Participants recruited

Of the 755 participants randomised in the ACUDep trial, 674 completed their 12-month follow-up; 518 had consented to be interviewed and of these 518, 464 (89%) were potentially eligible to join the study. Of the 61 participants invited, four declined participation and three did not respond. A total of 52 participants, comprising 24 men and 28 women with an age range of 22–89 years (mean 46 years, SD 13.8) were interviewed. At baseline, 26 of these participants had reported having moderate or extreme pain or discomfort on the EQ5D questionnaire; these people formed the pain group, the remainder formed the no-pain comparator group. As part of the ACUDep trial, 22 of the 52 had been randomised to receive acupuncture, 20 to counselling and 10 received usual-care alone. A summary is presented in the sampling frame in online supplement 1. On average, those allocated to acupuncture attended 11 sessions (range 4–12) and those allocated to counselling attended 10 sessions (range 6–12).

Symptoms experienced with depression and contextual factors

Participants reported a range of symptoms they experienced concurrently with depression: predominantly pain, fatigue and sleep disorders (see online supplements 3, 4). Most participants with depression and comorbid pain suffered from either persistent headaches or moderate to extreme muscular–skeletal pain that predated the onset of depression and compromised their mobility, to the extent that four men had considered suicide and one man had attempted suicide. Almost half of those in pain experienced sleep disturbances or an overwhelming loss of energy to the point where much of their time was spent in bed, withdrawing from social and day-to-day activities (see online supplement 3). There are times when things like headaches and neck aches prevent sleep...I sort of drift 48 hours without sleeping...I have in the past been, if you like, down for a prolonged period of time...just sleep and sleep and sleep and sleep and wake up and do something for half an hour and then go back to sleep again. I can just about function with pain killers...The only time I did try to top myself that led to even more depression because I couldn't even do that right! I’d taken a boat load of the diazepam I was on, to try and calm me down. I'd sort of stock piled some of that…washed it all down with Glenfiddich, and instead of, you know, just shuffling off quietly, all I did was end up waking up feeling absolutely dreadful in a puddle of my own vomit, and it was one of those things where, you know, it took me weeks afterwards, thinking well, I can't even kill myself properly. (p25,M,coun)

With regards to contextual factors, for the majority of the pain group, the pain they experienced had compromised their ability to work. Very few had social support, and for some, their being at home meant that they were the family member available to take on a caring role for a relative, which incurred further stress, ill health and isolation (see online supplement 5). Because I was off and not working I was able to have the time to look after my elderly mother and aunt who were both in their 80 s. So I was their carer for 4 years and unfortunately I lost both of them and my father 4 years ago, within 6 months of each other...My IBS is certainly related to depression yeah...When I was looking after the old dears, as I call them, I was offered an operation twice and I turned it down because I didn't want to be, you know, incapacitated and not able to look after them. Once they passed on, I was then able to address my own health problems. (p26,M,coun)

In summary, for the participants with depression and comorbid pain, the symptoms experienced impacted on the most basic level of physiological needs, and reduced their ability to engage in social activity, while the contextual factors compromised their security through reduced income. Together these factors suggest that this group of people have few internal and external resources remaining to effectively manage their depression.

Of the participants who were pain free at baseline, several people complained of tension headaches or gastrointestinal symptoms they experienced at times of heightened stress and anxiety. Several others identified distinct patterns of disordered sleep: either difficulty in settling to sleep or a pattern of early wakening. Similar to the pain group, a few tended to withdraw at times when they felt particularly low in mood. I get a lot of stomach problems actually when I feel depressed...And of course, really tired as well—very, very tired when I'm feeling down…Sometimes I find it really hard to cope with people. I can possibly be a bit grumpy sometimes, or really quiet. Because I can't really face talking to anybody on certain days...I just can't bear it. (p57,F,uc)

