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Depression

Public Health Priority of the21st Century

Hans-Ulrich Wittchen

Institute of Clinical Psychology and PsychotherapyCenter of Clinical Epidemiology and Longitudinal Studies

(CELOS)Technische Universitt Dresden.

Lecture 10/12/2009: Prevention of Depression and Suicide - Making it happen (Budapest)

25% of the EU population has been suffering or will sufferfrom depression at some point in life!

In any given year, 9%* of the EU population suffers fromdepressive disorders

This corresponds to 20 8 million women and men suffering

Depression a frequent and serious illness

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1,9

6,46,8

5,8 6,15,4

2,3

13,5

10,5

13,412,5 12,4

0

5

10

15

20

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Depression is treatable!

Effective drug and psychological treatments exist (e.g. cognitive-behavioralpsychotherapy, interpersonal psychotherapy, various types of drug treatments)

Effective secondary preventive interventions exist (e.g relapse prevention)

Effective preventive methods for complications exist (e.g. suicide prevention) If applied (accessible, early enough, comprehensive, adequately) these methods

should result in a lower prevalence (reduction of length and number of episodes)

Wittchen & Hoyer 2008

Ultimate goal of prevention is lowering the incidence (=prevent new cases)

Equally effective primary preventive measures are still lacking Yet a wide range of highly promising approaches are available

More research on causal mechanisms and targets needed (public health perspective)

Depression is treatable - but is it preventable?

The societal burden of depression has onlyrecently been fully appreciated

Years Lived with Disability (YLD) and Disability Adjusted Life Years (DALY) aretwo time-related metric indicators to quantify the burden of diseases allowing fordirect comparisons between diseases

In the 90ies, the Global Burden of Disease experts estimated that:

disorders of the brainaccount for

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These past burden of disease estimations (1990 data)were problematic, and do not adequately reflect the

situation in the EU!

Disease burdenDepression (1990)

Years lived withdisability (1990)

Massive direct and indirect burden of depression:

Individual (e.g. high distress, disrupts social roles, work productivity, sickness days,disability, premature mortality)

Family (e.g. high emotional distress, economic consequences, malignant effects ondependent family members

Society (direct and indirect health and social costs)

I. The future has arrived - depression burden in EU ranks already No 1

The burden of depression in the EU has already becomethe most challenging public health burden: Reasons?

disability

due to any

somatic

disorder

53%

disability due

to disorders

of the brain

44%

1. Improved data on disability burden, revealingthat disorders of the brain account for about40% of the total burden

15

Proportion (%)

depression

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1

0

27,6

16,8

24,7

29,9

23,1

5,4

2,20

34,2

30,9

60,1

63

34,5

10,1

3,5

0

10

20

30

40

50

60

70

0-4 5-14 15-29 30-44 45-59 50-69 70-79 80+

Males

Females

II. The burden is not equally distributed

Among all Disorder of the brain depression is responsible forthe largest disability burden - particularly for females!

Proportion (%)of all neuropsychiatric DALYS

Age groups

Wittchen et al, in press; European Health Report 2005

Estimates after age 65* remaincontradictory and problematic!

High disability burden even inearly years

Women carry by far the greatestdepression burden

For women in the reproductiveyears, depression accounts for17-19% of all causes DALYs!

All brain disorders: 386.176 billion Health care costs: 135.446

Direct non-medical 72.201 Indirect costs: 178.529

Mental disorders 294.719(w.o depression: 176.053)

Health care costs: 110.061Direct non-medical 51.673Indirect costs: 132 985

Mental disorders

Depression accounts for almost 1/3 of all direct andindirect costs of disorders of the brain

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1

7

8

32

2

3

11

12

8

17

0 10 20 30 40 50

premature death

early retirement

sick leave (absenteeism)

other direct costs

informal care

social services

outpatient care

medication

hospitalization

Distribution of depression cost is characterized byhigh indirect costs

Direct costs in EuroHealth care costs: 42.000- outpatient care 22.000

- hospitalisation 10.000- drug cost 9.000

Resource items depression

Proportion (%) of total costs

Indirect costs in EuroIndirect costs: 74.389

Relatively low direct costsVersus

High indirect costs

Jacobi & Wittchen 2007

The largest economic burdenassociated with depression is

carried by the employers and thesocial health system

Depression Diabetes CVD

Distribution of depression cost is markedly different from othertreatable diseases: A comparison with two other common

somatic illnesses

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Depression is already now Europe`s most costly anddebilitating illness (9.2% of all DALYs)

Why has the burden of depression persisted or evenincreased?

