Can we prevent depression? The story so far from 30 years of research - PowerPoint Presentation

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Can we prevent depression? The story so far from 30 years of research

Global Consortium for Depression Prevention

York, 10

th

December 2019

Prof. Pim

Cuijpers

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Overview

Why is prevention important?Is prevention effective?How to increase the impact of prevention on incident cases?The WMH-ICS initiativeConclusions

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Why is prevention important?

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Why is prevention important?

High prevalence (30.3 million Europeans), 322 million worldwideHigh incidence (almost 50% of prevalence)Huge burden of diseaseHighest burden of disease in 2030 in developed countriesIncrease with 18% between 2005 and 2015 (because of population growth)54 million YLD lost, 80% in LAMI countries

$2.5 – 8.5 trillion in lost output ($2.500.000.000)Treatments can reduce burden of disease with not more than 35% (currently 15%)

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Illnesses with highest disease burden

Illness

% dis. burden

Coronary heart disease

7.6

Anxiety disorders

5.1

Stroke

4.9

Depression / dysthymia

3.9

COPD

3.2

Diabetes mellitus

3.2

Lung cancer3Alcohol dependence2.5Artrosis2.5Dementia2.3

Source: RIVM, 2006

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Top 5 of diseases in The Netherlands

0-14

15-24

25-44

45-64

65-74

75+

1

Innate anomalies

Alcohol

Anxiety

Coron. Heart dis

Coron. Heart dis

Coron. Heart dis

2

Mental handicapsAnxietyDepres-sionAnxietyStrokeStroke3Privat accidents.

Depres-sion

Alcohol

Lung cancerCOPDDementia4Bronchial infections Traffic accidentsSuicideDepres-sionLung cancerCOPD5AsthmaMental handicapsTraffic accidentsDiabetes Diabe-tes Diabetes

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The problem with treatments of depression

Treatments are effective, but effects are limitedOn the one hand: high rates of spontaneous recovery, placebo response

38% reponse in placebo (54% in ADM; Levkovitz et al., 2011)41% in control conditions (54% in psychotherapies; Cuijpers et al., 2014)

Non-treated patients: 23% in 3 months, 53% in 12 months (Whiteford et al., 2012)

The majority of patients would get better anywayOn the other hand: A large group of patients who do not respond to any treatment (~30%)

Cuijpers, Journal of the American Medical Association 2018

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Currently averted YLD

Disorder Current Any mood disorder 15% Major depression 16% Any anxiety disorder 13% Any alcohol rel. dis. 2% Schizophrenia 13% Any disorder 13%Andrews et al., Br J Psychiatry 2004

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Averted YLD (current and with EBMH)

Disorder Current with EBMH Any mood disorder 15% 23% Major depression 16% 23% Any anxiety disorder 13% 20% Any alcohol rel. dis. 2% 5% Schizophrenia 13% 22% Any disorder 13% 20%

Andrews et al., Br J Psychiatry 2004

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Averted YLD (maximum)

Disorder Current EBMH Max Any mood disorder 15% 23% 35% Major depression 16% 23% 34% Any anxiety disorder 13% 20% 49% Any alcohol rel. dis. 2% 5% 34% Schizophrenia 13% 22% 22% Any disorder 13% 20% 40%

Andrews et al., Br J Psychiatry 2004

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ConsequencesCurrently avoided in MDD: 16%, maximum 34%

Currently avoided in anxiety disorders: 13%, maximum 49%Consequences:Better treatmentsDissemination (low/middle-income countries!)Prevention!

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Costs of depression

€132 million per milion adults for MDDOf which 47% is related to the incidenceAbout the same costs in minor depressionAbout twice as much in dysthymiaTotal costs about € 600 million, per million adultsSmit et al. Journal of Mental Health Policy and Economics, 2006

Cuijpers et al. Acta Psychiatrica Scandinavica, 2007

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Costs of depression

2.2% - 4.4% of Gross Domestic Product (GDP) in OECD Member States€610 billion per year across 27 EU Member StatesAbsenteism/presenteism: €270 billionLost output: €240 billionHealth care: €60 billionDisability benefit payments: €40 billion

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Chisholm et al., Lancet Psychiatry 2016

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So why is prevention necessary?

Because of highPrevalenceIncidenceCostsBurden of diseaseLimited possibilities of treatmentBut: Is prevention possible?

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Is prevention effective?

