Introduction
Anxiety and depression are two of the most common mental health disorders globally (The Lancet, 2021). They have significant implications for an individual’s social and occupational functioning (Saris et al., 2017; Gunnarsson et al., 2021), physical health and mortality (Ferrari et al., 2013; Roy-Byrne et al., 2008), leading to increased health and economic burden. Research reports that the costs of mental health problems across the United Kingdom (UK) pertained to approximately £117.9 billion, in 2019, with 72% of these costs resulting from the loss of productivity of people living with mental health problems and from unpaid informal carers (McDaid & Park, 2022).
Various pharmacological and psychological treatments are available for depression and anxiety. However, patients often prefer psychotherapy treatments as opposed to medication (Backenstrass et al., 2006; McHugh et al., 2013; van Schaik et al., 2004), which are also the recommended first step of treatment for anxiety and/or depression symptoms (NICE, 2014; 2022a). Guided Self-Help (GSH) interventions are low-intensity evidence-based psychological treatments (Baguley et al., 2010; Clark, 2018) that involve supporting patients to understand and overcome their anxiety and/or depression symptoms using techniques based in cognitive behavioural therapy (CBT).
GSH interventions offer individuals dealing with anxiety and/or depression symptoms an opportunity to access cost-effective and evidence-based psychological treatment that caters to their preferences (Palacios et al., 2023). This helps reduce barriers to care, such as limited access to high-quality treatment (Alonso et al., 2018; Thornicroft et al., 2017). The efficacy of GSH is substantiated by multiple systematic reviews (Cuijpers et al., 2010; Coull & Morris, 2011; Lewis et al., 2012; Powell et al., 2024), which present compelling evidence of its potential to alleviate symptoms of anxiety and/or depression. Notably, a recent systematic review involving various types of GSH demonstrated superior efficacy in reducing anxiety, depression, and worry compared to control groups (Powell et al., 2024). Furthermore, GSH interventions have exhibited positive outcomes in addressing social phobia and panic disorders, particularly when complemented with self-help materials such as books, leaflets, websites, and videos (Lewis et al., 2012).
In England, psychological wellbeing practitioners (PWPs), are qualified practitioners and are responsible for administering GSH (i.e., low-intensity interventions) (Coull & Morris, 2011; Falbe-Hansen et al., 2009) using written materials like booklets or digital tools. PWPs play a vital role in delivering GSH within talking therapy services, motivating a client throughout their treatment (McDevitt-Petrovic, 2019). Regardless of the mode of delivery of the GSH intervention, whether it is online, face-to-face, by telephone or group, PWPs provide patients with personalized tools and techniques for self-managing their symptoms of anxiety and/or depression (Stonebank, 2014).
For this scoping review, GSH refers to any low intensity psychological interventions involving support from trained practitioners and utilising self-help materials (Shafran et al., 2021). According to the National Institute of Health and Care Excellence (NICE), step 2 care for anxiety and/or depression symptoms involves individual facilitated self-help, computerised Cognitive Behavioural Therapy (CBT), self-help groups, and psychoeducational groups (NICE, 2011). Low–intensity treatments (i.e., GSH) are typically delivered across six to eight sessions lasting up to 30 min (Papworth & Marrinan, 2018), adhering to NICE guidelines (NICE, 2023).
The effectiveness of GSH treatments is evidenced in past research (Coull & Morris, 2011; Gellatly et al., 2007; Salomonsson et al., 2018). A systematic review of 21 studies demonstrated comparable effects of GSH with traditional face-to-face psychotherapies after a one-year follow-up (Cuijpers et al., 2010). Another systematic review exploring the effects of GSH via computerised CBT, provides evidence demonstrating the efficacy and acceptability of GSH interventions as treatment for anxiety and/or depression symptoms (Etzelmueller et al., 2020). In England, the effectiveness of low intensity interventions, like GSH, administered within NHS Talking Therapies services is evidenced by recovery rates of 50% meeting national standards (NHS, 2022).
Although psychological interventions are effective at reducing symptoms of anxiety and/or depression symptoms (Hoffman & Gomez., 2017), rates of relapse i.e., the recurrence of symptoms after a period of improvement (Bockting et al., 2015) following clinically and cost-effective psychological treatments are fairly high. Research indicates that the prevalence of a second episode after treatment for depression is 50%, this figure rising to 90% following three episodes (Burcusa & Lacono., 2007). The relapse rate for anxiety is also fairly high as demonstrated by a meta-analysis of nine studies which found an average of 23.8% relapse following CBT (Lorimer et al., 2021).