Regarding contextual factors, the majority in the no-pain comparator group were in full or part-time employment or were relatively affluent retired professional people. For many, their experience of depression concerned feelings of low self-esteem brought about by high expectations of themselves within their working life, or hectic social schedules. Others experienced low self-esteem and threats to their security from bullying at work or as a victim from domestic violence. We're also dance teachers, which is supposed to be a hobby but has somehow involved taking over our lives...we're teaching three nights a week, so it's a bit of a commitment for a hobby...Because when we started teaching last May time...that did give me more of an impetus to actually make the effort, because once you've got teaching you've got to go, because you're going to let people down. And I'm always glad that I do. If I'm having low days now, I'm always glad that I've been, because I'm concentrating on stuff that's completely outside of me or completely outside of my normal life...One of the things that's come through is that I hate letting people down. I'm very hard on myself. (p45,F,coun) I tend to keep my things bottled up...And it really gets me down. My work suffers. My home life suffers. And everything suffers if I'm really bogged down with something…following a particular incident, or a series of incidents...I chose to or had to be the brunt for a lot of the aggression and violent behaviour that this man displayed at the time. So if you like, there was a particular traumatic...there was a starting point for it. (p38,M,coun)

In general, the no-pain comparator group experienced fewer demands physiologically. Most had their basic security and social needs met; this group had larger reserves of internal and external resources available to them to cope with their depression.

Processes of change reported by those receiving acupuncture: positive and negative experiences

The processes of change identified within the data formed three stages: primarily, developing a therapeutic relationship; second, the individual diagnosis and treatment of symptoms; and finally, engendering changes in health behaviours. Within the pain group and the no-pain comparator group, the positive experiences tended to facilitate the process of change at each stage, while negative experiences contributed to the barriers to change. Most participants welcomed the opportunity to try something different for their depression. The acupuncturists’ understanding of their symptoms and explanations of how acupuncture might help their particular problems initiated the development of a therapeutic relationship. In contrast, two people described their acupuncturist as brisk, efficient and professional, yet lacking in bedside manner. She was very positive about things...I think you have more of an intimate relationship with the person doing that rather than just a person in an office somewhere. You're physically involved. (p11,M,acu) They could do with a course in empathy. (p22,F,acu)

Within the second stage of treatment, for most participants, the therapeutic relationship was further fostered through the acupuncturist listening to the participants’ concerns, and treating the symptoms of depression depending on what was diagnosed to be of most important to the participant at that point. Within the pain group, several people experienced relief from musculoskeletal pain which tended to last for a few hours or days after the session and improvement commonly built up over several sessions. Several also reported feeling deeply relaxed during the sessions and an uplifting sense of well-being afterwards. I thought it was quite a strange sort of feeling, but I sort of felt better quite quickly. And then I went to the second and the third, it was…it completely lifted my mood and it made me feel more motivated…It was almost as if a weight had been lifted off my head and all of a sudden I felt like some energy had come back. (p3,M,acu)

With regards to negative experiences, one woman reported extreme tiredness after the acupuncture session, a problem that was addressed by the acupuncturist by adjusting treatment during the next session, and one man with extreme back pain attributed needling pain to his damaged nerves from a previous injury. Both of these participants concluded that the treatment went well; however, they also reported, It was not for me. (p4,M, acu; p7,F,acu) she’d actually hit at the root for a problem that I have with my pain, because I think at one time she put a needle in me and I kicked her. Without wanting to I involuntarily kicked her. And she'd obviously hit upon-- I think there was one time when I kicked out and more than a few occasions where she'd twitched a nerve that obviously. (p4,M,acu)

In contrast, within the no-pain group two participants who were worried about the potential pain of needling prior to starting the treatment later attributed the needling sensations to the healing process. Three men thought they would have been equally relaxed if they had just rested or gone for a massage, and two other participants found the sessions too time consuming. A little bit sceptical as to whether the treatments (acupuncture) work anyway. So it was for me like, if I go and get a sport massage, it was like the equivalent of that... (p13,M,acu)