5,2

7,8

9,29,8

0

5

10

15

1990 2000 2005 2030

Individuals do not seek treatment! Prevention and Early intervention is not provided or effective!

Treatment is not effective, too expensive, unavailable or unacceptable!

DALY proportions (%) of all causes

Artefact of methods and statistics Disease is difficult to detect or diagnose

Increasing depression rates? Overwhelmingcauses?

Changes in the constitution of risk groups

Effective treatment and prevention is not orcan not been provided

year

Artefact of methods and statistics

Disease is difficult to detect or diagnose

Increasing depression rates? Epidemic?Overwhelming causes?

Why has the burden of depression persisted or evenincreased?

5,2

7,8

9,29,8

5

10

15 1990 2000

2005 2030

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0

2

4

6

8

10

12

14

16

18

20

0 50

1940

1950

19601970

1980

10 20 30 40

Birth cohort

Age of onset depression

Cum. Incidence %

(Kaplan Maeier)

60

Cross-National Group, JAMA

Mauz & Jacobi 2008

Strong evidence for asubstantial increase indepression risk since the 60iesin industrialized countries.

Strong evidence for increasedrates in the young! Age of onsetshifted forward Earlier andmore frequent!

These effect seem to haveweakened though in the past 15years.

No evidence for epidemicNor overwhelming causes!

Evidence for increasing depression rates in the past?Probably yes but little evidence for continued increases!

3.6

3.2

Risk associationdepression (RR)

Parkinsons Disease 2

Alzheimer dementia 1

Disease 3

Age-related disorders, associated with increased risk for depression

4,4

6,2

6

8

10

RR for Depression

Selected diseases among subjects aged 65+by their depression risk elevation (ref.:

persons w.o. condition)

Effect of comorbidity

Increase due to longer life expectancy? Population 65+ is increasing!

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Increasing proportions of the elderly contribute to increaseddepression rates among the physically ill and neurodegenerativedisorders

Neurodegenerative disease Somatic diseases associated with pain Other disabling comorbid somatic diseases

The situation and trend monitoring in the elderly remainsunderstudied!

Other high risk populations:

Substance abuse population: Little evidence of major effects Economic crises and unemployed populations?

Conflict and disaster populations?

low income groups (the poor)?

Increase due to the size of high riskpopulations?

Despite lower overall estimates of

depression in old age evidence ofincreased rates when other illnesses

are present and when ability tofunction becomes limitedThe Elderly Paradox!

Did we fail to reduce the burden, because treatment fordepression is unavailable, difficult, ineffective and expensive?

Not ( or only partly) true!

Effective first-line treatments are available

Effective treatment delivery is not difficult given appropriatetraining

Cost-effectiveness is robustly established

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Examples for room for improvement

51

94

78

90

51

29

21

0 20 40 60 80 100

Asthma

Diabetes

Heart disease

High bloodpressure

athritis

Depression

Social phobia

Treatment (%) among selected conditions

Ormel et al 2008; WMH-survey EU data

35

48

43

41

29

52

49

0 20 40 60 80 100

USA

Belgium,

France

Germany

Italy

Netherlands

Spain

% of cases with depression in the community

with treatment in the year of onset

1. Increase treatment rates of depression! 2. Initiate treatment sooner!

Wang et al 2007

Action:Ensuring access to adequate treatment!

Screening is not enough!

Rates of adequate

treatment fordepression in the EU:

< 10% of all affected

Depression increases

risk for cardio-vascular disease (Pieper et al 2007)

risk for worse outcomes in heart failure(Blumenthal et al 2009)

risk of premature mortality (DETECT 2008)

Designing and providing early targeted treatment in physically ill

Example: Depression and cardiovascular disease

4

5

Odds ratio

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Targeted interventions for anxiety and depression parents cansubstantially reduce these risks

Focus on gender-specific risk groups - providing early targetedtreatment

Pregnancy, motherhood and the anxiety -depression link

Martini et al 2008

Anxiety (as an early onset primary disorder), depression and

suicidality run in families

Children of mothers and/or fathers with anxiety ordepression are at increased risk for anxiety and depression

Examples for risks for mother and child Pregnancy and perinatal complications Postnatal depression in mothers

Early anxiety and depression onset in children Adverse childhood development and neurocognitive dysfunctions

0,5

Cum

Incidence

no parental anxiety

parental anx & depAnxiety or depression

in parents Abuse/Dep.MajorOR = 2.0 *OR = 2.6 *

Psychopathology inoffspring

You cannot be too careful in choosing your parents!

