Facilitators and barriers to modifying dietary and hygiene behaviours as adjuvant treatment in patients with depression in primary care: a qualitative study

Major depression Disorder (MDD) is a highly prevalent condition and has become the second most common cause of disease-induced disability in our society [1‐3]. Its pathogenesis is related to a wide variety of biological and psychosocial factors. Among these are factors related to lifestyle, as diverse studies claim [4‐9].

The relationship between depression, diet and obesity is well established [10], as is that between eating style, weight gain and depression [11]. The comorbidity of obesity and depression is highly significant, with depression being up to 20–45% more prevalent in obese individuals [12]. A systematic review of prospective studies describes a reciprocal cause-effect relationship between depression and obesity [12]. Furthermore, weight loss in the obese has been found to reduce symptoms of depression [13], and similarly an improvement in short-term depression has been associated with weight loss, not only in females [14], but also in the general population [15]. A poor diet, obesity and/or metabolic syndrome predispose individuals to metabolic changes that interact with cerebral function through very complex mechanisms, probably having an individualized effect on each patient [10, 16‐18]. The alteration of certain metabolic mechanisms has been associated with a poor outcome for depression, but this phenomenon also occurs in the opposite direction, creating a vicious circle of illness [10, 19]. Lee et al. [20] highlight the complex relationship between antidepressant drugs, MDD and weight gain. Hypothalamic-pituitary-adrenal (HPA) axis activation occurs during states of stress; concurrently, the HPA axis is also dysregulated in obesity and metabolic syndrome, making it the best understood shared common pathophysiological pathway with MDD.

Given this close relationship, lifestyle – more specifically dietary and hygiene behaviours – could play a major role in the initiation, maintenance and treatment of depression, at least as an adjuvant [4, 7, 19, 21]. The combination of different lifestyle-based interventions (diet, exercise, sun exposure, and sleep hygiene) appears to be an appropriate strategy to increase their effectiveness [19, 22], although it has been poorly investigated and has had varied results [4, 19, 23]. Furthermore, no studies exist regarding the difficulties and opportunities for change and how the healthcare system could help patients suffering from depression to modify their dietary and hygiene behaviours, as compared to other medical conditions such as diabetes [24, 25], Crohn’s disease [26] or cardiovascular disease [27].

Primary Care (PC) is the most accessible healthcare service, offering comprehensive and continuous patient-centred care, and it is the most frequently used by citizens. Therefore, it is an ideal scenario for conducting individual, group and community interventions to change behaviours [28]; in this case, those related to the treatment of depression [19] or even its prevention [29].

Thus, the objective of this study is to explore and identify facilitators and barriers to the promotion of healthy dietary and hygiene habits in patients suffering from major depression from the expectations and experiences of both patients and healthcare professionals. This study was developed in PC centres and those attending to the most important aspects when implementing behaviour modification programmes in this population.

A qualitative design was used to collect information from a wide range of purposefully and theoretically guided samples of depressed patients and health professionals from PC. With the intention of increasing the consistence of the study, both in-depth interviews (with depressed patients) and discussion groups (with depressed patients and health professionals, separately) were used to access the subjectivity and the processes involved in generating ideas and concepts [30]. This triangulation of techniques and informants has been used in other works [31], with the assumption that qualitative research is inherently multi-method [32]. In-depth interviews were conducted by a single interviewer, and discussion groups were moderated by an interviewer and an observer, both of them female psychologists and researchers with previous experience in the field and no previous contact with participants.

Patients were recruited from the Spanish autonomous regions of Aragon and the Balearic Islands during their visits to PC, taking advantage of their participation in a research project (randomized controlled trial, RCT) on lifestyle change recommendations in patients with major depression [10, 23, 33]. This RCT consisted of a series of written dietary and hygiene-related lifestyle recommendations to improve their depressive symptoms and quality of life with low socio-sanitary costs. Through a randomized, double-blinded, multicentre, two arm-parallel clinical trial, with 12 month follow-up, and a sample of 273 PC patients, it was observed that just giving written lifestyle recommendations is not enough for depressive patients to benefit from them. Therefore, there seems to be a need for deeper understanding into the patient and professional expectations and experiences that might point to the barriers and facilitators to the implementation of these kinds of programmes. For this purpose, a subsample of patients was created, selected after stratification based on the variables of age, (18–40; 41–60; > 60), sex, level of education (primary, secondary, tertiary), occupation (paid, unpaid, no occupation) and level of depression at the basal assessement of the RCT using the Beck depression inventory [34] (mild, moderate, severe), treatment group in the study (active vs control), and city (Palma, Zaragoza). Health professionals were contacted by telephone, based on their age (18–40; 41–60; > 60), sex, occupation (general practitioner vs nurse), years of experience (< 15; 15–30; > 30), type of work contract (temporary vs permanent), participation in the study (participation vs not participation) and city (Palma, Zaragoza), in order to gather plentiful and varied information. Both patients and professionals were aware of the research project about lifestyle change recommendations, but none of them had any knowledge on the group to which patients were assigned. Every contacted patient and health professional initially agreed to be interviewed, but a number of them eventually did not keep the appointment owing to incompatible schedules. Table 1 outlines the main characteristics of the final 41 participants (11 patients and 30 professionals). The profile of a participating patient is a woman, between 40 and 60 years of age, with primary studies and mild or moderate depression. The profile of a participating health professional is a woman, between 40 and 60 years of age, general practitioner, with a permanent contract and more than 15 years of professional experience. The interviews were conducted between November 2014 and January 2015.

