Provision of services for people with schizophrenia in five European regions

BACKGROUND

An increasing diversity of public, voluntary sector and private providers offer services for the mentally ill in the ongoing process of psychiatric reform. Good service description is one important prerequisite for mental health service research. Aims 1) To describe service provision for the mentally ill in five European centres using the European Service Mapping Schedule (ESMS); and 2) to discuss the use of the instrument in describing service provision.

METHODS

All services providing care for people with severe mental illness in five European catchment areas (in Amsterdam, the Netherlands; Copenhagen, Denmark; London, UK; Santander, Spain; Verona, Italy) were identified through various sources. The identified services were classified, and service provision was quantified in accordance with the ESMS manual. Descriptive information was obtained.

RESULTS

We identified from 10 to 45 different services for catchment areas of between 50,000 (Copenhagen) and 560,000 (Santander) population run by three to 16 providers. They varied in aims, staffing and functioning. Hospital and non-hospital residential services, community-based services, and social support agencies were available in all sites. There was substantial variation across centres in the range, number and activities of services. Collecting comparable data sets on all service types, particularly for day and structured activity services and outpatient and community services required substantial effort.

CONCLUSION

Operationalised description of mental health services across Europe is possible but requires further refinement.

Focus on fatty acids in the neurometabolic pathophysiology of psychiatric disorders

Continuous research into the pathophysiology of psychiatric disorders, such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and schizophrenia, suggests an important role for metabolism. This narrative review will provide an up-to-date summary of how metabolism is thought to be involved in the pathophysiology of these psychiatric disorders. We will focus on (I) the important role of fatty acids in these metabolic alterations, (II) whether fatty acid alterations represent epiphenomena or risk factors, and (III) similarities and dissociations in fatty acid alterations between different psychiatric disorders. (Historical) epidemiological evidence links fatty acid intake to psychiatric disorder prevalence, corroborated by altered fatty acid concentrations measured in psychiatric patients. These fatty acid alterations are connected with other concomitant pathophysiological mechanisms, including biological stress (hypothalamic-pituitary-adrenal (HPA)-axis and oxidative stress), inflammation, and brain network structure and function. Metabolomics and lipidomics studies are underway to more deeply investigate this complex network of associated neurometabolic alterations. Supplementation of fatty acids as disease-modifying nutraceuticals has clinical potential, particularly add-on eicosapentaenoic acid (EPA) in depressed patients with markers of increased inflammation. However, by interpreting the observed fatty acid alterations as partly (mal)adaptive phenomena, we attempt to nuance translational expectations and provide new clinical applications for these novel neurometabolic insights, e.g., to predict treatment response or depression recurrence. In conclusion, placing fatty acids in context can contribute to further understanding and optimized treatment of psychiatric disorders, in order to diminish their overwhelming burden of disease.

Patients' view on screening for depression in general practice

BACKGROUND

In general practice, depression is often not recognized. As treatment of depression is effective, screening has been proposed as one solution to combat this 'hidden morbidity'. The results of screening programmes for depression, however, are inconsistent and most studies do not show a positive effect on patient outcomes. Patients do not always accept this diagnosis and hence do not receive proper treatment. Nothing is known about the tendency of those patients who screen positive for depression to accept treatment for their 'disclosed' disorder.

OBJECTIVE

In this study, we aimed to better understand the views of patients who screened positive in a screening programme for depression.

METHODS

We performed a qualitative study with semi-structured in-depth interviews with 17 patients. These adult patients (nine females), all suffering from major depressive disorder, were disclosed by a screening programme for depression performed within 11 Dutch general practices. The transcripts were independently analysed by two researchers using MAXqda2.

RESULTS

All patients appreciated the active way in which they were approached for screening. Fifteen of the 17 patients recognized the depressive symptoms but nine of them did not accept the diagnosis. The first explanation for resistance to the diagnosis of depression is fear of stigmatization and scepticism about the usefulness of labelling. Secondly, patients experienced their depressive symptoms as a normal and transitory reaction to adversity. Thirdly, patients had doubts about the necessity and effectiveness of treatment. Depressive symptoms, such as feelings of guilt, self-depreciation and fatigue, hamper help-seeking behaviour.