Considering long-term effectiveness of low-intensity interventions, longitudinal research conducted in NHS Talking Therapies services indicates that both low and high-intensity treatments are associated with sustained increases in depression and anxiety symptoms post-treatment (Clark et al., 2009). Further research exhibits the high rates of relapse by discharged patients who achieved recovery, with significant deterioration evidenced within six months post discharge (Ali et al., 2017). Additionally, a systematic evaluation focusing on low-intensity interventions within NHS Talking Therapies services showed that 65.8% of patients experience relapse or recurrence within one year (Delgadillo et al., 2018). Notably, the risk of relapse following low-intensity interventions (i.e., GSH) is heightened for younger individuals, those unemployed, and reporting residual symptoms at discharge (Lorimer et al., 2021). Therefore, future research should contribute to further understand challenges faced by patients following end of treatment and design interventions accordingly to maintain treatment gains over time and mitigate the risk of relapse.
Furthermore, research shows that those who have previously experienced an episode of depression or anxiety, continue to experience impaired functions and work disability (Hendriks et al., 2015), showcasing the important need for support (NICE, 2022b) beyond the therapy setting.
Relapse prevention has been defined in many ways within a therapy setting for different disorders (Marlatt & George, 1984; Melemis, 2015; Menon & Kandasamy, 2018), but they all share two key principles: (1) the aim of relapse prevention is to identify and address any situation which could lead to deterioration, (2) it requires individuals to successfully develop and implement coping skills to address high risk situations. Through relapse prevention, individuals are able to maintain recovery and consolidate changes and acquisition of skills in the long term (Melemis, 2015).
The high rates of relapse following different psychological interventions demonstrates the need for preventative approaches to tackle the challenges of relapse and recurrence which prevent long-term recovery. By understanding the causes and processes of relapse, advances in the long-terms efficacy of psychological therapies can be made (Brandon et al., 2007; Scholten et al., 2013). Some practitioners delivering low-intensity treatment may discuss relapse prevention throughout the course of treatment to ensure sufficient time is provided to any relapse prevention work (Papworth & Marrinan, 2018). Additionally, providing patients with personalised treatment plans and increasing the ability for patients to make informed choices, are some of the ways in which relapse prevention programmes can be designed, as demonstrated through a discrete choice experiment (Muntingh et al., 2019).
Maintaining wellbeing over time can decrease the financial burden and the distress associated with living with issues associated with conditions such as depression and anxiety (Mental Health Foundation, 2016). Through the development of programmes focussed on supporting individuals after their treatment to help increase self-management, rates of relapse can decrease along with associated burdens.
Understanding what relapse prevention interventions, tools or resources are available following GSH would equip practitioners and researchers with the knowledge to determine effective strategies to address relapse and identify areas for improvement. This scoping review aims to explore available evidence on how to maintain treatment gains and prevent relapse following GSH. It will present a detailed inventory of the available relapse prevention materials/resources/interventions along with measures of effectiveness (if available) and it will highlight the gaps in the evidence, informing future research.
Method
A scoping review was chosen rather than a standard systematic review to provide an overview and synthesise the research evidence on a certain topic (Lockwood et al., 2019; Tricco et al., 2016). A standard systematic review, differently to a scoping review, aims to answer a specific research question (Tokgöz et al., 2021) and can be undertaken to confirm or refute hypotheses, report on the quality of the evidence base or address any variations or uncertainty (Munn et al., 2018). Unlike systematic reviews, scoping reviews do not aim to inform practice or consider questions related to feasibility, appropriateness, and effectiveness, instead seeking to clarify key concepts, provide background and context behind specific phenomena (Pollock et al., 2021) and identify knowledge gaps (Munn et al., 2018). Unlike systematic reviews, scoping reviews are helpful when identifying, reporting, and discussing specific characteristics and concepts across papers or studies (Munn et al., 2018). They provide baseline data about the availability of evidence on a particular topic (Lockwood et al., 2019), such as relapse prevention following GSH. Scoping reviews are exploratory in nature, aiming to address broader questions about the current literature rather than specific inquiries and questions (Munn et al., 2022). Hence, a scoping review was chosen to provide an overview of relapse prevention interventions designed following GSH and their core components without reporting on quality and effectiveness.
This scoping review follows the guidelines provide by Arksey and O’Malley (2005): (1) identification of a research question through discussions with the research team where the question was refined, (2) identifying relevant studies using electronic databases and grey literature searches, (3) study selection through the use of an inclusion and exclusion criteria, (4) charting data through a narrative review of included studies and resources and (5) collating, summarising and reporting results by providing an overview of the material reviewed and reporting basic characteristics of the included literature.
Protocol and Registration
This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews (PRISMA-ScR; Tricco et al., 2018). A scoping review protocol was registered on FigShare.
Eligibility Criteria
The inclusion criteria were (1) studies conducted in adults aged 18 or over, (2) studies reporting on symptoms of depression and/or anxiety, (3) studies reporting on relapse prevention interventions/tools/resources used for depression and/or anxiety following GSH. There were no restrictions regarding the methodology of the studies, allowing for the inclusion of qualitative and quantitative research.
