Applying Transtheoretical Model

of Change to Anti-Depression

Campaigns

Tatiana Levit

Magdalena Cismaru

University of Regina, Canada

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Outline

Depression and anti-depression campaigns

Research questions, need for theory

Appropriateness of TTM

Methodology

5 campaigns studied

How the campaigns align with TTM

Recommendations

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Common mental disorder is among the leading causes of disability and premature death in the world today • (NIH Medline Plus, 2012 ; WHO World Health Organization, Mental

Health, 2012)

Connected to reduction of quality of life, impairments, work disability, reduced productivity, financial difficulties, as well as suicide • (Katon, 2009; NIH Medline Plus, 2012 ; WHO World Health

Organization, Mental Health, 2012)

Worldwide depression affects more than 120 million people of all genders, ages, and backgrounds • (NIH Medline Plus, 2012)

Treatable and preventable in most instances • But often not recognized as a disease (WHO, 2012)

• Societal barriers: stigma and self-stigma (Jorm et al., 2003)

• Men find it especially difficult to acknowledge (Rochlen et al., 2005)

Depression

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Social marketing campaigns are developed by government and NFP organizations • Main messages: it is an illness, help is available, don’t judge

Anti-depression campaigns discussed in the academic literature (Nemec, 2005; Rochlen et al., 2006; Reavley and Jorm, 2011)

• The British Defeat Depression Campaign

• Beyond Blue, Australia’s national depression initiative

• Real Men. Real Depression

Findings • Somewhat successful in changing public views, improving

depression awareness and reducing stigma

• Need theoretical basis (Kelly, Jorm & Wright, 2007; Noar, 2006)

Campaigns Against Depression

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Research Questions

Examine social marketing campaigns aimed at preventing depression to determine:

How can we design more persuasive campaigns, effective in promoting behavioural change?

Are the existing campaigns based on any theoretical model?

If not, which model/s would be most appropriate?

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Transtheoretical Model

Precontemplation – people are most likely unaware that their

behaviour is problematic; have not intention to take action

Contemplation – people are beginning to recognize that their

behaviour is problematic and start to look at the pros and cons of

their actions

Preparation – people are intending to take action in the immediate

future, and may begin taking small steps towards change

Action – people have made specific overt modifications in their life

style, and positive change has occurred

Maintenance –people are working to prevent relapse (the return

from action or maintenance to an earlier stage)

Termination – individuals have zero temptation and 100% self-

efficacy... they are sure they will not return to their old unhealthy

habit as a way of coping (Prochaska and Velicer 1997).

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Transtheoretical Model (Norcross, Krebs, & Prochaska, 2011;

Prochaska, DiClemente, & Norcross, 1992;

Prochaska, Norcross, & DiClemente, 1994)

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Methodology

Snowball search methodology • Keywords: “depression”, “mental health”, “anti-depression”, “anti-

stigma”, “mood disorders”, “mental disorders”, “depression

campaigns”, “depression initiatives”, “depression and

Transtheoretical Model”, “depression and meta-analysis”

Mental health related government websites • US National Institute of Mental Health

• UK National Institute for Health and Clinical Excellence

• Mood Disorders Society of Canada etc.

Social Sciences Citation Index, Jstor, PsycInfo,

ABI/INFORM

Google and academic literature search

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Anti-depression initiatives

Inclusion / exclusion criteria

Included

• Target: adults (men, women, or both)

• Level: national and international

• Complexity: mass-media components,

such as television, radio, magazine

ads, posters, brochures, postcards

etc.

Excluded

• Target: youth or children

• Level: local (city, state)

• Complexity: websites that

simply provided links to

other websites or

campaigns

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5 major national campaigns from 5

English-speaking countries

Evaluations

Objectives

• Education, information, understanding

• Overcoming resistance

• Empowering individuals to feel confident, to

talk, to seek help

• Assisting individuals in their recovery

• Suicide prevention

Results of Search

Campaigns Studied: Objectives BeyondBlue (AUS)

Beyondblue’s work is aimed at achieving an Australian community that

understands depression and anxiety, empowering all Australians, at any

life-stage, to seek help.

