Design & ethical approvals

Focus groups were considered to be the most comprehensive way of assessing a broad scope of opinion from multiple participants on this relatively exploratory topic, in a relatively short space of data collection period [25]. We therefore approached this study as philosophically pragmatic [26]–both in terms of ontology (whereby we acknowledge differing and sometimes competing interpretations of the world exist, and that no single viewpoint is able to provide the whole picture–thus scoping many opinions via a focus group was deemed best practice to capture these differing opinions) [27], and epistemology (whereby we accept that the knowledge and reality held and lived by people, is measurable in the real world accounting for time and cultural shift) [28]. Ethical approvals were obtained from the King’s College London Research Ethics Committee (ref:- LRU/DP-21/22-28890). Verbal, audio recorded consent was also taken before the commencement of each focus group to ensure participants were happy to participate in the study. Participants were made aware of their right to withdraw and were fully debriefed after focus groups.

Participants

We recruited GPs (N = 16; five male; eleven female) across four focus group discussions. Participants were recruited using an advertisement template via email chains and social media platforms. Those who participated were UK-based practising GPs, with varied amounts of years of experience working in primary care (M_Years = 10; Range = 2–22 years). Participants worked in a variety of UK-based locations including Scotland, London, West and East England, and the Midlands. Two participants were excluded from the data analysis due to technical issues during the focus group and therefore 14 GPs (four male; ten female) were included in the final analysis.

Data collection

The focus groups were conducted via Microsoft Teams and took place between May and July 2022. The interviews lasted 46-67minutes (M_Time = 60minutes), and were moderated by two Master’s students (a Junior Doctor [EA], and a Psychology graduate [LJ]). Participants provided informed consent, before the questioning began. A common set of questions were used as a topic guide (S1 Appendix) for each focus group, however, pertinent conversations raised by each individual group were followed-up on by the moderators. Data were recorded and the audio transcribed ‘intelligently’ (i.e., without non-verbal utterances), ready for analysis.

Approach to analysis

A Template Analysis was selected to analyse the data, which is methodically stepped first refamiliarization with the data; then preliminary coding; organising themes; defining the initial coding template; applying the initial template; before finalising the template and applying it to the full dataset [29, 30]. The first pass analyses were completed independently by two authors (EA, LJ). Importantly, the initial template can be modified to ensure completeness of analysis, which was undertaken by another author (SAS), to harmonise any discordant themes as presented in the initial analyses [29]. Regular analytic discussion took place between all authors to ensure rigour, and thematic concordance.

Theme 1: Supporting effective conversations

In consultations for the management of depression, initial patient engagement and the timing of introducing lifestyle advice to patients was spoken about as being an important part of the process. Several participants expressed that the conversation was more effective over several appointments as readiness to engage can take time, requires building of trust and is important for the provision of tailored advice.

“Often it’s that engagement that you have to do before you even broach lifestyle advice because if they’re not engaged with you, if they don’t feel that you’re listening, then they may get the wrong assumption, maybe thinking that you somehow think it’s their fault or that they can solve it, and that’s very much not what’s happening.” (GP7)

Empathy, lack of judgement and building trust were highlighted as being important in conversations about lifestyle particularly for certain patient groups such as adolescents.

“I think it’s more about you not appearing judgmental, not appearing like you’re trying to convince them of something. I think you should appear more like trying to understand them and their habits… and then try to see how you can motivate them.” (GP10)

Some participants spoke about using personal experiences and anecdotes to build trust with their patients.

“…just your own personal experiences and anecdotes … we still all have the same experiences as our patients … and I think if patients can relate to you as a person, as a human being … it’s these little things that can instill confidence in your patient …” (GP5).

Theme 2: Willing, but blocked from establishing relational care

The participants showed willingness to discuss lifestyle advice with patients with depression but several challenges to establishing relational care were highlighted. Lack of time and not having in-person consultations were highlighted as impacting practice. Telephone consultations were viewed as challenging as opportunities to pick-up on non-verbal cues are missed.

“I think it’s sometimes lack of time and trying to squeeze it all in a ten-minute consultation, and most of the stuff is now done over the phone… you’re also missing out on the body language, on other non-verbal cues.” (GP1)

The participants varied in confidence in providing lifestyle advice. Experience was related to confidence and more experience helped participants develop the skills required to personalise lifestyle advice.

“I would say I’m more confident on the mild-to-moderate ones. Definitely for the severe ones I’m not sure it’s particularly my confidence in it but just more knowing that there’s a lot more complexity going on that will need to be taken into account.” (GP7)

The participants highlighted that doctors are not provided with adequate educational opportunities on lifestyle medicine during their training and often this resulted in not feeling qualified. Including more lifestyle medicine in educational curricula was suggested.

“… I’m not necessarily confident in all of the content … I don’t feel like I’ve got enough of an evidence-based knowledge bank … it would be really useful if there was more preventative medicine and more lifestyle education as part of the undergraduate course … we’re not as skilled in it as we should be really …” (GP12)

Theme 3: Working towards patient empowerment

The participants spoke about introducing the topic of lifestyle by asking open questions about daily routines and then using the information gained to personalise the discussion.

“I say something like ‘Talk me through your day’, so I can understand where they are at the moment ….and see whether they think there’s anything that they could fit into what they do at the moment.” (GP9)

Participants spoke about taking a patient-centred approach and using shared decision making to empower the patient to take control of the management of their health.