Children of anxiety and depression parents are at high forprimary anxiety and secondary depression at early ages

Increased risk of child onset byparental disorder

Parental disorders increased therisk many disorders

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Focus on the risk group with the highest burden

Pregnancy, parenthood, childhood and the anxiety -depression link

Martini et al 2008

The familial transmission of anxiety and depression and suicidality can beprevented (prenatal interventions in mothers, parent training, early child interventions)

Reducing the burden of parents pays off for the children as well

Anxiety is the most powerful risk factor for depression

Targeting anxiety and depression is particularly promising

Remember! 64% of all with suicide attempts have also anxiety disorders

The most powerful and effective interventions exist for anxiety

Preventing anxiety prevents depression and reduces morst effectively the overall burden

Awareness/screening campaigns are necessary, but not enough

It is not enough and effective to: offer just one or two encounters and deliver a prescription Leave the job largely on overly busy primary care doctors or rely on self-help structures

Improve treatment adequacy and continuity across the cycle of illness

Conclusionit is already worse than we thought! but we can make a change!

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(it is already worse than we thought!) Depression = public health challenge No 1 Depression treatment and prevention demands qualified personel

Depression is not mereley a psychological problem!

Need for evaluating medical, psychological, and social interventions on all levels

Understanding how they work, when they fail and how to optimize

From general prevention to targeted early interventions

Prioritize measures and programs to reduce the burden

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Depression and suicide

Fact sheet I: Depression in Europe

Every given year, about 9% of population suffers from a depressive disorder (21millions)

About 7% meet criteria for major depression (approx 18 million)

The lifetime risk for depression is considerably higher: Every 4th person in the EU hasor will suffer a depression in the course of their life (24%)

F l h id bl hi h lif i i k d b i hi h

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Fact sheet II: Depression in Europe

Special features and depression subtypes remain understudied:

1/3 take a chronic course (with no full remission)

1/3 a recurrent course (at least 2 episodes, mean 4.8 episodes lifetime)

Among those with single episodes the average duration of a depressive episode is 11.8 weeks

Bipolar depression is estimated with a 12-month prevalence of 1%

Melancholic depression 1.2%, seasonal depression 0.2%

Depression in the community is highly comorbid with all other mental disorders

Comorbid conditions typically affect course and outcome, precding comorbid disorder can bepowerful risk factors (anxiety disorders, substance use disorders)

About 1/3 of all depression cases have or will attempt suicide

Suicide attempt rates are highly elevated among highly comorbid cases

In all countries treatment rates are low! At best about 50% of depression cases

receive any professional attention

Primary care is the most frequent provider (21-43%)

Specialist care varies by country, but rarely exceeds 30%

Treatment typically occurs late in the illnes progression

The burden of depression children of depressed parents

Pregnancy, birth and depression

The depressed child increseaed risk for adverse social and mentaldevleopmental unless treated

Facets of Burden

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depression across the life span

patients needs (age, gender, risk groups)

burden (individual, societal, cost)

Mental health system characteristics (diversity, fragmentation)

Fragmentation of health care (lack of continuity)

Costs and cost benefits

causal prevention and therapy

Identifying the most promising targets

Filling the research gaps

there is no health without mental health!

Conclusion

Depression, number 1 as the most debilitating diseases in the EU

Depression, the most costly of all disorders of the brain in the EU

The high burden is mainly attributable to the indirect costs

Because of low recognition and low treatment rates the directt t t t ti l l

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Depression a frequent and serious illness

Lifetime risk: one out of four person in the community In any given year: 7-8% suffer from depression

Depression may affect the young and the old

Increasing rates particularly among the young

Leading cause of suicide

Major source of premature mortality in physical diseases

Ranks as number 1 among the most disabling diseases Underrecognized and undertreated in helathj care systems

The Situation

Only 50% of all 12-month depression cases receive treatment! Even in themost developed health care system

21,5

18,8

24,6

psychologists

other mental health

primary care

Health care sectorNote!Treatment rates within EU froma low of 24% to a high of 51.6%

Although primary care is in allcountries the most frequentprovider, rates vary from 21%t 43%!