The exclusion criteria were (1) participants where the main health disorder described is not anxiety and/or depression symptoms but this exists as a comorbidity, (2) studies not reporting information on relapse prevention, (3) studies that report information on relapse prevention work completed during GSH (i.e., not after completion of GSH) (4) studies where the primary outcomes are not related to anxiety and/or depression, (5) studies where the intervention is designed to replace existing psychotherapy treatment for anxiety and/or depression.
Information Sources
The original literature search was conducted on the 9th of May 2023 and updated on 30th May 2024. There was no limit for years and all results were from inception until the date of the search. Identification of relevant studies was achieved by searching four different electronic databases including PsycINFO, CINAHL Plus, PubMed and Web of Science. The search strategy was discussed and curated with the research team and comprised key subject terms associated with the research question which were combined using Boolean operators. The following search strategy was used: (“self -help” OR “self-management” OR “low intensity”) AND (“relapse prevention” OR “remission” OR “recurrence”) AND (“Anxiety” OR “depression”). The reference list of included studies was hand searched by two independent reviewers (SN and HD) to identify additional relevant studies not found through the search strategy. In addition, the reference list of any reviews or meta-analyses deemed relevant were also hand-searched.
The title and abstract of all retrieved searches were independently reviewed by SN and HD against the inclusion and exclusion criteria. Any articles that were deemed relevant or where there was not enough information during screening of the title/abstract, the articles were subject to a full text review by two independent reviewers against the inclusion and exclusion criteria. Further clarification regarding whether an article met the inclusion and exclusion criteria was sought through contacting the authors where available. In the case of disagreement between reviewers, the opinion of a third reviewer (CF) was sought.
Other Sources of Evidence
In addition to the literature search identifying peer-reviewed articles, this scoping review explored grey literature. Although there are many definitions of grey literature (Adams et al., 2016), the most widely agreed upon definition is literature that is “produced on all levels of government, academics, business and industry in electronic and print formats not controlled by commercial publishers” (Auger, 1998). Therefore, it is anything that is not formally published in a peer-reviewed journal (Cooper et al., 2009; Godin et al., 2015) and can include websites, policy documents, conference proceedings, and unpublished research (Higgins & Green, 2011). Incorporating grey literature in any forms of evidence synthesis, such as scoping reviews, is seen as good practice as it reduces aspects of publication bias (Hopewell et al., 2007), providing a more comprehensive review.
Following Godin et al. (2015), a systematic approach was used when searching for grey literature via three different methods: Google searches, grey literature databases and consultation with experts.
The google search strategy involved inputting the search string used for the literature search into the Google search engine. The first ten pages of results were reviewed by SN using the title and the accompanying short description appearing beneath the search. The grey literature databases strategy, repeated the process used for the Google search strategy, inserting the same search string into the National Grey Literature Collection Database (https://allcatsrgrey.org.uk/tematres3.2/vocab2/ ) and reviewing all of the results according to the title of the search and accompanying description beneath. An updated search using this grey literature database could not be conducted as the database has since been discontinued, resulting in limited access (Health Education England, 2023). The link to any records that appeared relevant across both search strategies were extracted into a separate file for further screening against the inclusion and exclusion criteria.
The consultation with experts’ strategy, involved contacting experts across the world with knowledge on relapse prevention in the context of GSH, including clinical academics and NHS project managers and practitioners who shared their knowledge regarding existing resources and/or tools routinely used.
Data Charting
Data from each article was extracted using a standardized table format developed apriori by the research team. The data extracted comprised the key article details (e.g., author, year and country), patient characteristics, content of the relapse prevention interventions/resources described following GSH and any relevant outcome data (where available).
Quality Appraisal
A quality appraisal of all included studies was carried out to provide an overview of the quality of the evidence. A scoping review does not seek to assess the quality of the evidence (Arksey & O’Malley, 2005; Pham et al., 2014) but rather provide an overview of all existing evidence related to a certain topic (Tricco et al., 2016). For this reason, the included articles will not be excluded irrespective of the results from the quality appraisal or allocated different weight in the results section.
The quality of the individual studies was assessed using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018) and evaluated against the appropriate methodological quality criteria pending on study design. This tool was chosen as it allows the appraisal of empirical studies across different study designs including qualitative, quantitative randomised controlled trials, quantitative non-randomised controlled trials, quantitative descriptive and mixed methods (Hong et al., 2018). Two authors (SN and HD) rated each criterion for each study and any disagreement over ratings between reviewers were resolved through discussion and consensus.
Synthesis of Results
Results were synthesised using a narrative descriptive synthesis following the guidance by Popay et al. (2006) due to the variation in type of studies included, allowing for the investigation of any similarities or differences between studies to provide a summary of the knowledge available (Lisy & Porritt, 2016). The synthesis provided a descriptive summary of the findings across the included studies, consistent with an integrative approach to synthesising data. The relationship between and across studies was explored to (i) identify any similarities or discrepancies across the studies and (ii) identify the key characteristics of studies describing resources/interventions to prevent relapse following GSH.