CONCLUSIONS

We conclude that some patients with undisclosed depression, who took the trouble of going through a complete screening programme, felt aversion to being diagnosed as having depression. In the context of screening for depression, we recommend that the patients' view on depression be elicited before diagnosing and offering treatment.

Aims, outcome measures, study sites and patient sample. EPSILON Study 1. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Cross-national research into the care of people with severe mental illnesses is hampered by a lack of standardised measures. The European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study is a European Union funded project within the BIOMED-2 programme. The project aims to develop standardised instruments to facilitate future cross-national research.

AIMS

To describe the aims, outcome measures, study sites and patient samples of the EPSILON Study.

METHOD, RESULTS, CONCLUSIONS

See companion papers in this supplement.

Effect of the selective serotonin reuptake inhibitor paroxetine on platelet function is modified by a SLC6A4 serotonin transporter polymorphism

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased bleeding tendency.

OBJECTIVES

To prospectively quantify the dose-response effects of paroxetine and the influence of the serotonin transporter gene (SLC6A4) promoter polymorphism (5-HTTLPR) on platelet function.

METHODS

Nineteen drug-free psychiatric outpatients (44.5 +/- 10.8 years) were tested before and after 6 weeks of paroxetine treatment (20 mg day(-1)). Based on clinical symptoms, paroxetine dosages were increased (40-50 mg day(-1)) for 6 more weeks in 11 patients. Parameters related to platelet function were assessed by bleeding time, platelet function analyzer (PFA), platelet serotonin, platelet factor 4 (PF4), beta-thromboglobulin (beta-TG), and aggregation tests.

RESULTS

Paroxetine 20 mg day(-1) increased mean bleeding time by 1.2 min (95% confidence interval (95% CI) -0.2-2.7) and reduced median platelet serotonin level (463 ng 10(-9) platelets; inter quartile range (IQR) 361-666), and platelet ss-TG concentration (3.1 IU 10(-6) platelets; IQR 0.3-6.0). Other platelet parameters did not change significantly. Serial platelet aggregation tests did not become abnormal. Paroxetine dose-escalation did not further influence platelet function. However, 5-HTTLPR polymorphisms modified these effects: in L(A)/L(A)-carriers, bleeding times did not change (-0.2 min; 95% CI -0.6 to 0.9), while bleeding times significantly increased in <2L(A)-allele carriers (2.3 min; 95% CI 0.5 to 4.07; P = 0.032). Platelet serotonin decreases were larger in patients without L(A)-alleles (868 ng 10(-9) platelets; IQR 585 to 1213) than in > or =1 L(A)-allele carriers (457 ng 10(-9) platelets; IQR 392 to 598; P = 0.035). PFA closure time and PF4 increased significantly in patients without L(A)-alleles.

CONCLUSIONS

Paroxetine 20 mg day(-1) does not increase overall bleeding time, but impairs platelet function by decreasing the levels of platelet serotonin and platelet ss-TG. These paroxetine effects appear to be mediated by 5-HTTLPR, with most pronounced effects in patients without L(A)-alleles.

The psychometric properties of the panic disorder module of the Patient Health Questionnaire (PHQ-PD) in high-risk groups in primary care

AIMS

To study the validity of detecting panic disorder (PD) using the Patient Health Questionnaire (PHQ) in a high-risk population in primary care and to test whether modified evaluation algorithms improve the operating characteristics of this questionnaire. Furthermore, the influence of psychiatric comorbidity on the test characteristics of the panic module was studied.

METHODS

The PHQ was administered in a primary care sample with patients at high-risk for psychiatric disorders. The total sample of 479 high-risk patients comprised 311 frequent attenders (FA), 39 patients with unexplained somatic complaints (USC) and 191 patients with mental health problems (MHP). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID- I) was the reference standard for the presence of PD. Sensitivity, specificity, and predictive values were calculated. The conditional test characteristics were calculated based on the observed prevalence of PD in the three high-risk groups.

RESULTS

PD was diagnosed in 4.8% of the FAs, in 9.8% of the USCs and in 7.6% of the MHPs. The PHQ achieved moderate operating characteristics. Modified evaluation algorithms of the questionnaire led to an improvement of test characteristics, especially the screening question: sensitivity .71 and specificity .83. Psychiatric comorbidity increased sensitivity while decreasing specificity.