Factors that influenced long-term change reported by those receiving acupuncture

As treatment progressed, many participants reported that their acupuncturist began guiding them to make changes to their lifestyle in order to engender beneficial long-term outcomes. For most people with pain, fear of pain and potential injury posed a barrier to engaging in physical activity. The majority of the pain group reported being encouraged to take up gentle exercise for their overall health and they also distracted themselves during periods of low mood. The things, they seem so small, but they are important. Things like, getting out and going for a walk and getting some fresh air. And just opening your eyes in the mornings and trying to cope with life. (p7,F,acu) He started about exercise, you know, how that can make you feel more up… (p8,F, acu) I read a lot and try to keep my mind off it. Really. (p9,F,acu)

One man developed his own technique based on how he felt during the acupuncture to help him manage low moods, while another relied on monthly acupuncture treatments alone to stay well; another considered further treatments but found the cost prohibitive. I sort of developed this technique and I don't know, it was like…The way I was feeling during the acupuncture...I sort of clung on to this feeling that, or this technique of gaining that feeling, so I remember on a couple of occasions where I was out and about walking, and thinking about things that would normally would start leading me to start feeling a bit down, but it was like I'd been given this tool in my head and I just sort of—it just sort of went onto auto-pilot. It was like pulling those feelings away and just sort of throwing them away...Well, it lasted for a while but it started subsiding. (p1,M,acu) I go for acupuncture now once a month and I find that any more than a month and I can feel myself sort of slipping and feeling really, you know, starting to get worse again. And then I go and I feel much, much better… (p3,M,acu)

The advice given to the no-pain comparator group was qualitatively different. Acupuncturists advised on dietary change, the reduction of caffeine and alcohol, and relaxation, which varied with the presenting symptoms and by gender. Those participants with the least rapport also tended to be those who were less willing to make behavioural changes. She also helped with giving me other things that I can do. Suggesting different foods for me to eat to make me feel more energetic...I was cold all the time and that made me feel more lethargic as well, because all I wanted to do was stay in and go to bed and stay warm. So she was suggesting that I literally ate warmer foods, and she gave me a list of sort of Chinese medicine sort of foods that they had. (p20,F,acu)

In general, the process of change evolved in three stages. The therapeutic relationship and active engagement in recovery acted as mediators of the outcome throughout each stage of the process. In the short term, acupuncture often relieved physiological symptoms of depression and of comorbid pain. Longer-term improvement in depression was developed through the participants’ active engagement in health promoting behaviours, supported by a positive therapeutic relationship. Several participants with comorbid pain had less physical ability to engage in lifestyle changes and tended to be the passive recipients of care. These participants often had fewer external resources in the form of finance and social contact to manage their depression and comorbid symptoms in the longer term. Additional quotes are presented in online supplement 6.

Processes of change reported by those receiving counselling: positive and negative experiences

Based on their previous experiences of counselling the majority of participants spoke of their low expectations of counselling. However, when engaged with the counselling process within the trial, most reported being relieved to have someone to talk to in confidence. For the pain and the no-pain groups, the process of change followed a common pathway: beginning with the participants’ disclosure of personal information and being listened to. I found that process to be very valuable…I found X was very much listening and empathising, but maybe offered interpretation a bit more than the National Health person. (p37,M,coun)

For most participants this two-way active engagement appeared to nurture a therapeutic relationship between the participant and counsellor. Four male participants welcomed the opportunity to speak to a male counsellor, a choice which put them at their ease, and facilitated the process. Three others found difficulty engaging with their counsellor and attributed this problem to a personality clash. This presented an early barrier to the process of change. A lot of it does depend on who the counsellor is…I'm saying probably same sex works better. They probably have a clearer understanding of the male mind...I found him particularly sympathetic and, you know, very constructive. I think that was...I was very pleased with the way it went... (p40,M,coun) Every single counselling cliché that you have about, oh it's parenting issues—she kind of wheeled them all out one after the other and they were already things that I'd thought about, considered and looked at and examined to the nth degree and then thought, no that's not the problem...It felt like she was reading a script almost—like a guidebook to deal with this kind of disorder...it was almost the complete opposite of what I felt like I needed. (p28,M,coun)

