Depression: Self-management workshops can help

In a nutshell: A Danish randomized controlled trial study concludes that a 7-weeks peer-to-peer self-management workshop for people with anxiety and/or depression is at least as good an intervention as treatment with medicine or psychotherapy.

The team lost, but Pernille won

Two months ago, Pernille had to take her son and some of his friends to the final match between her all-time favorite football team Aarhus GF and FC Copenhagen. Pernille has lived with social anxiety and depression for more than 20 years. The thought of travelling to the capital city, entering a stadium with 40.000 other spectators and having the responsibility for her son and friends would normally be too much for her. But instead of cancelling the trip, she used the problem-solving and action planning techniques she learned at the CDSMP mental health workshop.

She started by identifying things that could trigger an anxiety attack during the match. She found out that she had to know

  • where exactly their seats in the stadium were
  • what kind of help she could expect, if necessary
  • which were her escape possibilities.

She formulated an action plan, called the staff at the stadium and explained her situation and needs.

Having taken these measures for preventing an anxiety attack, she went on the trip. Unfortunately, Aarhus GF lost – but Pernille and her group had a great day and made a good memory. And she didn’t have any symptoms of anxiety or stress during the entire trip.

Before the workshop Pernille used a lot of medicine to cope with everyday life. During and after the workshop, she began reducing the amount of medication in cooperation with her doctor. By now she has achieved to stop taking any medication at all.

When she entered the stadium, she felt butterflies in her stomach for the first time in 20 years. A feeling she had almost forgotten after being medicated for so long.

Active self-help as good as medical treatment and psychotherapy

The Danish Committee for Health Education (DCHE) holds the national license for operating the Chronic Disease Self-Management Program (CDSMP) in Denmark.  The DCHE was founded in 1964 and is a non-profit non-governmental organization with close working relations with public authorities like the Ministry of Health, the National Board of Health and private organizations in the health field. Fore more information about the CDSMP in Denmark, have a look at my previous blog post

The DCHE conducted a randomized controlled trial study, which concludes that the CDSMP mental health workshop has significant effects on symptom reduction and increase in self-efficacy. In other words: the research study results support the experiences of Pernille. The participants with moderate symptoms of anxiety or depression have effect sizes as good as treatment with medicine or therapy. Read the full report in Danish

 

step-by-step-out-of-depression
Step by step out of depression

From ‘New beginning’ to ‘LÆR AT TACKLE angst og depression’

10 years ago, Denmark implemented the Stanford-developed CDSMP on a national scale. After 3 years with CDSMP, the Danish Committee for Health Education introduced CPSMP, a pain self-management program developed in Canada by Professor Sandra LeFort and Professor Kate Lorig. CPSMP is a derived version of CDSMP. Up to 40 % of the participants had moderate to severe symptoms of anxiety and/or depression, so the natural next step was to introduce a mental health version of CDSMP as well. In the United Kingdom, the national health service had developed a CDSMP derivative called ‘New beginnings’. This workshop is focused on all kind of mental health issues. In Denmark, we narrowed the purpose to focus only on anxiety and depression.

The workshop is about creating plans and strategies for preventing anxiety attacks and periods with depression in the future, combined with the traditional self-help tools such as action planning, problem solving and decision making.

The workshop leaders are peers who have experienced anxiety and/or depression themselves and function as good role models. The workshop group meets once a week for 2½-hour sessions over seven weeks. So it is a small, intensive intervention.

The Danish Committee for Health Education (DCHE) celebrated the 10-years-anniversary of CDSMP in Denmark this spring with 250 volunteer peer leaders.

An example of a perfect randomized controlled trial

The study was done by researchers at Aarhus University. The Danish Committee for Health Education (DCHE) had no access to any data. In fact, the study was initiated by the Ministry of Health. The analysis and results were discussed among experts at the National Board of Health before publication.

37 municipalities participated and 51 workshops were included in the study. 853 individuals (age 18-81 years old) participated, and 1/3 went into a control group. The participants answered questionnaires beforehand, afterwards and after 3-4 months. In addition to the quantitative study, a qualitative study of group dynamics was conducted in order to complement the data from the questionnaires. This means that the intervention has been tested in the same setting that it will be operated in. This set-up gives the results even more credibility.

