DeSTRESS 2: Implementing effective primary care responses to poverty-related mental distress

Mental health problems are responsible for over 20% of the burden of disease in England (PHE 2018) and will rise due to the impact of COVID-19. Providing effective treatment and support for mental distress is a stated government aim. However, because current strategies tend to frame mental distress as an individual psychological problem, available support is dominated by medical or psychological interventions that aim to ‘fix’ the person, rather than interventions that seek to address (at individual or community level) what are often broader social and structural stressors associated with poverty e.g. poor housing, unemployment.

Empirical data show that low-income populations experience high levels of mental distress, yet frequently struggle to ask for and receive appropriate mental health support. In many low-income communities, use of antidepressant medication is high and can have adverse side effects and withdrawal reactions and limit personal agency whilst doing little to improve health and wellbeing.

The DeSTRESS project, led by Dr Felicity Thomas of the University of Exeter, examined how current mental health treatment options were being used within low-income communities; how patients experienced GP consultations and treatments prescribed to them; and how small changes within consultation practice could be harnessed to provide more supportive outcomes for low-income patients. 

This study will examine how best to deliver the DeSTRESS training across diverse practice and place-based settings (rural/urban/coastal/inner city) encompassing diverse poverty-affected populations (rural, urban, older people, BAME groups) to optimise the impact of consultation practice for patients and for GPs.

Based on this evidence, we aim to develop further guidance and a manual for GPs about how best to deliver supportive consultations for patients presenting with poverty-related mental distress.

We will research how the training is delivered and received and what changes result from this. 

After 18 months, all regions across England will be offered the optimised training resources.

We will undertake the research across three Applied Research Collaboration (ARC) regions in England encompassing diverse poverty-affected populations (focusing on rural and urban poverty; older adults and BAME groups); the South West England (PenARC region); North London (ARC NT); North West England (ARC NWC). We recognise that GPs will be using different approaches so training will be delivered in a way that endorses existing good practice and encourages team-based support for change. We will work with GP training hubs/PCNs to identify GPs who can help deliver the training in each ARC region alongside the community partners.

We will use a phased mixed methods approach to researching the implementation of DeSTRESS training across the three ARC regions. An initial logic model of the key mechanisms and hypothesised short, medium, and long-term outcomes has been produced and will be refined according to the research findings.

The training aims to change consultation culture away from ‘quick fix’ antidepressant prescribing towards a more scientifically robust personalised bio-psycho-social approach to providing support that aims to improve trust and engagement with low-income patients, fosters shared decision-making with patients around treatment and support (including social interventions to address mental distress), co-creates continuity in support, and recognises and seeks to build on personal strengths.

The finalised project theory, as it will emerge from the data analysis, will be used to refine the training which will then be developed as a manual for use by primary care practitioners. 

The training resources will be offered to all ARC regions through Continuing Professional Development providers.

The researchers and community partners will follow-up with GPs to understand their experiences of delivering the adapted consultation and any barriers and enablers to this.

We will disseminate and discuss emerging findings with community members via bi-monthly meetings to ensure the research remains relevant to community concerns. Community workshops will be offered to feedback and discuss the final findings.

After 18 months, the optimised training materials will be made openly available for use across England.

We will disseminate findings through accessible reports and presentations, and via academic and practitioner conferences. We will publish research findings in peer-reviewed journals – all publications will be available via Open Access.

Felicity Thomas – Principal Investigator
Associate Professor in Culture and Health Inequalities, University of Exeter

Professor Richard Byng
Professor in Primary Care Research / PenARC Deputy Director 

Professor Katrina Wyatt
Professor of Relational Health (PenARC)

Susanna Hughes
Community Embedded Researcher & C2 Connecting Communities Programme Lead, University of Exeter

Jane Horrell
Research Fellow, University of Plymouth

Kathryn Berzins
Senior Research Fellow, University of Central Lancashire

Ilse Lee
Implementation Manager, UCLPartners