Results
Electronic Databases
The search strategy identified 954 records. These records were exported to Endnote for easy management and after removing 467 duplicates across databases automatically using EndNote, 511 records were screened for eligibility at title and abstract, from which 28 were reviewed at full text. Two papers screened at full text were review articles (Moriarty et al., 2020; Tokgöz et al., 2021) and their reference lists were hand searched by two independent reviewers (SN and HD) identifying 14 additional papers which were subject to screening at title and abstract. Three of the 28 papers, identified via the electronic databases, and screened at full text were book reviews (Kannis, 2010; Rosenquist, 2012; Watt, 2006) and the references of these reviews resulted in the inclusion of three additional papers subject to screening at title and abstract. Of these 17 additional papers identified via citation searching, three were reviewed at full text. Figure 1 illustrates the study selection procedure using a PRISMA-ScR flow diagram and includes the reasons for exclusion at different stages of the scoping review. A total of 26 papers identified via electronic databases were screened at full text and five authors were contacted for further information regarding six different papers (Biesheuvel-Leliefeld et al., 2017; Bockting et al., 2011; Krijnen-de Bruin et al., 2019, 2022; Lucock et al., 2018; Malins et al., 2020). Of the five authors contacted two responded providing clarification regarding sample population characteristics, and whether the treatment received prior to the relapse prevention intervention was GSH. For the narrative synthesis, three peer-reviewed publications were included, and their data was extracted and presented in Table 1. The quality of the three published articles was assessed and findings are presented in Table 2. All three publications met at least 60% or more of the MMAT criteria.
Fig. 1
Adapted from Page et al. (2021). PRISMA diagram detailing screening process
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Table 1
Descriptive results of included studies and resources
Article details/Context | Participant Information | Study/resource Details | Intervention Details | Findings | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Author | Year | Country | Number of participants | Age range (Years) | Anxiety or depression | Design | Study period | Aim | Mode of delivery | Intervention Content | Effectiveness evaluated? (Y/N) | Results | |
Wright et al. | 2000 | USA | 45 | M = 46.7 | Panic Disorder (Anxiety) | Quantitative randomized controlled trials | 6 months | To examine the effects of a relapse prevention program for individuals completing the first two phases of the study | Telephone | Relapse prevention manual comprising relapse prevention techniques. Monthly 15 min follow up telephone calls. | Y | Clinically significant improvement for full-blown panic attacks were significantly higher for the intervention group (89%) compared to the waiting list control (38%). Proportion of participants meeting criteria for clinically significant improvement increased from before to after treatment for panic cognitions (21% vs. 53%), agoraphobic avoidance (47% vs. 59%) and panic symptoms (12% vs. Y35%) for the relapse prevention group compared to the waiting list control. | |
Lucock et al. | 2018 | UK | 11 (Quant) 6 (Qual) | 21–63 | Depression | Mixed methods | 4 months | To describe the development of a new intervention to support self-management and to reduce the likelihood of relapse after therapy for depression. | Face to Face and Telephone | One face to face meeting with a low intensity practitioner within 4 weeks after discharge to agree upon up to 5 implementation intentions. Monthly 30-minute telephone support calls to monitor extent to patients carry out implementation intentions. | Y | 86% still in remission after 3-month follow up. Suggestion that the intervention is feasible and acceptable | |
Lucock et al. | 2021 | UK | 107 (Quant) 16 (Qual) | 19–83 21–83 | Depression | Mixed Methods | 4 months | The aims of this study were to investigate: 1. Relapse rates for patients receiving the SMArT intervention. 2. The perceived effectiveness and acceptability of the SMArT intervention. 3. Effective relapse prevention strategies which support longer term recovery. | Face to Face and Telephone | One face to face meeting with a low intensity practitioner within 4 weeks after discharge to agree upon up to 5 implementation intentions. One telephone support call every month to monitor extent to patients carry out implementation intentions. | Y | Relapse rate of 11% based on a reliable and clinically significant increase on the PHQ-9 and 13% based on either the PHQ-9 or GAD-7. 7 themes identified that supported effective self-management i.e., Relationship with the practitioner; support networks; setting goals, implementation, and routine; changing views of recovery; smart sessions mode, content, timing, and duration; suitability for the person; suitability for the service. | |
Chellingsworth et al. | 2013 | UK | N/A | N/A | Both | N/A | N/A | To help patients stay well following low-intensity treatment | Workbook to be completed by patient | Comprises information on relapse and relapse prevention strategies with exercises to be completed by the patient. | N | N/A | |
Paddle | 2019 | UK | N/A | N/A | Both | N/A | N/A | To help patients make the most of therapy by storing all related information in one secure location | Digital Application | App designed to create a space to digitally store therapy materials and to access/submit clinical scores for 12 months following treatment. | N | N/A | |
OxCADAT | N/A | UK | N/A | Both | N/A | N/A | N/A | Workbook and protocol | The workbook is to be introduced in the penultimate session detailing prompts ad exercises around goal setting, reflection on progress and action plans. The accompanying protocol is to be used by practitioners to understand how to use the workbook during therapy. | N | N/A | ||
Table 2
Quality appraisal results according to MMAT criteria
Wright et al., 2000 | Lucock et al., 2018 | Lucock et al., 2021 | ||
|---|---|---|---|---|
Screening Questions | Are there clear research questions? | Yes | Yes | Yes |
Do the collected data allow to address the research questions | Yes | Yes | Yes | |
2.Quantitaive Randomised Controlled Trials | 2.1. Is randomization appropriately performed? | Can’t tell | - | - |
2.2. Are the groups comparable at baseline? | Yes | - | - | |
2.3. Are there complete outcome data? | Yes | - | - | |
2.4. Are outcome assessors blinded to the intervention provided? | No | - | - | |
2.5 Did the participants adhere to the assigned intervention? | Yes | - | - | |
5. Mixed Methods | 5.1. Is there an adequate rationale for using a mixed methods design to address the research question? | - | Yes | Yes |
5.2. Are the different components of the study effectively integrated to answer the research question? | - | Yes | Yes | |
5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted? | - | Yes | Yes | |
5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? | - | Yes | Yes | |
5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? | - | Yes | Yes | |
Quality overall score | * | ** | ** |
Other Resources
The first search strategy for identifying evidence via different resources involved searching the first ten pages of results equating to 100 resources at each search time point. Through a manual search by SN, this google search strategy resulted in six hits. The majority of results that were excluded comprised publications that had been reviewed from the electronic databases search or did not meet inclusion criteria upon the initial scope of the title and accompanying description, websites detailing self-management strategies and information regarding GSH but not specifically focussing on relapse prevention, and manuals or guides related to the treatment of anxiety and/or depression. Upon further exploration of the six hits, four results were excluded as they did not focus on relapse prevention following guided self-help. The second search strategy, via the grey literature database, resulted in 102 hits. However, upon screening using the methods above and inclusion criteria, none of the results were relevant to this scoping review and all were excluded. An exploration of the grey literature database used and additional databases that may have been appropriate but were inaccessible is listed in the Appendix. Through consultation with two experts, the third strategy resulted in two pieces of grey literature – a webinar and an app. Both items were further explored through a targeted search on google to identify any other accompanying resources and through consultation with experts associated with the relapse prevention app. This resulted in access to two unpublished reports, facilitated by members of the team involved in the relapse prevention app, which described the development of the app and a workbook pdf of the document described in the webinar. However, the unpublished reports surrounding the app focused on its development not implementation and thus are not included in this review. Instead, information regarding the app is limited to everything listed on the website. Therefore, three items identified via different resources were included in the scoping review.
Overview
The characteristics of the included studies and resources are presented in Table 2. From the electronic databases, three published peer-reviewed studies were identified (Wright et al., 2000; Lucock et al., 2018, 2021) and three other resources were identified through the grey literature (Chellingsworth et al., 2013; Paddle, 2019; OxCADAT, n.d.). The three peer-reviewed publications, CEDAR relapse prevention booklet (Chellingsworth et al., 2013) and the Paddle app (2019) were published online and developed between 2000 and 2021. Information regarding the year of development for the staying well resources (OxCADAT, n.d.) was not available. One study (Wright et al., 2000) was conducted in the United States whereas the two peer-reviewed publications and three other resources were conducted and produced in the UK. The three published studies examined a total of 164 different participants between the ages of 19–83 years. One study (Wright et al., 2000) explored panic disorder, two studies (Lucock et al., 2018, 2021) focussed on depression and the additional resources did not specify whether they focussed on anxiety or depression alone or both. Two studies exploring the Self-Management after Therapy (SMArT) intervention (Lucock et al., 2018, 2021) reported qualitative findings derived from interviews.
Relapse Prevention Description
The study by Wright et al. (2000) focussed on adults who had formerly received bibliotherapy for panic attacks. It examined the effect of a relapse prevention programme that utilised a seven-chapter manual for participants to practice independently for six months. The program comprised information about the booklet, hypothetical scenarios, examples of multiple relapse prevention techniques and exercises. Participants were encouraged to focus on the most relevant techniques/exercises and received brief telephone calls across six months to enhance treatment compliance.
The SMArT (Self-Management after Therapy) intervention described in both publications by Lucock et al. (2018, 2021) explored the same relapse prevention intervention for depression but with different participants. It involved creating up to five different implementation intentions unique to each participant, decided collaboratively with a psychological wellbeing practitioner during a face-to-face session up to 4 weeks following discharge. Using' if-then' statements, these implementation intentions linked any situation (i.e., an internal or external cue) to a response, such as a behaviour, feeling or cognition, and accompanied any relapse prevention plan discussed during therapy. Additionally, the intervention involved using diary sheets to monitor the usage of implementation intentions and any issues that occurred. Participants also received three monthly telephone support calls from a practitioner following end of treatment.