A standardized protocol was designed to guide the interviews and groups, including the preparation of a topic list to be addressed, with previously tested, open suggestions that could be of interest. The topic list was compiled from the experience of a panel of expert researchers who had developed and conducted a previous study on hygienic-dietary recommendations as adjuvant treatment in depression [19, 35] and taking into account the NICE behaviour change recommendations [36]. This topic list, shown in Table 2, comprised the following: previous knowledge of lifestyle recommendations (diet, physical exercice, sun exposure, sleep hygiene) as an adjuvant treatment for depression; where there was compliance with instructions: difficulties, feelings; in case of non-compliance with recommendations: causes, feelings; perception of efficacy; aspects that facilitate compliance with recommendations; appropriate level or means to change behaviour; ability of health system to help patients to change their behaviour and mood; proposals by health professionals when consulted about a mood problem; type of proposals that health professionals give and their characteristics; type of proposals that can be given; effectiveness of the proposals. After a short introduction about the study, patients and health professionals were asked open, general questions in order to raise a response and begin discussion. More direct questions were asked when specific topics did not spontaneously arise in the discourse. These are given in Table 3.

The objectives of the study were indirectly raised and questions asked about the topics in an open and progressive way. The interviewers and/or moderators were introduced to the participants as research psychologists and assumed a minimally orientative role, limiting their interventions to addressing the topics in the script. The settings for data collection were a neutral room in the different health centres at which the patients were registered, without the presence of non-participants. In-depth interviews lasted between 35 and 55 min and the discussion groups lasted 50–75 min. All of them were digitally audio-recorded and a verbatim transcription made in order to obtain the final set of qualitative data for the analysis, which was revised by the participants and added to the field notes made during and after the interviews/groups. An inductive thematic content analysis was performed from grounded theory in order to explore, develop and define the emergent categories of analysis derived from the individual interview and group data until saturation [37‐40].

The type of analysis used was therefore of a qualitative, vertical and interpretative nature, with stratified and projected sampling aimed at gathering plentiful and varied information, and with an emerging and non-frequential design for the analysis categories [41, 42]. The aplication of the ‘constant comparative method’ strategy enabled conceptual categories to be systematically generated, and analysis and explicit coding to be combined with theory building, highlighting significant properties and relationships among all of them [43]. Specifically, we used ‘open coding’ to develop the first provisional interpretations; ‘axial coding’ to deepen and discover properties and relationships in each category; and also a ‘core category’, which was able to integrate and summarize all the emergent categories by means of ‘selective coding’ that finally provided the esential framework [44, 45]. Theory integration throughout the design, implementation and evaluation of the previously mentioned parallel RCT intervention also provided valuable insight into how these emergent categories contribute to effectiveness in changing behavioral outcomes [46].

All the analyses were performed iteratively using Maxqda-2007 software in agreement between two researchers (BOB, JMM), and the interpretations made from the data were discussed with interviewers (PR, PHM) and participants to obtain their approval [47]. This methodological triangulation was able to increase consistency and rigour by combining multiple techniques and maximizing the breadth and depth of perspectives.

Participants provided written informed consent to participate in the study. No interview/group was repeated. As previously explained, this study forms part of a research project that includes an RCT on the effectiveness of a lifestyle change recommendation programme in depressed patients [10, 23, 33]. Once the clinical trial stage was completed, this qualitative study was carried out to analyse the facilitators and barriers that patients with depression experience with regard to modifying their dietary and hygiene behaviours. The project was independently approved by the Research Ethics Committee of Aragon (PI12/0022) and the Research Ethics Committee of the Balearic Islands (PI11/1563), Spain, on March 2012.

Both patients and PC professionals noted a series of central aspects with respect to the implementation of a programme for depressive patients to acquire healthy dietary and hygiene habits, which may be organized around ‘personal’, ‘programmatic’, and ‘transversal’ aspects. In relation to personal aspects, from the patients’ perspective, topics regarding their ‘personal history’ and their personal readiness or ‘disposition’ were found. On the other hand, the programmatic aspects included topics such as programme ‘presentation and monitoring’, from both the patients and professionals’ perspective; the modification of ‘cognitive habits’, from patients’ perspective; and the modification of ‘behavioural habits’, from professional’s point of view. All of them were interconnected in a synergetic manner towards the achievement of the transversal aspects, which were delimited by the possibilities of ‘social support’, from patients’ perspective, and definition of ‘objectives’, from professional’s point of view. Figure 1 provides a graphic representation of the core aspects that configure the central category (e.g., personal, programmatic, and transversal), and the main categories for the implementation programme for patients with major depression to acquire healthy dietary and hygiene habits. Table 4 provides quotes (Q) in which the properties or characteristics that make up each of the emerged categories are explained in the participants’ own words.