A second stage of the process of change was often identified as occurring around midway within the course of treatment. The iterative process of participants’ disclosure continued, with deeper exploration of their past, which helped to clarify the participants’ understanding of themselves and their situation. At the end of it, it actually for me opened up a can of worms really, and I think it did me more harm than good. A lot of my problems, especially with low self-esteem, come from the way I was brought up by my parents and my father especially. And its stuff that I'd never addressed and it brought it all out, actually. And I actually felt worse at the end of it...I don't feel so bad about it now, because I recognise why I am like I am and some of the problems I have, where they come from...Although I say they'd opened up a can of worms, and brought some upsetting experiences back...I think it was good to do that. Because those sort of things had been bottled up for many, many years...it's actually made me address them. (p26,M,coun) It made me realize that I just held everything in. From being a little girl, everything that had ever bothered me it was never talked about. You know, I'm quite lucky that I've never had any real abuse or anything like that. It's just that I've got memories of being a child and things were said and it hurt. And I just locked it away. And I did that for years. (p41,F,coun)

Several participants realised what factors triggered and perpetuated negative thoughts, some of which were unfounded. For one man with chronic pain, this meant going through a grieving process for the loss of his former way of life before setting in place new ways of thinking and coping. You know, I think that was the big thing that I got from it, you know—that I could see myself more positively after having the time with him. And understand that some of the negative thoughts that were coming to my mind were not reality, if you like. To let them sail past and focus on the good things that I've done in the past. (p38,M,coun) Everything that defined what I was has now gone. And it took an awful lot of grief, if you like, to come round to the fact that it was worth trying again. (p25,M,coun)

The use of metaphors was particularly useful for de-cluttering unnecessary thoughts about their past, regaining perspective, setting their problems into context and focusing on what was important. the discussions were much more free than I'd kind of anticipated they might have been, was using metaphors and analogies and stuff like that, to be able to describe things and move through things. And the pictures were just coming to me in my head, like. I had one which was sort of like a circuit board and it felt like some of the wires were not quite wired up properly and they weren't working and stuff like that. And I can kind of track the metaphors throughout the whole process and it feels like it was much more of a—like it all opened up. (p38,M,coun)

Factors that influenced long-term change reported by those receiving counselling

The final stage in the process of change was directed towards enabling the participants to maintain progress independently. Gender differences became apparent in the coping strategies adopted; the majority of women took up health and well-being strategies. Compared with the women in the pain group, the women in the no-pain comparator group were able to use a wider range of resources to cope with, and engage in social activities more easily. One woman recalls being given cognitive behavioural homework to overcome a particular anxiety. She gave me sort of little exercises. I found it very difficult to walk down to a friend of mine. She lives in quite a built up area...People were sitting out in their gardens and I found it very intimidating. I didn't like it. I’d become really sweaty, short of breath walking down through her estate to go and see hear...basically she just taught me to get a grip on myself really, by pointing out, you know, that everything was going to be all right...short sharp steps really. And that I'd got the coping mechanisms and I could do it. (p32,F,coun)

Many male participants appear to have continued to practise the cognitive strategies learned within the earlier sessions, and applied them to their life outside the sessions. However, male participants with depression and comorbid pain found greater difficulty sustaining these strategies and returned to their general practitioner for further help.

In summary, the majority of participants had had previous experience of counselling; however, their initial low expectations of success receded as the course of treatment progressed. A few counsellors practiced a more directive intervention than humanistic counselling, according to the need of the participant. The process of change comprised three stages, each mediated by the quality of the relationship and the participant's active engagement. Additional quotes are presented in online supplement 7.