CONCLUSION

The original and modified algorithms of the PHQ-PD performed moderately in screening for panic disorder. Using only the first question of the PHQ-PD showed the best psychometric properties (sensitivity). For screening purposes requiring high sensitivity we endorse to use the screening question instead of the original algorithm.

Mental disorders and personality traits as determinants of impaired work functioning

BACKGROUND

Both mental disorders and personality characteristics are associated with impaired work functioning, but these determinants have not yet been studied together. The aim of this paper is to examine the impairing effects that mental disorders and personality characteristics (i.e. neuroticism, locus of control and self-esteem) have on work functioning.

METHOD

Data for a representative sample of 3570 working people were derived from the first two waves of the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective cohort study in the Dutch adult population.

RESULTS

Higher neuroticism, more external locus of control and lower self-esteem were each significantly associated with subsequent impairment in work functioning, independently of any effects from mental disorders. Associations between mental disorders and subsequent work impairment disappeared once personality traits were taken into account. Personality traits did not moderate the relationships between mental disorders and work functioning.

CONCLUSIONS

Working people with vulnerable personalities have a greater risk of impaired work functioning, independent of the risk from any mental disorder they may have.

Mental health care reform in The Netherlands

OBJECTIVE

To describe the major changes in mental health care for adults in the Netherlands during the past 25 years.

METHOD

Scientific literature and official documents.

RESULTS

Phases of the reform process are the integration of ambulatory services in the early 1980s and the following implementation of community mental health centres (RIAGGs); the differentiation and extramuralization of mental hospitals; the differentiation within the field of living accommodations; and the final fusion process between these three into integrated regional mental health care organizations. Current issues in the development of services are, e.g. the ever growing demand for mental health care, special programmes for defined target populations, legislation and patient rights, rehabilitation and empowerment.

CONCLUSION

The Dutch mental health care system has a low threshold and a comparatively good quality. There is a long-lasting and strong influence of user and family organizations on the content and quality of services. Recently important organizational changes are taking place.

Effectiveness and application of partial hospitalization

Especially during the past 15 years, partial hospitalization (PHP) has been studied extensively. This article reviews the effectiveness and applicability of PHP. To clarify where PHP might fit into the overall mental health care system, the results of empirical research are evaluated with special attention to topics such as treated population, program evaluation, comparison of PHP with inpatient treatment, PHP as alternative to outpatient treatment, comparison of different PHP's, cost effectiveness and burden on the family. The general conclusion is that PHP can be a reasonable alternative to inpatient as well as to outpatient treatment, taking into account factors such as symptomatology, cost and family burden. PHP seems in particular to enhance social role functioning, which might be attributed to the fact that contact between patient and environment is not disturbed by hospitalization. Suggestions for further research are presented. Furthermore it is recommended in order to improve generalizability of results to differentiate the different functions PHP can fulfil in the mental health care system.

Different types of partial hospitalization programs: results of a nationwide survey in The Netherlands

An outline is presented of four characteristically different types of partial hospitalization programs currently operating in the Netherlands. The findings are based on empirical data gathered from a study of 85 institutions active in this particular field. The institutions are distinguished according to the function they perform within the total mental health care system, the assumption being that these programs are capable of fulfilling four main functions: 1) an alternative to full-time hospitalization; 2) a continuation of full-time hospitalization; 3) an extension of ambulatory treatment; 4) a day care or rehabilitation service for the chronically mental ill. A study was made of the differences and similarities between four types of institution specializing in one of the four functions mentioned above. In this connection, the authors have particularly concentrated on staffing, number of places, accommodation, organization, referral, patient population (age, education, diagnoses), treatment (type, duration, drug use) and contraindications.

Negative memory bias as a transdiagnostic cognitive marker for depression symptom severity

BACKGROUND

Negative memory bias is a strong risk factor for the development and maintenance of depression. Recent evidence also found negative memory bias in other mental disorders. Here, we aim to: 1) assess the presence and strength of negative memory bias in a range of (comorbid) mental disorders, 2) investigate which disorder-specific symptoms are associated with negative memory bias, and 3) test whether negative memory bias might be a transdiagnostic mechanism.

METHODS

Negative memory bias was measured in patients with at least one diagnosis of a stress-related disorder (n = 86), a neurodevelopmental disorder (n = 53), or both (n = 68), and 51 controls. Depression, anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorder symptom severity was assessed using questionnaires. Groups were compared on negative memory bias and the associations between negative memory bias and symptom severity were made using linear regression models.