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60.2% of

affectivedisorders

54.3% of anxietydisorders arecomorbid

49.2% ofsomatoform

disorders

41.2% of substancedisorders

OR anxiety withSubstance: 2.6Depression: 6.9

Somatoform: 3.4

OR substance withAnxiety: 2.5Depression: 2.7Somatoform: 1.9

OR depression withAnxiety: 7.0

Substance: 2.7Somatoform: 3.5

OR somatoform withAnxiety: 3.5Substance: 2.1

Depression: 3.5

Bittner et al. 2004. APS

Mental Disorders and Depression Are Frequently Comorbid:12-Month Comorbidities Among Mental Disorders

II. Prevalence and incidence: Special features

Ich brauche die DALY und oder YLD

getrennt nach Altersgruppe und Geschlecht Bitte machen

Treatment of mood disorders (12-month) in the EU(Wittchen & Jacobi, 2005; adapted from ESEMeD/ MHEDEA 2000 Investigators, 2004)

6%

12%

5%

no consultation

only drug treatment

only psychological

1

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Epidemiological approaches

Unselected sample of thegeneral population (or

fractions thereof)

Sample of persons at risk (i.e. with anxiety, after stressful events)

Persons in primary care

Persons in treatment settings

Treated patients

(adaequate/inadaequate)

Clinicalresearch

Epidemiological methods allow a representative

description of patterns of morbidity and supplementand complement clinical research findings

I. Methods

Life expectancy continues to grow! 3-4 years per decade in the EU!Proportion of population aged 65+ is increasing!

Japan

Sweden

Israel

Italy

Spain

Netherlands

UK

France

EU-15 average

Austria

Japan

Spain

France

Italy

Sweden

Finland

Austria

EU-15 average

Germany

Israel

1

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1,1 Mio (0,9 - 1,7)

2,0 Mio (1,4 - 2,1)

2,6 Mio (2,4 - 3,0)

3,6 Mio (2,8 - 5,3

2,4 Mio (1,7 - 2,4)

3,9 Mio (3,3 - 4,7)

5,8 Mio (5,2 - 6,1)

5,2 Mio (4,3 - 5,3)

6,6 Mio (5,4 - 9,2)

7,1 Mio (5,8 - 8,6)

0 1 2 3 4 5 6 7 8 9

major depression

specific phobias

somatof. disorders

alcohol dependence

social phobia

panic disorder

GAD

agoraphobia

bipolar disorder

psychotic disorders

OCD

ill. subst. dep.

eating disorders

18.9 Mio. (12.6-21.1)

18.5 Mio. (14.3-18.6)

18.4 Mio. (17.2-19.0)

12-month prevalence (%, 95% CI) and estimated number of subjects affected inthe EU

1212--month prevalence (%, 95% CI) and estimated number of subjects afmonth prevalence (%, 95% CI) and estimated number of subjects af fected infected in

the EUthe EU

Note:Numbers add up to more than 27% and 82 million subjects because subjects can havemore thanone disorder (comorbidity)

Wittchen & Jacobi (2005), Neuropsychopharmacology

II. Prevalence

The Lifetime risk up to age 60 is even higher!

Alcohol dependence

Drug dependence

Nicotine dependence

Any mental disorder

12-month

lifetime risk

DSM-IV mental disorders

Because only full threshold depressivedisorders are assessed in the 12-month prevalence (blue), parally

remitted, prodromal, and lifetime

cases add to the overall lifetime

II. Prevalence

1

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The lifetime risk of depressive disorders of males and females in thecommunity up to age 65

Cumulativehazardrate (%)

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30 35 40 45 50 55 60

depression - total

depression females

depression males

Age of onset (years)

Incidence Major depression andDystymia

NGS: Wittchen et al (1999),

Lifetime riskestimate

Females: 35%

Total: 24%

Males 21%

Wittchen & Jacobi 2005

Prevalence estimates of depression in community studies

Point prevalence3

mean: 3.4% (range: 1.2-6.5)

12-month prevalence2,3

mean: 6.9% (IQR: 4.8-8.0)

Lifetime prevalence1

Age of subject when examined, eg 45

Point prevalence

12-Months prevalence

1

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0.0

0

0.0

5

0.1

0

0.1

5

0.2

0

0.2

5

0.3

0

Proportion

10 20 30 40 50 60 65

Age1974-1981 1965-1974

1955-1964 1945-1954

1935-1944

Cumulative lifetime incidence of Major Depression

Is this trend continuing? Most current German examination in birth cohorts

Shifting forward of age of onset

Birth cohorts

IV. Is depression increasing?

Evidence for Increasing Rates of depression in succeivly youngerbirth cohorts

20umulative li etime pro a ility in

Bi th h t

0,090cumulative lifetime probability

Pure and primary MDComorbid secondarydepression

1

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Rates of abuse or dependence; ** Epidemiologic Catchment Area study; National Comorbidity Study, ages 18-64 years