Processes of change reported by those receiving usual care

Participants in all three arms received usual care throughout the trial. The process of change within usual care was less evident. Differences in the appraisal of general practitioner care were apparent: three older participants with depression and comorbid pain who were allocated to usual care alone reported a lack of understanding and continuity of general practitioner and they felt abandoned without hope. One 89-year-old woman reported: I would never go to a doctor again. I am, because I suffer a lot of pain that I needn't have done if he'd been different…if he'd have listened to me instead of just pooh-poohing it off and saying, oh no, it's not that. If he'd have really listened to what I was saying, he could have done more for me...he's ignored what I've told him. Well, in fact he's very often just ignored it all together. Pretended I hadn't said it...You see, at my age you can't really change doctors. There's not many doctors want to take somebody on that's 90 years old, do they? When I'm having a really bad day...you know, and I feel I can't turn even to the doctors, you know, then yeah, I do get depressed. (p51,F,uc)

In contrast, the majority of participants who were pain free pointed to a relationship based on trust as being a component of their steady improvement over time. For most people, a regular monthly 10 min consultation was helpful and constructive. A few felt that their general practitioner had made additional time for them when they were most in need. He sees me every month. I have monthly meetings with him just to have a general chat about how things are... I get on fine with him. As I say, I can talk about just about anything with him, so I suppose in a way, he's sort of, if anything he's been maybe a counsellor for me, because, you know, I can sit and talk to him about stuff... (p58,M,uc)

All participants at some time had been prescribed antidepressant medication. The majority of participants on long-term antidepressant medication raised concerns about the side effects; participants in the pain group were particularly concerned about the potential effects of mixing medication for their other medical problems with their antidepressants. A few acknowledged that they needed antidepressants to maintain long-term stability. Staying on medication, it has transformed my life and made everybody else's life around me better as well. And I wish I'd have done it sooner...It must be four or five years now and yes, it's been life transforming...When I started on my medication and I could realize the difference—the two people I was, almost. (p7,F,acu)

In addition to medication, during the period of the trial general practitioners referred participants to a range of secondary services: two young women received three sessions with a mental health link worker, an intervention which had enabled them to regain control of their lives; three others had been advised to try online cognitive behavioural therapy which two found to be easily accessible and effective; one man at risk of suicide was referred for urgent psychiatric help. I was referred rapidly to A&E and was assessed by X the psychiatrist. And I was put on to intensive home treatment. Which was invaluable. As a condition of not being sectioned... (p59,M,uc)

Referrals for younger patients had been beneficial although the waiting times were long and not always found to be acceptable, leaving most patients without adequate support in a time of crisis, and without sufficient money to pay for private care. I go to the doctors and I have to wait a matter of I don't know how many months before I can get, you know, onto the counselling and you know, it's just like the moment's gone, sort of thing...Unfortunately that can cost a lot of money—I'm on benefit. I can't afford it...I don't hold out much hope. (p50,F,uc)

Factors that influenced long-term change reported by those receiving usual care: positive and negative experiences

For those who received help via a referral, the advice followed a familiar pattern: to engage in lifestyle changes, to add structure to the daily routine, and to use distraction to reduce the focus on the symptoms and negative feelings. However, without support the stoicism of ‘forcing myself’ was a prominent default strategy among most usual care participants. I force myself to do things and then I generally feel better (p57,F,uc) It's forcing myself. Well, it's a survival strategy... (p59,M,uc)

Overall, the continuity of always seeing the same general practitioner was reported to be important and beneficial. By contrast, some older participants with depression and comorbid pain remained caught in a seemingly hopeless cycle of seeking diagnosis and treatment for a physical complaint and without resources to seek private healthcare services. Most patients who received acupuncture or counselling were also happy with the attention from their general practitioner, but had welcomed the additional treatment provided within the trial as an adjunct to their usual care. Online supplement 8 presents a number of representative quotes.