The Staying Well Workbook (OxCADAT, n.d.) is a resource for use within and beyond low-intensity therapy to enable patients to record information during therapy sessions, to prevent relapse. It consists of seven chapters across nine pages, and encourages patients to reflect on their therapeutic journey. This includes differentiating between lapse and relapse, reviewing techniques used during treatment, creating if-then plans for early warning signs, monitoring and signposting for further support. The therapist and patient collaboratively, create if-then plans and the patient is encouraged to continue monitoring change and referring to this workbook following end of treatment. There is also a guide for professionals on using this workbook, including information on scheduling a follow-up session.
The paddle therapy support app (Paddle, 2019) was designed to help patients stay well after treatment by storing therapy-related information for easy access. It allows users to upload workbooks, record session details, complete questionnaires, visualise progress, create a resource library, and add emergency information. The app is accessible online and offline.
The relapse prevention workbook, known as CEDAR, was designed by Chellingsworth et al. (2013) and comprises eight chapters with information on how to differentiate between a lapse and relapse, identifying early warning signs, reflecting on progress, rating goals, well-being action plans, areas for improvement and further support resources. It also includes information about activities for patients to refer to during difficult times.
Across all these relapse prevention interventions and resources, participants were asked to refer to a manual or workbook consistently following the completion of GSH to prevent relapse and practice various techniques independently. A checklist of the key components is summarised in Table 3.
Table 3
Checklist of key characteristics and components of relapse prevention interventions/tools
Author | Patient contact with therapist after treatment? | Workbook/manual | Collaborative work with a therapist at the start to tailor intervention? | Follow-up | Usage within and beyond GSH treatment sessions | Digital/online accessibility |
|---|---|---|---|---|---|---|
Wright et al., 2000 | Yes | Yes | No | Yes | No | Cannot tell |
Lucock et al., 2018 | Yes | Yes | Yes | Yes | No | Cannot tell |
Lucock et al., 2021 | Yes | Yes | Yes | Yes | No | Cannot tell |
Chellingsworth et al., 2013 | No | Yes | Yes | No | Yes | Yes |
OxCADAT, n.d. | Yes | Yes | Yes | Yes | Yes | Yes |
Paddle, 2019 | No | Yes | No | No | Yes | Yes |
Qualitative Findings
Qualitative feedback regarding the SMArT intervention was also collected for both studies (Lucock et al., 2018, 2021) through a brief telephone call after completing the relapse prevention intervention. The first study (Lucock et al., 2018) reported feedback received via telephone from six patients who completed the intervention. The supplementary material highlighted eight themes from the data surrounding experiences of different aspects of the intervention and the difficulties in implementing their relapse prevention plans. This includes a patient reporting that they were not inclined to implement their plans due to a lack of connection with the practitioner delivering the intervention and it was also reported that difficulties in carrying out their relapse prevention plans were influenced by external factors which were not specified. The second study (Lucock et al., 2021) included 16 semi-structured interviews following the end of the intervention and identified seven themes– four surrounding relapse prevention and self-management, one concerning the delivery of the SMArT intervention and two themes relating to the suitability of the intervention for patients and services. For both studies, patients reported that contact with the practitioner via follow-ups provided reassurance and was useful for continued support. Features described as helpful by patients in both studies included having an initial face-to-face session to develop an implementation plan, which was seen as necessary in building the therapeutic relationship and the social support received from sharing plans with family and friends. Both studies interviewed practitioners delivering low intensity interventions, who reported that the interventions aligned with their role and training. The second study (Lucock et al., 2021) also reported that some challenges expressed by practitioners included increasing awareness of the intervention to other staff and incorporating it into the service demands. The qualitative results across both studies highlighted how patients viewed the inclusion of follow-ups as positively influencing their recovery by providing a safety net following discharge and allowing patients to consolidate their learning in practice.
Follow-up
The relapse prevention interventions described across the three peer-reviewed publications (Lucock et al., 2018, 2021; Wright et al., 2000) all included monthly telephone follow-up calls. The guidance accompanying the staying well booklet (OxCADAT, n.d.) also included one follow-up; however, it was not specified whether this was via telephone or face-to-face. The duration of these follow-up sessions varied with the study by Wright et al. (2000), limiting the telephone calls to a maximum of 15 min, whereas the follow-up telephone calls described in both papers by Lucock et al. (2018, 2021) were each 30 min long. The Staying Well booklet (OxCADAT, n.d.) did not include any details regarding the length of the follow-up. The purpose of the follow-up sessions across these four relapse prevention interventions/tools was to encourage compliance and provide social support if needed. Excluding the Staying Well booklet (OxCADAT, n.d.), the other three relapse prevention interventions used follow-ups to assess the effectiveness of the intervention and collect outcome measure data.