Looking into the future

Right now 49 Danish municipalities are running the workshops and they are experiencing waiting lists to participate. A great operational success!

Furthermore, the municipalities have started testing the intervention on youngsters (age 15-25), and as an online workshop for people suffering from social anxiety. Experience from Canada shows, that people who have attended an online workshop are more likely to say yes to a traditional workshop afterwards. So this is a way to reach out to the most fragile potential participants.

In general, DCHE are testing the workshops in various settings at the moment to find out potential target groups, who can benefit from CDSMP. For example: self-management workshops to prevent stress for people with a higher education, and to create a workshop in “easy danish” to immigrants with poor language skills (see also the project “Evivo Migration” for Switzerland in this regard).

All reports and knowledge will of course be presented in this blog. We’ll keep you posted!

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Tell us your thoughts

  • What do you think is important when delivering self-management workshops?
  • What are your worries about peer-leaders delivering workshops?

We would appreciate your comment below!

Nicolaj Holm Faber

Nicolaj Holm Faber, MA in philosophy and rhetorics, is working at The Danish Committee for Health Education, Copenhagen, as a senior consultant. He is a T-Trainer for Stanford self-management programs and is training health care professionals in patient empowerment. He is involved in the European Network on Patient Empowerment ENOPE and is collaborating with the Careum Foundation on self-managing chronic conditions.

10 thoughts on “Depression: Self-management workshops can help

  • 2016-10-12 at 22:27
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    Really usefull addition to the literature. Be very interested in the cost comparison between the course and the cost of treatment through medication and visits to the doctor.
    Hope we get a English translation some time soon.
    Also be interested in how you have got enough intrest to have waiting lists and what support is there after people finish the 7 weeks

    Reply
    • 2016-10-14 at 12:50
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      Dear Jim
      Thanks for your comment!
      Well recruitment is allways an interesting task. In the Danish municipalities, the only option for support and treatment if you suffered from anxiety or depression, was psychotherapy or medication, before we introduced the mental workshop, derived from New Beginnings.

      So a lot of people who experienced symptoms, had to wait for the condition to be so severe, that they were qualified to treatment. Now the municipalities are using the workshop as the first possible step to take. This means that all people with a fragile mental status will be introduced to the workshop as a voluntary intervention.

      Another explanation is that there is a major economic incentive for the municipalities to prevent that people are readmitted to the primary healthcare system, after periods with health issues. If a person is readmitted for the same condition, the municipality will pay 20 % of the expenses. And at the same time, focus is on mental health issues, so a lot of danes are living with a fragile mentale habitus.

      We have not done any ROI studies, so I have no practical answers to that reflection. But on a theoretical level, I can provide some kind of answer. In Denmark, researchers have identified the 6 most important and influential indicators, regarding the unemployed citizens farest away from ordinary employment.

      4 out of the 6 indicators is about mental health, reduction of symptoms/functional limitations and self-efficacy. And we have data that supports, that participants will benefit within those indicators after taking the workshop. Then we can conclude, that regarding one of the expensive consequences of mental illness – unemployment – will be reduced if you are running the CDSMP mental health workshop.

      But Jim – I know that we need to do more economic studies….

      Reply
      • 2016-10-16 at 09:32
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        Dear Jim
        Forgot to adress your last question about follow up after the workshop.
        Contrary to the other cdsmp workshops, in the mental health version we have included an 8th meeting. The topic of the meeting is what kind of networking the group will participate in. DCHE did some research on different models for networking, and one factor seems very important. The leaders must articulate the value of networking when you problemsolve throughout the workshop. If they do that there is an higher possibility that the group will motivated for future networking. So we emphazise that during training of leaders.

        Reply
  • 2016-10-13 at 11:30
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    I think the only real way to enjoy sustainable self-efficacy is for an individual to be a proactive part of developing a self-management program.

    It worked for me. So extrapolating from my own personal experience, peer-led and co-creation modalities promise a pathway for lasting positive change.

    Therefore, these are the kinds of programs into which I will invest my efforts to spread the possibilities to others who are facing cancer.

    Reply
    • 2016-10-13 at 12:51
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      Dear Karin
      Sounds like a very good self-management strategy.