RESULTS

All patient groups showed stronger negative memory bias than the controls. Negative memory bias was individually associated with all symptom severity indices, but when added into a single model, only the association with depressive symptom severity remained. This persisted after controlling for diagnostic group.

LIMITATIONS

Due to the cross-sectional sectional study design, we could only look at the associations between negative memory bias and disorder-specific symptoms and not at the direction of the effects.

CONCLUSIONS

Negative memory bias is characteristic of a depressotypic processing style and present in different mental disorders. It might play a mechanistic role in the development of (subclinical) co-occurrence between mental disorders.

A survey of an organization for families of patients with serious mental illness in The Netherlands

OBJECTIVES

Members of Ypsilon, a Dutch family organization for relatives of patients with schizophrenia or chronic psychosis, were surveyed to determine whether patients whose families were involved in the organization were representative of all patients with schizophrenia in the Netherlands and whether Ypsilon was similar to family organizations in other countries, to learn about members' experience of the course of their relatives' illness, to determine the kinds of mental health care received by the patients, and to discern members' opinions of that care.

METHODS

An extended version of the Involvement Evaluation Questionnaire, which measures consequences of psychiatric disorders for patients' relatives, was sent to a random sample of 1,000 Ypsilon members. The response rate was 70 percent.

RESULTS

Members of Ypsilon are mainly older mothers of young male patients with a long history of schizophrenia. The patients as a group appeared to be more severely ill than the overall population of patients with schizophrenia in the Netherlands. Many respondents reported dissatisfaction with the quality of mental health care for their relative, particularly with their lack of access to treatment professionals, lack of information about their relative's illness, and lack of family involvement in treatment planning.

CONCLUSIONS

Members of Ypsilon represent patients with severe mental illness who do not benefit sufficiently from treatment. Members want a greater role in treatment planning and more information and support from mental health care professionals. Members of Ypsilon and of family organizations in other countries have much in common, even though the extent of deinstitutionalization varies between countries.

A mechanistic model for individualised treatment of anxiety disorders based on predictive neural biomarkers

Increased amygdala responsiveness is the hallmark of fear and a characteristic across patients with anxiety disorders. The amygdala is embedded in a complex regulatory circuit. Multiple different mechanisms may elevate amygdala responsiveness and lead to the occurrence of an anxiety disorder. While top-down control by the prefrontal cortex (PFC) downregulates amygdala responses, the locus coeruleus (LC) drives up amygdala activation via noradrenergic projections. This indicates that the same fearful phenotype may result from different neural mechanisms. We propose a mechanistic model that defines three different neural biomarkers causing amygdala hyper-responsiveness in patients with anxiety disorders: (a) inherent amygdala hypersensitivity, (b) low prefrontal control and (c) high LC drive. First-line treatment for anxiety disorders is exposure-based cognitive behavioural therapy, which strengthens PFC recruitment during emotion regulation and thus targets low-prefrontal control. A treatment response rate around 50% (Loerinc et al., 2015, Clinical Psychological Reviews, 42, 72-82) might indicate heterogeneity of underlying neurobiological mechanisms among patients, presumably leading to high variation in treatment benefit. Transforming insights from cognitive neuroscience into applicable clinical heuristics to categorise patients based on their underlying biomarker may support individualised treatment selection in psychiatry. We review literature on the three anxiety-related mechanisms and present a mechanistic model that may serve as a rational for pathology-based diagnostic and biomarker-guided treatment selection in psychiatry.

Visuospatial planning in unmedicated major depressive disorder and bipolar disorder: distinct and common neural correlates

BACKGROUND

Cognitive impairments are an important feature of both remitted and depressed major depressive disorder (MDD) and bipolar disorder (BD). In particular, deficits in executive functioning may hamper everyday functioning. Identifying the neural substrates of impaired executive functioning would improve our understanding of the pathophysiology underlying these disorders, and may eventually aid in discriminating between MDD and BD, which is often difficult during depression and remission. To date, mostly medicated MDD and BD subjects have been investigated, which may have influenced results. Therefore, we investigated executive functioning in medication-free depressed and remitted MDD and BD subjects.

