MBCT being delivered in services. •Articulate the critical success factors for the routine and successful use of MBCT as recommended by NICE.•Synthesise the evidence from these data sources and in consultation with stakeholders develop an implementation plan that services can use to facilitate the implementation of MBCT.Study FrameworkWe will use the Promoting Action on the Implementation of Research in Health Services (PARIHS)framework to underpin this study (Rycroft-Malone 2004; Kitson et al. 2008). The work will involve a two-phase exploratory and explanatory research study using an interview survey and in depth case studies. ApproachThis is a two phase exploratory and explanatory research study using an interview survey and case studies. Phase 1 will provide a broad overview of current implementation across the UK using an interview survey. Up to 70 purposively sampled semi-structured telephone or face-to-face interviews with a range of stakeholders across UK services will be conducted. We will scope existing provision and focus on perceptions about MBCT ascertain views about embedding MBCT into service delivery including models of teacher training facilitators barriers costs and benefits. Phase 2 will provide a contextually rich picture of MBCT service delivery through up to 10 in-depth case studies using exploratory and interpretive methods. A ‘case’ is defined as an NHS Trust Health Board or commissioned organization where NICE recommendations would suggest there should be MBCT provision. We are interested in uncovering what the critical success factors are for the routine and successful use of MBCT as recommended by NICE for people with recurring depression in service delivery. Additionally we want to know what impedes the routine use of MBCT. In each case study we will conduct semi-structured interviews with service users managers commissioners and practitioners non-participant observation of relevant meetings and document analysis. Across both phases we will sample across different levels of implementation and key contextual variables. Data will be analyzed using a thematic analysis approach informed by Ritchie and Spencer (1994) and Yin (2008).Synthesis and outcomes: Guided by the study’s conceptual framework data will be synthesized across phase 1 and phase 2 to provide a rich and robust explanation about MBCT implementation in UK services. The output of this will be an MBCT Implementation Plan which will include a toolkit (i.e. strategies for successful implementation implementation approaches training manuals measurement/evaluation tools) for service providers to use to facilitate more successful implementation of MBCT into service delivery and to evaluate the impact of implementation. Benefits to the NHS Depression typically presents in the NHS as a recurrent long-term condition associated with significant disability and repeated presentation to services. By improving the accessibility of a cost-effective psychosocial intervention programme many more people will be able to benefit by reducing their risk for depressive relapse and enjoying improved quality of life and functional status. In addition the costs associated with depression would be offset. This study could have considerable impact given the size of the problem being addressed the modest cost of the intervention and the way it could in principle integrate with existing care pathways for depression. Our dissemination plan includes a proactive and collaborative approach to ensuring the Implementation Plan is accessible and used across the NHS.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH