Offering mental health first aid to a person with depression: a Delphi study to re-develop the guidelines published in 2008

Background Depressive disorder is ranked as the largest contributor to non-fatal health burden. However, with prompt treatment, outcomes can improve. Family and friends are well placed to recognise the signs of depression and encourage early help seeking. Guidelines about how members of the public can provide mental health first aid to someone who is experiencing depression were developed in 2008. A Delphi study was conducted to re-develop these guidelines to ensure they are current and reflect best practice. Methods A survey was developed using the 2008 depression mental health first aid guidelines and a systematic search of grey and academic literature. The questionnaire contained items about providing mental health first aid to a person with depression. These items were rated by two international expert panels – a lived experience panel (consumers and carers) and a professional panel. Results Three hundred and fifty-two items were rated by 53 experts (36 with lived experience and 17 professionals) according to whether they should be included in the revised guidelines. There were 183 items that met the criteria to be included in the updated guidelines. Conclusions This re-development has added detail to the previous version of the guidelines, giving more guidance on the role of the first aider and allowing for a more nuanced approach to providing first aid to someone with depression. These guidelines are available to the public and will be used to update the Mental Health First Aid courses. Electronic supplementary material The online version of this article (10.1186/s40359-019-0310-3) contains supplementary material, which is available to authorized users.

1. Do you meet these criteria? *

Yes No
How this questionnaire was developed The statements in this questionnaire were derived from information collected during a search of websites, books, and journal articles on how to provide mental health first aid to somebody with depression.
Some of the statements may seem contradictory or controversial; however, we have included them because they reflect the wide range of people's beliefs about the best ways to provide mental health first aid to someone with depression. It is important to note that we do not necessarily agree with these statements; we have included them because we do not believe that we should decide what the best practice is in this area. Rather, we have invited you to be a member of an expert panel to help develop a set of guidelines that reflect current expert opinion.
You will note that there is a place for you to add comments at the end of each section. This is so you can suggest any additional helping statements you think are important to providing mental health first aid to someone with depression. These statements will then go into the Round 2 survey to be rated by the expert panels.
12. The first aider should be aware that the experience of depression can vary in severity, e.g. from feeling irritable to feeling suicidal.
18. The first aider should not ignore any signs or symptoms of depression that they have noticed or assume that they will just go away. 19. The first aider should not assume that any signs or symptoms they have noticed means that the person is experiencing depression. 20. The first aider should know that many people who experience depression may also be affected by other mental health problems like anxiety or substance use problems. Approaching someone who may be experiencing depression (cont)

Starting a conversation
Essential Important

Depends/Don't know Unimportant
Should not be included Tell the person that they care and want to help.
Tell the person about the specific changes that they have noticed in a supportive and sensitive manner.
Let the person choose when to open up.
27. If the first aider is worried about someone who may be depressed, they should: * 28. If the person does not initiate a conversation about how they are feeling, the first aider should take a direct approach and raise the topic with them.
29. If the person says that they are feeling sad or down, the first aider should ask them how long they have been feeling that way.   Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Approaching someone who may be experiencing depression (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Giving the person information 11 37. The first aider should ask the person if they would like some information about depression.      Approaching someone who may be experiencing depression (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
13 When talking to the person (cont) 45. The first aider should know that each person's situation and needs are unique. * Essential Important Don't know/Depends Unimportant Should not be included 46. The first aider should respect the person's autonomy while considering the extent to which the person is able to make decisions for themselves and whether the person is at risk of harming themselves or others.  48. The first aider should let the person know in advance that they will intervene and seek professional help for the person if they ever believe the person's life may be in danger. 49. The first aider should use the same terminology that the person uses when discussing their experience, e.g. if they say they are "moody" or "down", use these terms rather than "depressed", or vice versa.

Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Understanding depression 51. The first aider should know that those who haven't experienced depression cannot fully understand what it is like for those who have. 52. The first aider should tell the person that they are not to blame for feeling 'down'. * Essential Important Don't know/Depends Unimportant Should not be included 53. The first aider should let the person know that they are not weak or a failure because they have depression, and that they don't think less of them as a person.  56. The first aider should know that the person is experiencing depression as a set of feelings about themselves, others and the world. Therefore, the first aider should not imply that the person simply has a medical illness, as this may invalidate their experiences. 57. The first aider should try to see any irritable or unpleasant behaviours as part of the illness and not take these personally.    Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Being supportive (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Offering support 62. The first aider should know that a depressed person may be overwhelmed by irrational fears. * Essential Important Don't know/Depends Unimportant Should not be included 18 63. The first aider should know that the person may become obsessive in talking about their feelings, making them seem self-absorbed.  67. The first aider should be aware that their support is likely to be having a positive impact, even if it does not feel this way. 68. The first aider should let the person know that they will not abandon them. 69. The first aider should not use a 'tough-love' approach to try and make the person better, e.g. the first aider telling the person they will not spend time with them until they get better or get professional help.

20
Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Offering support (cont) 72. If the person judges themselves too harshly, the first aider should remind the person of their strengths.  75. The first aider should tell the person that they are trying to imagine how they feel. 77. The first aider should know that often just taking the time to talk to or be with the person lets them know that someone cares.  Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Being supportive (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Offering assistance 81. The first aider should ask the person what practical assistance they need. * Essential Important Don't know/Depends Unimportant Should not be included 82. The first aider should ask the person if they would like any practical assistance with tasks, but should be careful not to take over or encourage dependency. 83. The first aider should make any decision that they can for the person. * Essential Important Don't know/Depends Unimportant Should not be included 84. If the first aider is particularly concerned about the person, they should organise to have close friends or family members to make contact with the person each day, e.g. to provide practical help, have a coffee, simply to say hello.  86. The first aider should let the person know that stress is a risk factor for depression and encourage them to find ways to reduce stress in their life.  Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Being supportive (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Offering assistance (cont) 25 90. The first aider should encourage the person to lead a healthy lifestyle by being an example to the person, e.g. maintaining a positive outlook, eating better, exercising, etc.   93. The first aider should encourage the person to participate in some activities that once gave them pleasure, e.g. hobbies, sport, religious or cultural activities. 94. The first aider should try to provide a change of scenery for the person, e.g. go for a walk in a different area.       102. The first aider should continue to involve the person in any activities that they have shared previously.

29
Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Essential Important
Depends/Don't know Unimportant Should not be included They are not alone in this.
The first aider is there for the person.
Although the first aider may not be able to understand exactly how the person feels, they care and want to help.
They are important to the first aider and their life is important.
They may not believe it now, but the way they are feeling will improve.
With time and treatment the person will feel better.
107. The first aider should consider telling the person that: * 108. The first aider should offer emotional support and hope of a more positive future in whatever form the depressed person will accept. 109. The first aider should give the person the message that they believe that the person can resolve their problems themselves. Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Being supportive (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
What not to do or say 111. The first aider should know that there is no point in just telling the person to get better.  113. The first aider should not tell the person that they just need to stay busy or get out more. 114. The first aider should not trivialise the person's experiences by telling them to "put a smile on their face," to "get their act together," or to "lighten up". 115. The first aider should avoid using the words "I know how you feel" or "I understand". 116. The person should avoid saying the following: * 117. Even if the first aider feels that the person is unpleasant to be around, they should not tell them so. Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Being supportive (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
What not to do or say (cont) 119. The first aider should not adopt an over-involved or over-protective attitude towards the person.

35
Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Talking to the person 130. It is more important for the first aider to be genuinely caring than for them to say all the 'right things'.  132. The first aider should know that some people may find it difficult to discuss their thoughts and feelings openly. If this is the case, the first aider should suggest going for a walk together, as this may make it easier for the person to talk.  135. The first aider should not be hostile or sarcastic when the person is struggling to respond, but rather accept these responses as the best the person has to offer at that time.  Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Talking to the person (cont) 138. The first aider should tell the person how they are being affected by the person's depression.    142. The first aider should ask specific rather than general questions, e.g. rather than asking "How are you?" they should ask, "How are you today compared to yesterday?"

Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Listening to the person 149. The first aider should listen to the person without expressing judgment.    Should not be included Withholding any and all judgments that you have made about the person or their circumstances, e.g. if the first aider feels the person is being lazy, they should not express this.
Choosing words carefully so as to avoid causing offence, e.g. not applying any labels to the person that they may find stigmatising, such as 'mentally ill'.
155. The first aider should adopt an attitude of acceptance of the person by: * 156. Please provide any additional items or comments related to this section.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Please keep our definitions in mind when responding. Listening not only to what the person says, but how they say it, e.g. their tone of voice.
Using minimal prompts, such as "I see" and "Mmmm" when necessary to keep the conversation with the person going.
Being patient, even when the person may not be communicating well, may be repetitive or may be speaking slower and less clearly than usual.
Not being critical or expressing their frustration at the person for not being able to communicate well.
157. The first aider should use the following verbal skills to show they are listening: * 43 Avoiding giving unhelpful advice such as "Pull yourself together" or "Cheer up." If this was possible the person would do it.
Not interrupting the person when they are speaking, especially to share their own opinions or experiences.
Avoiding confrontation, unless necessary to prevent the person from committing harmful or dangerous acts.

Essential Important
Depends/Don't know Unimportant Should not be included 158. The first aider should know that pauses and silences are okay and that while they may feel uncomfortable, the person may need time to think or find the right words. Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Communicating effectively (cont) Maintaining an open body position, e.g. not crossing arms, as this may appear defensive.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
If it is safe, sitting down, even if the person is standing. This may seem less threatening.
Sitting alongside the person and angled towards them, rather than directly opposite them.
Avoiding distracting gestures (e.g. fidgeting with a pen, glancing at other things or tapping your feet or fingers), as these could be interpreted as a lack of interest.
160. The first aider should use the following non-verbal skills to reinforce their non-judgmental communication: * 45 161. Set aside any negative beliefs and reactions in order to focus on the needs of the person they are helping.  Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Communicating effectively (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Cultural considerations when communicating with the person 46 164. If assisting someone from a cultural background that is different from the first aider's, the first aider should be willing to adjust their verbal and non-verbal behaviours, e.g. the person may be comfortable with a different level of eye contact, or may be used to more personal space. Seek advice from someone from the person's cultural background.
165. If cultural differences are interfering with the first aider's ability to help the person, they should: * 166. Please provide any additional items or comments related to this section.
Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
When to encourage help-seeking 47 167. The first aider should not assume the person's depression will just go away. 168. The first aider should know that treating depression early is important to getting the best outcomes. 175. The first aider should discuss the options that the person has for seeking help and should encourage them to use these options.  Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Help-seeking (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
How to assist the person with help-seeking 50 178. The first aider should help the person find a mental health professional.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
The first appointment with the health professional 187. The first aider should offer to make the first appointment for the person.     Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Help-seeking (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Preparing for the appointment with the health professional 54 193. The first aider should avoid labelling the person's behaviours or feelings as symptoms of depression when talking to them about seeking help.          204. The first aider should know that it may take some time to find a health professional with whom the person is able to establish a good relationship. If this is the case, the first aider should encourage the person not to give up.    Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.
Please keep our definitions in mind when responding.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
209. The first aider should know what self-help strategies have evidence to support their effectiveness and should encourage the person to use these strategies.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
218. The first aider should know the barriers to seeking treatment for depression, e.g. the person feels like no one can really help. Seek advice from someone who has experienced depression and received treatment.
Encourage the person to find out more about depression.
Encourage the person to attend a support group. Encourage the person to use self-help strategies.
Let the person know that they will keep checking in on them because they are concerned about the person.
Suggest to the person that they try evidencebased alternative treatments, e.g. exercise.
Use deception, coercion, threats, or whatever is necessary to ensure professional help is received.
Not use deception, coercion or threats to ensure professional help is received.
Not suggest that they get professional help again unless the person asks about it.

Essential Important
Depends/Don't know Unimportant Should not be included 62 220. If the person refuses to seek or accept face-to-face professional help, the first aider should encourage them to get online professional help.

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
222. If the person lives in a family, the first aider should label the person's depression as a 'family problem' and suggest that the whole family attends therapy. This will take the focus off the depressed person.       Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
What to do if the person doesn't want help (cont)

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
232. If the person is reluctant to admit there is a problem, the first aider should be gently persistent with their concerns.

Depends/Don't know Unimportant
Should not be included

Stay calm
Acknowledge the anger.
Not make assumptions about the cause of their anger.
238. If the person becomes angry during the conversation, the first aider should: * 239. If the person appears irrational, the first aider should not try to talk the person out of their thoughts or feelings.    Should not be included Find someone to talk to about their feelings without sharing the personal details of the person they were helping.
Use evidence-based self-care strategies.
243. If the first aider is feeling upset or worn out after helping the person they should: * 244. Please provide any additional items or comments related to this section.

Please keep our definitions in mind when responding.
What to do if there are concerns for safety

Updating the Mental Health First Aid Guidelines for Helping someone with Depression
Non-verbal communication 69 245. The first aider should respect the person's right not to seek help unless the first aider believes that the person is at risk of harming themselves or others. Tell the person that the first aider needs to get someone else involved even without their permission.
Seek help on their behalf even without the person's permission.
246. If the person is at risk of harming themselves or others, the first aider should: * 247. The first aider should be aware of the Mental Health First Aid Guidelines for how to assist someone with suicidal thoughts or behaviours.

Purpose of this research
The aim of this current research project is to update the mental health first aid guidelines for how a member of the public should give assistance to a person who is experiencing depression. These guidelines are being developed for high income Western countries.

How this questionnaire was developed
The statements in this questionnaire were derived from the results of the Round 1 survey. You will note that each statement is marked as either a NEW or RERATE item. New items were derived from the comments provided in the first survey. An item is rerated when: 70%-79% of panel members from both expert groups rated it as essential or important, OR 70%-79% of one group rated it as essential or important and 80%-100% of the other group did.

Consent to participate
It is important for you to know that participation in this study is completely voluntary. You are not under any obligation to participate and you can withdraw at any time.
We would like to thank you for your time and effort, and encourage you to provide us with feedback on this process.

Definitions used in this survey
Mental health first aid is the help offered to a person developing a mental health problem, experiencing a worsening of an existing mental health problem, or in a mental health crisis. The first aid is given until appropriate professional help is received or until the crisis resolves.
The person refers to the person who the mental health first aider is concerned may be experiencing depression.
The first aider refers to a concerned family member, friend, work colleague or member of the community, who provides help to a person who may be experiencing depression.
Mental health professional refers to a trained health professional who is treating/working with the person. This could be a psychologist, mental health nurse or psychiatrist. It could also be another health professional who has specialist mental health training, e.g. social worker, occupational therapist or GP.

Instructions
Please complete the questionnaire by rating each statement according to how important you believe it is for inclusion in the guidelines for providing mental health first aid to a person who may be experiencing depression. Please keep in mind that the guidelines will be used by the general public. The statements need to be rated according to their importance for someone without a counselling or clinical background.
This questionnaire should take approximately 45 minutes to complete. You can complete the survey in two or more sittings. Your answers are saved when you click 'Next' at the bottom of a page. This marks your page and you can begin again at a later date on the next page. Please be aware that once you have logged on and started responding you must complete the questionnaire on the same computer.

Information about you
Round 2: Updating the Mental Health First Aid Guidelines for Helping someone with Depression 1. What is your name? (This allows us to determine who has completed the Round 2 survey and is therefore eligible to participate in Round 3. Your name will be deleted from your data when the project is complete). Overview of the study Section 1: Learning about depression Section 2: Approaching someone who may be experiencing depression Section 3: Being supportive Section 4: Communicating effectively Section 5: Encouraging help seeking Section 6: Encouraging self-help strategies Section 7: What to do if they do not want help Section 8: Concerns for safety Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Learning about depression 3. The first aider should learn more about depression by:

Please keep our definitions in mind when responding.
Approaching someone who may be experiencing depression

Round 2: Updating the Mental Health First Aid Guidelines for Helping someone with Depression
If the first aider notices signs or symptoms of depression 5. The first aider should consider whether they are the best person to approach the person or whether somebody else might be more appropriate. 31. The first aider should not use a 'tough-love' approach to try and make the person better, e.g. the first aider telling the person they will not spend time with them until they get better or get professional help. 71. The first aider should use the same terminology that the person uses when discussing their experience, e.g. if they say they are "moody" or "down", use these terms rather than "depressed", or vice Communicating effectively (cont) 80. If cultural differences are interfering with the first aider's ability to help the person, they should: * Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
Help-seeking  102. If the person is interested in self-help strategies, the first aider should: * 103. If the person is interested in self-help activities and it is appropriate to their relationship, the first aider should offer to do self-help activities with the person. (New) * Essential Important Don't know/Depends Unimportant Should not be included Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
What to do if the person doesn't want help 104. If the person refuses to seek or accept professional help, the first aider should: * 33 105. The first aider should find out if there are specific reasons why the person does not want to seek professional help (e.g. concerns about finances, not having a doctor they like, or being worried they will be sent to hospital), as sometimes such reasons are based on mistaken beliefs, or can be overcome with help. ( What to do if there are concerns for safety Round 2: Updating the Mental Health First Aid Guidelines for Helping someone with Depression 6. The first aider should not use language related to a potential diagnosis when talking with the person. * Essential Important Don't know/Depends Unimportant Should not be included Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Being supportive
Round 3: Updating the Mental Health First Aid Guidelines for Helping someone with Depression Offering support 7. If the first aider does not feel that they are able to help the person, they should ask someone else to take on the first aider role.  9. The first aider should let the person know that getting better takes time, but that it will happen. Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Communicating effectively
Round 3: Updating the Mental Health First Aid Guidelines for Helping someone with Depression Talking to the person 11. The first aider should use the same terminology that the person uses when discussing their experience, except if the person uses unhelpful or stigmatising language. 13. If cultural differences are interfering with the first aider's ability to help the person, they should talk to a mental health service that specialises in working with people from different cultural backgrounds. 15. The first aider should ask the person how much involvement they want the first aider to have with planning for and attending their appointment. Please keep our definitions in mind when responding. 16. If the person is interested in self-help strategies, the first aider should: * Please rate how important (from 'essential' to 'should not be included') you think it is that each statement be included in the guidelines.

Please keep our definitions in mind when responding.
What to do if there are concerns for safety Round 3: Updating the Mental Health First Aid Guidelines for Helping someone with Depression