METHOD

We used the Tower of London (ToL) visuospatial planning task to assess behavioural performance and blood oxygen-level dependent responses in 35 healthy controls, 21 remitted MDD, 23 remitted BD, 19 depressed MDD and nine depressed BD subjects.

RESULTS

Visuospatial planning per se was associated with increased frontostriatal activity in depressed BD compared to depressed MDD. In addition, post-hoc analyses indicated that visuospatial planning load was associated with increased parietal activity in depressed compared to remitted subjects, and BD compared to MDD subjects. Task performance did not significantly differ between groups.

CONCLUSIONS

More severely affected, medication-free mood disorder patients require greater parietal activity to perform in visuospatial planning, which may be compensatory to maintain relatively normal performance. State-dependent frontostriatal hyperactivity during planning may be a specific BD characteristic, providing clues for further characterization of differential pathophysiology in MDD v. BD. This could potentially provide a biomarker to aid in the differentiation of these disorders.

What patient characteristics make clinicians recommend brief treatment?

OBJECTIVE

Assessing self-rated items that might have an impact on clinicians recommending brief treatment (BT) over unlimited or long-term treatment (ULT).

METHOD

On the basis of patient self-report data we compared patients referred by clinicians to BT (n=71) with those referred to ULT (n=145).

RESULTS

The final multiple logistic regression model indicates that the chance of being allocated to BT increases with: more satisfaction with support, higher self-esteem, primary education or less, and high desire for support as an intervention. With regard to desire to confess in treatment, low and high scores make the chance of being allocated to BT lower. This is also the case for daily hassles. Finally, some specific target complaints, in particular anxiety, lower the chance of being allocated to BT.

CONCLUSION

Using data about patient's complaints and symptoms, stress and support, personality and coping, and request for type of intervention, we built a regression-model that classified 80% of the patients correctly with regard to allocation to BT or ULT.

The evaluation of mental health care transformation in the cities of Europe

At the WHO International Conference 'Changing Mental Health Care in the Cities of Europe' an invitational workshop was organised for participants interested in evaluation research. This report of the workshop first summarises the activities of the Commission of European Communities working on the 'Evaluation of Comprehensive Care of the Mentally Ill'. Secondly current issues which arose in the discussions on problems of scientific evaluation of changing mental health care in Europe are described. Thirdly three particular research programmes are summarised especially focussing on research methodology.

A randomized controlled trial of a standard 4-week protocol of repetitive transcranial magnetic stimulation in severe treatment resistant depression

BACKGROUND

Treatment options for major depressive disorder (MDD) in individuals who are depressed for at least 2 years and failed two or more different types of therapeutic intervention, remain scarce. Being less invasive than electroconvulsive therapy, repetitive transcranial magnetic stimulation (rTMS) might be an alternative treatment option.

RESEARCH QUESTION

Does high frequency rTMS applied over the left prefrontal cortex ameliorate depressive symptoms in patients with treatment resistant major depressive disorder and is the efficacy dependent on treatment resistance?

METHOD

We performed a randomized controlled trial investigating the effect of twenty sessions of real or sham-rTMS, during 4 consecutive weeks. Efficacy was blindly rated with the Hamilton depression rating scale (HDRS-17) at baseline and 1 week after end of treatment, and the Dutch method for quantification of treatment resistance in Depression (DM-TRD) was assessed at baseline.

RESULTS

An interim analysis showed no differences in antidepressant response between real and sham rTMS and we therefore discontinued the RCT after 31 patients. The mean difference of the HDRS score between baseline and post-treatment was 3.7 (± 4.0; change 16%), indicating a small but significant improvement across time (F(1,30)=25.4;p < 0.01). There were no differences however between the treatment arms (F(1.30) = 1.5;p = 0.23). We did find a negative correlation between the change in HDRS score and DM-TRD in the active rTMS group, but this correlation was not significantly different from the sham group.

CONCLUSION

"Standard" 4-week rTMS treatment is not effective in chronic, severe treatment-resistant depressed patients. While a replication of our data in this patient group may be ethically difficult, further research with less treatment resistant patients might help in positioning rTMS within the current stepped care approach to depression.

[Tailored pharmacotherapy. Consultations about medication in a care programme for depression]

BACKGROUND

Despite the increasing rationalisation of mental health care, there are no specific recommendations regarding the number of contacts between a patient and a psychiatrist for the pharmacotherapy that forms part of the combined outpatient treatment (antidepressants and psychotherapy) of depression.