Suicide attempts in cross national study standardised bypsychological disorder

Suicide attempt Rate/100 (SE) among

Major depression Any anxiety Alcohol/drug*

US

ECA (1980s)**

3.13 (0.19) 3.13 (0.19) 3.13 (0.19)NCS (1990s), - - -Edmonton, Canada 3.12 (0.36) 4.33 (0.42) 3.76 (0.39)Puerto Rico 6.08 (0.69) 6.38 (0.71) 7.05 (0.82)Savigny, France 3.27 (0.59) 4.23 (0.65)West Germany 3.08 (0.91) 3.39 (0.95) 3.50 (0.97)Taiwan 1.32 (0.12) 1.22 (0.12) 1.92 (0.19)Korea 3.81 (0.28) 3.80 (0.29) 3.69 (0.30)New Zealand 3.56 (0.57) 4.75 (0.65) 4.35 (0.62)

Weissman et al (1999)

II. Prevalence and incidence: Special features

Across studies 1/3 of all cases of major depression attempt suicideHowever due to comorbidity rates are also high in anxiety and addictive disordersComorbidity increases the risk of suicide attempts and suicide two- to threefold

15%

Conclusion: Estimates for depression are considerably differentdepending on what we are interested in

Lifetime riskestimate

Total: 24%

Lifetimeprevalence

Total: 15%

24%

Note! 6 9%

1

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In Western countries depressive disordersin the community are increasing

Consistent evidence for successively higher incidence in young cohorts; age ofonset for fisrt episode of depression is decreasing

Subjects born after 1934 have twice the risk, those born after 1964 almostthree times the risk for MDE

There is little evidence that these effects are artefactual (different methods,willingnes to speak about symptoms etc)

Increases are due to higher incidences of comorbid secondary depressions

Projecting to beyond the year 2000

if increases continue, the prevalence of depression will double

.. making major depression the second most costly and disabling(DALY) single disease worldwide

ICPE, SHO, World Bank, HMS: The Global Burden of Disease

IV. Is depression increasing?

Depression may occur at any point in life in females twice asoften as in males

13,5 13,4

12,5 12,4

15

20males

females

cumulative incidence (%)of MDE (Kaplan-Meier) 12-months prevalence of MDE

Fewdata

childhood

0,25

0,30

0,35

Males

Females

1

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Depression 2000

Point prevalence of depression in primary care by age group

9,4

11,9

10,9

0

2

4

6

8

10

12

14

16

16-19 20-29 30-39 40-49 50-59 60-69 >70 Total

Males Females Total

Point-Prevalence in %

Age groups

N=20.304 primary

care patients

Year 2001

Point prevalenceICD-10 depressionaccording to DSQ

As compared to thecommunity (4%)2-3 times higher

rates!

Wittchen et al JCP 2004

III. Prevalence in primary care

In in the EU fairly convergent estimates of number of persons affected

Evey year 7-8% (males females?)

Little evidence for cultural and regional effects

Fact sheets

1

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The burden of depression as a proportion of all causesand neuropsychiatric conditions by age

(GBD 2004: Projected DALYs by cause for the year 2008, optimistic scenario Europe)

More recent and more sophisticated global burden of diseasefindings supported this projection

1

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8,9

11,9

10,4

5,5

36,3

15,3

0 10 20 30 40 50

Inpatient

outpatient

medication

suicide relatedcosts

absenteeism

reducedproductivity

The largest economic burden associated with depressionis carried by the employers and the social health system

proportion (%) of depression costs

Kessler & Wittchen 2007

Work place

costs:51,5%

Direct treatmentcosts:

31%

Evidence for an epidemic?

Increases are relatively small not due to larger proportions of the elderly

Increase in depression rates has slowed down over the past 15 years

Definitely not!

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This paper was produced for a meeting organized by Health & ConsumersDG and represents the views of its author on the

subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of

the Commission's or Health & ConsumersDG's views. The European Commission does not guarantee the accuracy of the data

included in this paper, nor does it accept responsibility for any use made thereof.