According to the results of this study, certain personal, programmatic and transversal properties affect the general objective of modifying dietary and hygiene behaviours. These characteristics, which may act as barriers or facilitators, are all interrelated.

The properties particularly emphasized for modifying dietary and hygiene behaviours in patients suffering from depression include the need to conduct a simple and motivating intervention at the appropriate moment when the patient is receptive and capable of overcoming apathy. For this, the patient must receive the support and supervision of a healthcare professional. Thus, PC may be an appropriate level at which to implement lifestyle modification programmes in individuals suffering from depression, since the conditions for effective change can be provided by patient-centred care that is accessible, comprehensive and ongoing [28]. The intervention might be planned between a general practitioner/nurse and the patient, using a motivational interview, because health professionals are trained in the field of changing habits, and a tailored intervention can be set up [48, 49] based on their knowledge of the patient. Moreover, they are in a position to motivate and enable, assess patient evolution and provide constant feedback [50, 51].

The main barriers faced by patients are of a psychological nature and are directly related to the symptoms of depression: apathy, feelings of guilt or incompetence, intrusive thoughts, cognitive avoidance and the need for cognitive restructuring [3, 6]. These barriers reduce motivation and hinder compliance, which is why interventions must be appropriate and timely, and should take into account the course of the disorder [52]. Time pressures in medical consultations [53], the possible inability to implement recommendations, and more particularly, not having the purchasing power to implement and maintain healthy habits are also perceived barriers to changing habits by professionals, who highlight the importance of driving modifications from a behavioural point of view. As expressed by some participants, by way of example, a healthy diet is more expensive than an unhealthy one. In fact, several studies conducted on the general population highlight a relationship between affordable or lower prices and the consumption of fruits and vegetables, and the resulting impact on body weight [54‐57]. This relationship is also evidenced in the opposite direction, i.e. a tax on certain types of food and drinks reduce their consumption [54‐57]. Furthermore, it has been demonstrated that specific changes in diet are maintained while there is purchasing power [55], so this is a particularly important factor when implementing an intervention for the modification of dietary and hygiene behaviours.

On the other hand, facilitators are factors that enable programme adherence, such as the simplicity of recommendations, which do not require instrumentation and are largely dependent on only the patients themselves, the tailoring of recommendations to their situation and the importance of motivating patients. These factors are consistent with several studies [24, 36] that highlight the importance of giving simple, progressive and tailored messages depending on the evolution of the disorder, and frequent repetition [58]. Behaviour modification is a process that usually requires successive approaches to learning, and it is important for patients to play a proactive role in change. The new experiences must be beneficial but also rewarding, since this increases the probability of repetition [59]. Supervision and assessment of compliance have been considered facilitators by patients and health professionals, respectively. ICTs (mobile apps, software, etc.) are an option to improve monitoring or its intensity, and they may be able to serve as support and complementary tools for both patients and health professionals in this regard [36]. Another important facilitator category is the perceived social support provided by the social network, or even better, that provided by the programme itself, as affirmed by patients. The social support provided by family, friends, associations, groups, etc. helps to create an appropriate environment in which patients feel capable of changing their habits and behaviours [36]. Social support has been defined as a protective factor against depression [60, 61], but it is modulated by the subjects’ perceptions of the support that they receive; and for certain mental illnesses, it is known that depressed patients perceive less social support than they in fact have [62] . Thus, as has been observed by patients, professionals should try to create an intimate, trusting atmosphere in which patients feel entirely supported.

As discussed, general agreement exists regarding the idea that PC is the optimum level at which to implement lifestyle programmes for the modification of dietary and hygiene behaviours with depressive patients. However, other studies reveal that excessive workloads and time constraints to which health professionals are subjected make it difficult to implement these types of interventions in real practice, and continuous implementation is still sub-optimal [63, 64]. Educational, legislative and fiscal measures regarding food prices, environmental planning, and communication and marketing campaigns are important factors that have been highlighted by healthcare professionals to help assure the success of the intervention. This idea is consistent with results from other studies: fiscal measures regarding food prices help to regulate consumption [54‐57] and marketing campaigns and audio-visual messages broadcast on television, in particular, have demonstrated their effectiveness in changing habits at a community level [65] through the use of emotional drivers to encourage behaviour change [66], such as affiliation, the presentation of aversive stimuli, etc. Nevertheless, at this time the role of the education system is still in question given the inconsistent results from several studies [67].

This study has certain limitations, mainly arising from the complexity of establishing a theoretical framework and taxonomy for changing lifestyles [68]. On the contrary, the main strength of this study is the triangulation of information related to the techniques of individual and group interviews, including the complementarity of patients and healthcare professionals, and therefore providing result with greater perspective. As for the generalizability of the results, the selection criteria for participants were defined with pragmatic intention; thus they are wide and relatively unrestrictive. This increases the heterogeneity of the sample and brings it closer to the real population of depressed patients served by PC professionals, while also allowing for the collection of a wide range of opinions.