What Better Feels

Like (Canada)

MDSC embarked on a project to assist individuals suffering from

depression in their recovery. MDSC believes that consumers, families and

caregivers are entitled to clear, accurate information about mood disorders

and other mental illnesses. Informing yourself about your own or a loved

one’s illness is an essential step in the journey to recovery.

Time to Change (UK)

Time to Change is England's biggest program to challenge mental health

stigma and discrimination. The goal is to to empower people with mental

health problems to feel confident talking about the issue without facing

discrimination, and the three quarters of the population who know

someone with a mental health problem to talk about it too.

Real Men. Real

Depression. (USA)

The National Institute of Mental Health (NIMH) focused on educating men

and those close to them about the symptoms of and treatments for

depression. The goal is to overcome resistance to mental health services

by sending a message that it takes courage to ask for help, it is not

unmanly or weak to admit to needing help and that by looking at your

feelings one can become a better man.

National Depression

Initiative (NZ)

(NDI) is a national project which is part of the Government’s commitment

to addressing suicide prevention, as well as improving the mental health

and wellbeing of all New Zealanders. The goal is to reduce the impact of

depression on the lives of New Zealanders.

Campaigns Studied: Primary Target

All

Adults

Men Additional

BeyondBlue (AUS)

Y Aboriginal, Multicultural, GLBTI,

Women /perinatal, Men, Older,

Youth, Workplace (materials and

programs)

What Better Feels Like

(Canada)

Y Workplace. Classroom or workplace

(“Elephant in the Room” posters)

Time to Change (UK)

Y Two sides: those who suffer and

helping others (family, friends,

coworkers, students)

Real Men. Real

Depression. (USA)

Y Latino (PSAs for television, radio,

and print, fact sheets and brochures)

National Depression

Initiative (NZ)

Y High risk groups, affected but

reluctant to seek help, whānau,

family, health sector

Campaigns Studied: Components

Mass media components

• TV, radio, magazine, posters, websites,

postcards, washroom door panels, beer mats,

billboards, bus stop advertising

Helplines

‘Talking points’

Training, educational kits, action packs

Events and sponsorship

Internet media, discussion and support

groups, forums, online self-help program

Campaign

Transtheoretical Model:

Stages of Change

PC C Pr A M

BeyondBlue (Australia) H H H H H

What Better Feels Like / Defeat Depression

(Mood Disorders Society of Canada)

M M H H H

Time to Change (Mind, UK) H H H H M

Real Men. Real Depression. (NIMH, USA)

H H H H L

National Depression Initiative (Ministry of Health, New Zealand)

H H H H H

TTM Stages

H-High M-Medium L-Low

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Precontemplation Target: people are most likely unaware that their behaviour is

problematic; have not intention to take action

Testimonials inform about signs of disease

Fight stigma: “It takes courage to ask for help”

Real Men.

Real

Depression.

(NIMH)

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Precontemplation

Use a celebrity (Sir John Kirwan,

rugby coach)

Include self-assessment tools

National

Depression

Initiative (NZ)

Over the last two weeks I have felt down or hopeless

Not at all For several days Nearly every day

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Contemplation Target: people are beginning to recognize that their

behaviour is problematic and start to look at the pros and cons of their actions

Where to get more information and help

Encourage to seek support from others

Time to

change.

Time to talk.

(UK)

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Preparation

Target: people are intending to take action in the immediate

future, and may begin taking small steps towards change

Give options

Encourage to take small steps

BeyondBlue

(Australia)

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Action and Maintenance

Target: Action – people have made specific overt modifications in their life style Maintenance –people are working to prevent relapse

Encourage to fully commit to recovery

Remind about rewards

Help plan for setbacks

What Better

Feels Like

(MDSC)

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Assess the client’s stage of change

Only about 20% of people are in the action stage (Velicer et al., 1995)

• Do not impose action on precontemplators

Set realistic goals by moving one stage at a time

Tailor the processes to the stages

Avoid mismatching stages and processes, practice integratively

• Consciousness-raising at the earlier stages

• Behaviouristic methods in later stages

Anticipate recycling • Most people will recycle several times before achieving long-

term maintenance

Recommendations for using TTM of Change

based on meta-analysis of 39 studies (Norcross, Krebs, & Prochaska, 2011)

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Our Recommendations: What

campaigns should do at each stage

Precontemplation Inform about definition of depression (signs and symptoms). Help recognize and

admit the problem. Inform about increased risks (costs)of doing nothing and vast benefits of change. Take the stigma away and fight the defenses. Provide

testimonials and evaluation tools.