Measures of Effectiveness
The three peer-reviewed publications (Lucock et al., 2018;2021; Wright et al., 2000) tested the effectiveness of their interventions. Whereas data concerning the effectiveness of the relapse prevention intervention across the grey literature documents (OxCADAT, n.d.; Chellingsworth et al., 2013) was not reported or has yet to be collected (Paddle, 2019).
The effectiveness of the SMArT intervention (Lucock et al., 2018, 2021) was measured by the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) and Generalized Anxiety Disorder-7 (GAD; Spitzer et al., 2006) which was collected at six different time points, including before therapy, at discharge, during the face-to-face session and at each of the three telephone follow-up sessions.
To test the effectiveness of the relapse prevention manual, Wright et al. (2000) compared the frequency of full and limited-symptom panic attacks of the relapse prevention group with a waiting list control group.
Discussion
Within the ever-evolving field of clinical psychology, this is the first comprehensive summary of the relapse prevention resources and interventions administered to patients after completing a GSH intervention in primary care. This scoping review provides an overview of the knowledge available, and the key features considered in developing a resource to tackle the global concern of patients with anxiety and depression relapsing following treatment. Additionally, essential gaps in the literature were identified predominantly surrounding the scarcity of relapse prevention interventions or tools specifically for individuals who have completed low-intensity treatments. To provide a comprehensive overview of the advances and gaps in the literature surrounding relapse prevention following GSH, this section will discuss the main findings in accordance with the Patterns, Advances, Gaps, Evidence of practice, and Research Recommendations (PAGER) framework (Bradbury-Jones et al., 2021, 2022). The PAGER framework (Table 4) is used to guide the discussion and planning for future research and uses model themes (Bradbury-Jones et al., 2021).
Table 4
Practice and research implications following PAGER framework
Pattern | Advances | Gaps | Evidence for practice | Research recommendations |
|---|---|---|---|---|
Continued access to relapse prevention materials | Understanding of the importance of providing additional resources to enable patients continued access to skills learnt during therapy beyond the therapy setting has improved. | The process surrounding the development of such materials remains unclear as there is little evidence available concerning development with a concentration on content of the intervention. | Evidence to emerge from future research. | Research is needed that explores the best ways to develop a relapse prevention intervention. Further research is needed exploring multiple key stakeholders’ (commissioners of services, mental health practitioners who deliver low intensity interventions, and patients and carers who will benefit from the intervention) views on relapse prevention interventions. |
Individual motivation | Our understanding of the potential influence that brief continued support through follow-ups has on patient engagement has improved. | The patients’ motivation to continue with the intervention following treatment and what support will be appropriate and in which format is under-researched. | Evidence to emerge from future research. | Further research understanding what motivates patients to continue practicing the skills learnt during their treatment over time is needed to ensure long term benefits. |
The importance of additional support after GSH - Incorporating an additional element following the end of treatment that focuses primarily on relapse prevention would be beneficial to ensuring patients can maintain their recovery for a more extended period. The three peer-reviewed studies reporting on the evaluation of their interventions have shown to be effective at reducing the risk of relapse for depression symptoms (Lucock et al., 2018, 2021) or anxiety symptoms (Wright et al., 2000). This suggests that interventions supporting patients following GSH can maximise long term benefits of treatment. These findings corroborate a previous systematic review exploring how interference using a range of psychological therapies following recovery from depression can help reduce the risk of relapse (Clarke et al., 2015). In another systematic review (Moriarty et al., 2020) findings demonstrate that relapse prevention interventions are highly effective at reducing the risk of relapse for patients with depression; however, both reviews do not focus on administering these interventions following GSH treatment. Nonetheless, findings from this scoping review look promising due to the effects reported from two relapse prevention interventions for patients with anxiety or depression treated in short-term, low-intensity care. Although this review does not report on the effects of the intervention, adding a relapse prevention component following the treatment phase has beneficial properties for reducing the likelihood of relapse as patients continue to feel supported following discharge. However, due to the scarcity of evidence highlighted in this review and the restricted evidence evaluating their impact in reducing long-term relapse, further research is needed before concrete conclusions regarding the effectiveness of relapse prevention interventions can be drawn.
