Abstract

Background
UK policy recommends non-pharmacological interventions as a first-line response to depression, yet antidepressant prescribing continues to rise, particularly in low income communities. Structural barriers, including short consultation times and long waiting lists for talking therapies, often lead to prescribing as a pragmatic but limited response to social suffering, costing the NHS approximately £230 million annually. While clinicians and patients seek more holistic approaches, there is a lack of actionable guidance on how to implement these alternatives under primary care service pressures. The aim of this study was to co-develop a theory-informed intervention, to help primary care staff improve their understanding of how poverty and social determinants impact mental health. The intervention seeks to build empathy and trust within short consultations, promote more prudent antidepressant prescribing, and encourage the use of non-pharmacological support through enhanced team working.

Methods
The Behaviour Change Wheel was used to co-develop a complex intervention (Destress-II) aimed at primary care staff. A group of GPs (n=19) and members of low-income communities (n=17) followed BCW stages to create the intervention. In 2022-3, Phase 1 piloted an in-person iteration with 53 practices; qualitative data from trainers and participants were analysed using descriptive thematic analysis. Refined into a practice-delivered web-resource, the intervention was tested in a further 30 practices in Phase 2 and re-evaluated using interviews.

Results
Both phases identified three main themes: content, delivery, and acceptability within time-pressured services. Participants valued the content and the team-discussion aspect, finding the brief duration appropriate for existing training meetings. Many appreciated the intervention for reinforcing holistic approaches rather than introducing entirely new concepts.

Conclusion
The study successfully co-developed an acceptable and feasible intervention to improve clinical responses to mental distress exacerbated by poverty and wider social circumstances. The co-development approach to complex interventions is transferable to other clinical areas.