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Overview of the development of the field

During 1970s and 1980s it was considered impossible to prevent mental disordersFirst randomized trial in late 1980s (Ricardo Munoz)More trials started in late 1990sFirst meta-analysis in 2005 (13 trials across all mental disorders; Cuijpers et al., 2005)

Since then: dozens of randomized trials in depression, psychotic disorders, PTSD, eating disordersIn 2014: >30 trials in depression aloneMajor development in 20 years

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Meta-analysis of randomized trials in depression

32 trials (6,214 participants)Universal: 2 studiesSelective: 15 studiesIndicated: 17 studiesDifferent target groupsadolescents/students: 14adults in general: 8pregnant women/young mothes: 9

Other: 1Intervention based onCBT: 15 studiesIPT: 5 studiesPST: 2 studies

Cuijpers et al., Am J Psychiatry 2008; Van Zoonen et al., Int J Epidem 2014

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Type of prevention

Type

N

IRR95% CI

NNTIndicated

17

0.74

0.62~0.89

14

Selective

15

0.81

0.64~1.02

20

Universal

21.010.66~1.53-1000With new improvements (stepped-care; Internet-based) IRR approaches 50%, with NNT=8Growing evidence for cost-effectivenessVan ‘t Veer-Tazelaar et al., Arch Gen Psychiatry 2009; Buntrock et al., JAMA 2016

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Dias et al., JAMA Psychiatry 2019

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Example: Prevention of major depressive disorders through web-based guided self-help

Buntrock et al., Journal of the American Medical Association (JAMA) 2016

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Design and outcomes

406 participants with subthreshold depression (no MDD)Randomized to guided web-based prevention (PST + behavioral activation) or care as usualIncidence of MDD was 27% in the prevention group compared with 41% in the control groupHazard ratio: 0.59 (95% CI: 0.42~0.82) at 12 monthsNNT=6

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Rough example

of how impact of prevention could look like100.000 population5.000 have subthreshold depression

500 10% participate in indicated prevention36 N of cases prevented (

with NNT=14)2000 new cases of MDD

1.7% of new cases are prevented by intervening in 500 people5% if we intervene in 20% and

increase

NNT

to

10 (100 cases)

=> Modest impact

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How to increase the impact of prevention?

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How to increase impact of prevention?

Increase participation among subthresholdIdentify high risk groups

with high incidence ratesFocus

on universal preventionInstitutionalized prevention (Ormel et al., 2019)

Increase effects of interventionsCommunity interventionsGeneral communitiesWorkplace

Schools,

=> Colleges, universities

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World Health Organization World Mental Health International College Student initiative (WMH-ICS)

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International Journal of Methods in Psychiatric Research, 2019

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Three main parts

Epidemiological researchDevelopment and testing of interventions for students (and hopefully including personalizing interventions)Dissemination of interventions at participating universities=> Full community

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25,543 students in 29

universities in

11 countries

Wmh-ICS

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Survey

30

Digital informed consent

Socio-demographic, e.g., age, gender, faculty, etc.

Overall Physical health

Attention and concentration

Emotional problems: depression, GAD, PD, Bipolar disorder, other (e.g., anger)

Alcohol and drug use

Self-harm behaviors

Seeking treatment attitudes

Sexuality

Sleeping patterns

Personality traits

Family

Educational performance

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Journal of Abnormal Psychology, 2018

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rEsults

Surveys started in 2012Started by Prof. Ronny Bruffaerts (Leuven), Ron Kessler (Harvard)Strong increase in number of participating countries and total number of studentsDifferences between countries

>30 papers on many aspects of mental health of college students (suicide, depression, anxiety, help-seeking, treatment rates, role impairment, prevalence/incidence, etc)Second and third part of WMH-ICS not yet well-developedFirst projects have started in Holland, Germany, US

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The dutch ‘branch” of WMH-ICS

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Four universities:

Vrije Universiteit Amsterdam,

Leiden,

Utrecht

Maastricht

~100,000 university students (1/3 of all Dutch university students)

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Students with psychosocial problems (N=605)

 

% saying “All the time”% PHQ9 >

5Learn to cope?

Learn to cope (PHQ>5)Procrastination0.23

0.78

0.44

0.50

Self-criticism

0.19

0.88

0.32

0.40

Worrying

0.16

0.930.340.43Perfectionism0.150.720.160.20Low self-esteem0.150.950.330.42

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Development of e-health tools

Any subject that students bring forward (co-creation):DepressionStressProcrastinationSleep

Self-esteemDelivered by trained clinical psychology studentsIn three phases

Development and pilot testing in open study Randomized trial

Dissemination through survey and other channels, across the world

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Two scenarios

Scenario 1

Scenario 2

100,000Population

100,000Population5,000subthresh depr5,000subthresh

depr

500

10%

indicated

prevention

2,500

50%

psychosocial

problems36 Cases prevented250Cases prevented2,000New MDD cases2,000New MDD cases1.7%Prop. prevented12.5%Prop. Prevented0.5 fte750 hours of coach (1.5 hours per case)2.5 fte3750 hours of coach(1.5 hours per case)

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Conclusions

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Conclusions

Public health challenge of depression: high prevalence, disease burden, economic costs, limited effects of treatmentsPrevention can reduce incidence with ~22%, and possibly up to 50%, but impact is smallDevelopment of community interventions may be one method to increase impact

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Thank you for your attention!

Contact: p.cuijpers@vu.nl

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