Providing accessible tools and resources - Despite the limited evidence discussed in this scoping review, many commonalities existed. To aid relapse prevention, an integral feature across all tools and resources was helping individuals to develop the skills necessary to overcome and prevent any incidence of relapse, such that patients become independent in their recovery journey. The process of developing and implementing skills to address situations that could result in relapse is a key principle of relapse prevention (Marlatt & George, 1984; Melemis, 2015; Menon & Kandasamy, 2018), which was addressed across all studies and identified resources. The development and ongoing use of skills are common strategies in materials created to help overcome depression and anxiety. This is evident in workbooks available to the public, which can be utilized by anyone, whether they have received professional help, to support their recovery journey (Williams, 2012) and in practitioner guides for conducting relapse prevention work in low-intensity care (Papworth & Marrinan, 2018). Regardless of whether these skills were developed in collaboration with a therapist at the start of treatment or at the start of the relapse prevention intervention, or through a more generalised plan, they remained helpful to maintain recovery over time. Most importantly, ensuring that the skills are recorded in an accessible format – written or digital – for access outside of the therapy session without the aid of a therapist is an important feature evidenced across all the resources listed in this review, supporting relapse prevention. Having access to written information that is tailored to an individual’s problems has formally been identified as helpful in enabling self-management across various conditions (Dineen-Griffin et al., 2019; Liddy et al., 2014). By ensuring individuals have the appropriate resources to help them independently manage their condition, the immediate benefits of recovery following GSH can be maintained. However, it is important to note that the lack of information about the development of the relapse prevention interventions deters understanding of the development process. In addition, the benefits and challenges of different intervention development approaches in this topic is scarce. Future research which explores the development of relapse prevention interventions should consider the involvement of multiple stakeholders and report each step in the development of the intervention to ensure transparency and improve understanding of how best it is to create relapse prevention interventions and resources.
Continued brief support after treatment - A follow-up was also an integral feature for relapse prevention as this component was included in five of six relapse prevention tools and interventions. To ensure that patients continuously apply the skills learnt during their GSH treatment outside of the clinical setting, checking in with patients for a brief amount of time reinforces the implementation of the relapse prevention tool or resource and enables the therapist to track their progress or identify any early signs of relapse before they develop into something bigger (National Collaborating Centre for Mental Health, 2018). Having additional contact with a practitioner, regardless of whether an individual relapses following treatment, is a preferred feature of relapse prevention programmes influencing the rate of engagement with the programme as evidenced in previous research (Muntingh et al., 2019; Scholten et al., 2021). Follow-ups are also recommended for low-intensity treatment to ensure patients are maintaining treatment gains, continue to implement their techniques and identify signs of relapse early (Papworth & Marrinan, 2018; NHS, 2024). However, continuous contact with a practitioner is often not feasible in routine care in the long term and previous research has demonstrated that motivation can influence the continuity of treatment (Runge et al., 2022). Therefore, future research should explore patient motivation to increase engagement and ensure sustained positive effects of therapy.
Strengths and Limitations
To our knowledge, this is the first scoping review to explore relapse prevention interventions explicitly administered following a specific type of psychological treatment, i.e., GSH. The publication of a review protocol accessible on a publicly available research data repository ensures transparency of the research design and demonstrates whether the findings of the scoping review align with the researchers’ objectives set out at the start, which can be seen as a strength of this review.
This review addresses relapse prevention for individuals with anxiety and/or depression symptoms after GSH through the inclusion of peer reviewed publications and other resources. However, there are limitations that warrant discussion. Firstly, our search strategy was not exhaustive, and the search string used was narrow, focussing on the most relevant terms to address the aim of this scoping review considering the time constraints, which may have meant that the papers extracted through the reference lists did not appear during the electronic database search, as a result. Nonetheless the inclusion of reference checking supported the electronic database search, strengthening the findings of this scoping review. Secondly, despite the inclusion of evidence beyond what is published in the literature, the use of a singular grey literature database limited the comprehensiveness of the search and the use of a database, which yielded no results suggests that the chosen database may not have been appropriate for this scoping review. However, access to other grey literature databases was restricted; thus, future reviews may consider including multiple grey literature databases. Finally, it is crucial to consider that the inclusion/exclusion criteria focussed on GSH, which, for many countries such as the Netherlands, is not commonly administered, unlike within England, where it is often used within talking therapy services, which may be why the majority of the includes studies/resources are from England. Here, it is essential to note that although this review explores relapse after treatment, discussions regarding relapse prevention may occur during and throughout GSH treatment by PWPs in step 2 care (Papworth & Marrinan, 2018), and the resources or tools focused on relapse utilised during treatment may differ from those discussed (as evidenced by the Staying Well Resource (OxCADAT, n.d.) which is used within treatment and beyond). Nonetheless, this review focussed on identifying what is available for patients when they are no longer in treatment and do not have access to the support of their practitioners instead of understanding the relapse prevention discussions that may occur during GSH.
Conclusion
This scoping review sought to provide insight into ways in which relapse prevention is approached following GSH and revealed a shortage of resources and interventions specifically tailored to target relapse prevention among people with anxiety and/or depression symptoms who received GSH. Nonetheless, many commonalities were observed in the characteristics of available resources including continued utilisation of learnt techniques and further development on acquired skills beyond GSH, alongside follow-ups to enhance compliance with relapse prevention interventions. However, further investigation is warranted to assess their effectiveness at reducing relapse in the long-term. Providing additional interventions and resources following treatment aimed to prevent relapse may be integral in facilitating long-term positive change in mental health by supplying individuals with all the necessary tools to independently continue their recovery journey. However, further research is still needed to inform how relapse prevention can be best and efficiently addressed following GSH treatment to ensure the skills learnt during GSH transition to lifelong skills.
Declarations
Conflict of interest
None.
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