AIM

To consider the possibility of drawing up an advisory document regarding frequency, number and duration of consultations about medication in combined treatment for depression.

METHOD

We reviewed the literature and had qualitative interviews with psychiatrists and trainees in psychiatric residency.

RESULTS

The literature focuses predominantly on diagnostics and patient characteristics that determine the amount of care required. Advice on medication and pharmacotherapy is provided only by experts. According to the interviews, in psychiatric practice many factors influence the number and duration of consultations. Nevertheless, a distinctive pattern emerged.

CONCLUSION

Regarding medication in the acute treatment phase, five or six visits to a psychiatrist are sufficient for most patients. Extra consultations have to be arranged for smaller groups of less stable patients and for crisis-prone patients.

Methodology of a multi-site reliability study. EPSILON Study 3. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

The European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study aims to produce standardised versions in five European languages of instruments measuring needs for care, family or caregiving burden, satisfaction with services, quality of life, and socio-demographic and service receipt.

AIMS

To describe background, rationale and design of the reliability study, focusing on reliable instruments, reliability testing theory, a general reliability testing procedure and sample size requirements.

METHOD

A strict protocol was developed, consisting of definitions of the specific reliability measures used, the statistical methods used to assess these reliability coefficients, the development of statistical programmes to make inter-centre reliability comparisons, criteria for good reliability, and a general format for the reliability analysis.

CONCLUSION

The reliability analyses are based on classical test theory. Reliability measures used are Cronbach's alpha, Cohen's kappa and the intraclass correlation coefficient. Intersite comparisons were extended with a comparison of the standard error of measurement. Criteria for good reliability may need to be adapted for this type of study. The consequences of low reliability, and reliability differing between sites, must be considered before pooling data.

[Does less seclusion create a safer environment? An attempt to map the concept of 'feeling safe']

The degree of restraint imposed by a psychiatrist seems to be influenced by the safety of the team. So far, there have been few attempts to map the concept of 'feeling safe'.<br/> AIM: To analyse, define and quantify the concept of 'feeling safe'.<br/> METHOD: Concept mapping involves combining, in a structured way, qualitative (item collection) and quantitative methods (multi-dimensional scaling and hierarchical clusteranalysis) with the knowledge of professionals from psychiatric practice (N=24), first on an individual basis and then as a group (N=8).<br/> RESULTS: The participants generated and prioritised a total of 97 different items. These were then divided into six clusters: organisational structure, professionalism of team members, increased expertise, marginal conditions, internal and external features of the hospital building, views on mental health care and policy. Group members gave almost equal priority to the clusters, but they assigned different degrees of importance to separate items (ranging from 4.63 to 2.38 on a five-point scale).<br/> CONCLUSION: Concept mapping is an adequate method of defining the concept of 'feeling safe'. Professionalism of the team and qualities such as openness and ability to communicate, expertise and trusting one's colleagues and having an adequate alarm system available are all important factors that help to make employees 'feel safe' in their respective departments.

[The patient's perspective on the self-management and professional treatment of depression]

More than two-thirds of all patients suffering from depression experience insufficient improvement despite treatment. Self-management strategies and treatment objectives should be more in line with what patients consider to be helpful. This would improve the treatment efficacy of domains relevant to patients and allow for self-management of depression where possible.<br/> AIM: To explore the patient's perspective on self-management and professional treatment for depression.<br/> METHOD: Predominantly qualitative methods: in-depth individual interviews, concept mapping (mixed method) and a nationwide self-report survey.<br/> RESULTS: Participants generated 50 self-management strategies addressing themes such as engaging in activities (e.g. 'leaving the house regularly'), focus on the diagnosis depression (e.g. 'acceptation') and treatment (e.g. 'trusting the therapist'), remaining socially engaged (e.g. 'informing family about the depression') and good structure and self-care (e.g. 'setting realistic goals'). A lack of clarity and consensus about either the nature of the depression or the content of treatment and a precarious relationship with the professional were perceived as impeding characteristics of treatment.<br/> CONCLUSION: Patients appear to be able to contribute actively and in various ways when managing their own mental health. By exploring the patient's perspectives, professionals could offer treatment established through shared goals.