Contemplation Encourage to seek professional and social support. Inform about ways to receive

immediate help and where to find more information. Discuss what can help. Encourage to try small actions to see how they help.

Preparation Encourage to reconsider the importance of benefits versus risks. Provide with

more helpful techniques. Encourage to create an action plan. Remind of the importance of positive self evaluation (Cismaru et al., 2008)

Action Encourage to notice the benefits of change and use of self-encouragement

Maintenance Remind of temporary slips, effective coping with setbacks and recycling.

Continue to stress the importance of positive self-image and confidence.

Stage campaigns should target

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Defeat Depression

…with TTM theory

Thank you!

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References

Cismaru, M., Lavack, A. M., Hadjistavropoulos, H. D., & Dorsch, K. (2008). Understanding health behavior: An integrated model for social marketers. Social Marketing Quaterly, 14, 2–32.

Jorm, F., K. M. Griffiths, H. Christensen, A. E. Korten, R. A. Parslow and B. Rodgers (2003), Providing information about the effectiveness of treatment options to depressed people in the community: a randomized controlled trial of effects on mental health literacy, help-seeking and symptoms, Psychological Medicine, 33 : pp 1071-1079

Katon, Wayne J. (2009). The impact of depression on workplace functioning and disability costs. American Journal of Managed Care, Dec;15(11 Suppl):S322-327.

Kelly, Claire M, Anthony F Jorm and Annemarie Wright (2007). Improving mental health literacy as a strategy to facilitate early intervention for mental disorders, Medical Journal of Australia, 187 (7): 26

NIH Medline Plus http://www.nlm.nih.gov/medlineplus/depression.html

Nemec, Kathryn (2005). Phoenix Research Public Health Depression Initiative: A Review of Depression Campaign Lessons for New Zealand.

Noar S. (2006). A 10-year retrospective of research in health mass media campaigns: where do we go from here? Journal of Health Communication 2006; 11: 21-42.]

Norcross, J.C., Krebs, P.M., & Prochaska, J.O. (2011), Stages of change. Journal of Clinical Psychology 2011 Feb;67(2):143-154.

Prochaska, , J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47, 1102–1114.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good. A revolutionary six-stage program for overcoming bad habits and moving your life positively forward. New York, NY: Harper Collins.

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References

Reavley Nicola J.; Jorm Anthony F. (2012) Public recognition of mental disorders and

beliefs about treatment: changes in Australia over 16 years, British Journal of

Psychiatry, Volume: 200 Issue: 5 Pages: 419-425

Rochlen, Aaron B.;Whilde, Margaret R.;Hoyer, Wayne D. (2005). The Real Men. Real

Depression Campaign: Overview, Theoretical Implications, and Research

Considerations. Psychology of Men & Masculinity, Vol 6(3), 186-194.

Rochlen, Aaron B.;McKelley, Ryan A.;Pituch, Keenan A. (2006). A preliminary examination

of the "Real Men. Real Depression" campaign. Psychology of Men & Masculinity, Vol

7(1), 1-13.

Roadways to Healthy Living: A Guide for Depression Prevention (2009), written by Pro-Change Behavior Systems, Inc., in collaboration with Recardo F. Munoz, Ph.D., West Kingston, Rhode Island.

Mastering Change: A Coach’s Guide To Using The Transtheoretical Model (2006), written by Pro-Change Behavior Systems, Inc., West Kingston, Rhode Island.

Velicer, W.F., Fava, J.L., Prochaska, J.O., Abrams, D.B., Emmons, K.M., & Pierce, J.P. (1995). Distribution of smokers by stage in three representative samples. Preventive Medicine, 24(4), 401-411.

WHO World Health Organization, Mental Health http://www.who.int/mental_health/en/