      I like the thought behind co-creation, since it makes it quite clear, what the peer leader can offer, that it so difficult for health care professionals.

      Reply
      • 2016-10-14 at 10:02
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        Dear Nicolaj,
        I also wonder about the cultural aspects of self-management in Denmark vs. Switzerland, because as my name reveals, I have Danish roots.

        But the Denmark I knew was from 35 years ago, and now I sometimes have difficulty recognizing the Danishness I once knew. There seem to be so many “U.S. American” characteristics in the population and in the capital city now (where I just attended the huge ESMO conference) — for both the benefit and detriment of the national identity.

        The Janteloven has been left behind for the most part, but probably still lingers below the surface.

        The Swiss population I sense has not been so strongly (yet, or if ever) impacted by the positive and negative aspects of the U.S. mentality and so I wonder if that will affect certain aspects of peer-leadership and co-creation?

        There might be fertile ground (pent up demand) or there might be bigger challenges to empower cancer patients.

        What do you think?

        Reply
        • 2016-10-14 at 12:07
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          Dear Karin
          Thanks for your comment! I dont know if I agree with you about your perception of Denmark today! Janteloven exist in a good way, meaning that we have a very homogenic population.

          I don’t know about the cultural differences between Switzerland and Denmark and the influence from USA. One thing is, that the american and european teaching style is very different and in this perspective, I think the Danish and Swiss methods and approaches to teaching technics are more alike.

          Both in Denmark and in Switzerland we have done a lot of cultural editorial work, to make the materials work in a Danish setting. And E-vivo was translated the materials with a lot of support from us in Denmark, to benefit from our experiences.

          We still have participants saying that it is a very americanizes program we are running, but when I look at the american manual, I can see that our materials are to some degree different. And the swiss and danish materials are almost 100 % alike.

          So if we assume that the cancer program works as well as the other CDSMP programs, it will have similar effects no matter whether in Copenhagen or Zurich.
          Next time your in Copenhagen, I will show you some new sites that are very far away from U.S. influence 😉

          Reply
  • 2016-10-14 at 08:38
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    Dear Nicolaj,

    I am following the development of the Stanford program in Denmark quite a while now. And I am still stunned about the great success you have in your country. Great!

    The story of Pernilla (great “anecdata” btw) shows the great potential such programs have and the benefit they offer to participants.

    I would be interested to learn more about how you supported the recruitment of this often hard-to-reach group of people living with mental health problems? And where can I find some details on the RCT and how the randomized the participants? Cluster-randomization?

    As you have also mentioned your most recent steps towards making the program more accessible, I think it would be great to establish a roundtable meeting in 2017 to discuss and share current European developments on the Stanford program. You might have noticed the here in Switzerland we are currently adjusting a Stanford cancer program for breast cancer survivors

    Keep up the good work! Jörg

    Reply
    • 2016-10-16 at 09:46
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      Dear Jörg
      Thank you for your comment. I think it would be great with a roundtable meeting in 2017. Im impressed by the speed you have expanded e-vivo the last couple of years.
      We are working on an english version of the report. Spring next year we expect Søren Christensen to publish the first article about the results in english.
      In Denmark we learned a lot about reaching hard-to-reach groups the last to years and have developed sort of a guide as well. It will be great to be able to discuss it with you. The key element is to team up with People or organisations that have contact with a target group, e.g. the danish association of social drop inn centres. In this way we got to test cdsmp for active and recovered drug addicts and alcoholics. And now the 3 drop inn centres that participated in the test are operating cdsmp on a regular basis.

      Reply
      • 2016-10-16 at 17:57
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        Thanks, Nicolaj, for the reply! And the credits… 🙂 Nice to read that you experience the evolution of Evivo as speedy. Sometimes it is important to have peer-feedback to see the accomplishments. Like in the workshops. All the developments and success stories so far are based on support from you and others, thus, on team work – also like in the workshops.

        I agree, a roundtable in 2017 is definitely important, in particular because of your new findings and insights on the program. And to learn from the UK as well (Hi, Jim!). Let us re-connect soon to arrange dates for 2017.

        All the best, Joerg

        Reply

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