“They need their own way to feel empowered and their own thing that’s going to pull them forward is digging into what was important to them, so that’s what I tend to try to focus on.” (GP3)

Understanding the patients’ interests and goals was discussed by the participants as being an important component of counselling. This was spoken about in the context of postpartum women and adolescent patients. Introducing realistic, specific and achievable changes was highlighted by the participants as an important part of lifestyle medicine. Often, the participants would focus on one or two goals at a time.

“‘Can you go outside?’ that could be like climbing Everest for that patient… Opening the curtains, that was one of the goals that we set with one of my patients… I think it’s shifting those goalposts.” (GP3)

Theme 4: Control over the prognosis

The importance of access to additional support, such as social prescribers, specialist mental health nurses, or other mental health practitioners was discussed by the participants. These specialists were viewed as having more up-to-date knowledge and better awareness of what resources are available to patients and hence can contribute to better care, and despite being based in the community, were linked to specialist mental health Trusts.

“If we do have a Mental Health Nurse, she is much more up to date with what else is going on and what else can we do.” (GP1)

Access to resources which are often free to support patients with lifestyle changes was discussed. Participants spoke about different resources including local physical activity clubs, podcasts, and websites. However, the participants highlighted how economic challenges impact patients’ ability to make lifestyle changes, such as access to exercise classes, dietitians, and resources which are not routinely available on the NHS.

“I think about my local area, we kind of have most of the things you would want, it’s just that they might be under-resourced or underfunded or oversubscribed or difficult to access.” (GP12)

Conversations with particular groups of patients were spoken about as being associated with additional considerations. For example, the participants acknowledged the importance of discussing lifestyle changes with patients with postpartum depression. However, some aspects such as sleep were highlighted as untimely to discuss in the postpartum period.

“As much as you’d like to talk about lifestyle medicine… it’s just not going to work for them because they’re not going to sleep; it’s a major issue and that’s just a part and parcel of being a new mother… I think trying to go down the lifestyle medicine route might come across as being a bit condescending to them.” (GP4)

Likewise, the social environment was also perceived as a challenge for other groups such as parents.

“People aren’t always entirely in charge of what they’re doing in terms of their lifestyle. Some people might want to go outside and exercise and they just don’t have that autonomy to do it, or they’re looking after their kids, and it’s just finding out what exactly is the barrier there and seeing if there’s a way around it.” (GP8)

Summary of main findings

Establishing a doctor-patient relationship by building trust and rapport was fundamental in having effective conversations on making lifestyle changes as an adjunct to the management of depression. Additionally, empowering patients to make positive lifestyle changes requires tailoring advice using a patient-centred approach. Confidence in lifestyle advice provision varied between the participants, and was associated with differing training, education, experience, severity of depression and patient sub-group. A common organisational challenge to establishing relational care was lack of time. It is well-established that lack of time is a barrier to lifestyle advice provision in chronic disease management in primary care [31–34]. This is despite in 2014 the Royal College of GPs proposing that GPs should be allotted longer consultations for patients with mental ill-health [35]. The participants further highlighted longer consultations are required for patients with depression due to the individualised approach required when giving lifestyle advice and due to the complexity of patients with mental ill-health. Therefore, increasing appointment length could have a significant positive impact on the care of patients with depression and facilitate conversations on lifestyle changes. Additionally, participants highlighted telephone consultations are disruptive to establishing relational care as non-verbal cues are missed. Although there is evidence suggesting telemedicine can be beneficial to patients with depression due to increased access to care [36], emphasis on in-person consultations in primary care for patients with mental ill-health is still needed to ensure patients with depression receive individualised advice on behaviour change.

The participants found patient-led decision-making was effective for empowering patients to make lifestyle changes, with the patient directing the doctor on which area of lifestyle to focus on. Further evidence suggests that a patient-centred approach appears to be valued by patients with depression and may be associated with better treatment outcomes [37, 38]. Tailoring the lifestyle advice for patient subgroups, such as adolescents, postpartum women, and those with severe depression was also evident. Another key component to patient empowerment was educating the patient about the link between lifestyle and mood. Some participants provided evidence-based lifestyle advice from existing research, while others used patient anecdotes [39]. Empowering patients to make lifestyle changes using a patient-centred approach may lead to more effective management of depression using lifestyle medicine.

GPs identified economic and access challenges which may impact patients’ abilities to make lifestyle changes as supportive resources were location dependent, and some were costly. To achieve standardised care provision and reduce health service inequalities, the access to supportive and free resources needs to be standardised across NHS practices. This is particularly important as depression is more common in lower socio-economic groups [40]. Some of the GPs had access to social prescribing and mental health nurses and felt they were particularly supportive to patients with depression and were experts in the area. Evidence shows social prescribing can reduce levels of depression and improve quality of life [41]. Access to social prescribing should be addressed within primary care to improve healthcare outcomes for patients with depression.

Strengths and limitations

This study provides knowledge to the limited body of qualitative research exploring GPs’ experiences of providing lifestyle advice to patients with depression. The participants who opted to participate in the study may be motivated to provide lifestyle advice which might have resulted in selection bias. Further, during the focus group interviews, two participants were lost from the focus groups due to technical issues and therefore also from the overall dataset, reducing the sample size of this study and the amount of data collected. The study unfortunately did not have a participant group which reflects the general UK GP workforce, which has a lower proportion of male to female participants. Finally, further information on the GP practices such as the practice size was not gathered and future work should be cognisant of these socio-demographic factors. The sampled participants did however provide strength to the data as the GPs were from both urban and rural areas across the UK. Having a varied representation of UK settings is useful in determining how location can influence provision of lifestyle advice and access to resources. Additionally, the participants had a range of experience which is important given that experience was found to influence confidence.