Preventing the onset of depressive disorders
Transcript of Preventing the onset of depressive disorders
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Preventing the onset of depressive disorders
Pim Cuijpers
30 November 2009Canberra
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Overview
• What is prevention?• Why is prevention important?• Is it possible to prevent new incident
cases?• How can depression be prevented?• Conclusions
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What is prevention?
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Intervention spectrum for mental disordersPr
even
tion
Treatment
Maintenance
Universal
Selective
Indicated
Case identification Stan
dard
trea
tmen
tLon
g term
treatm
ent
After-care
(Mrazek & Haggerty, 1994)
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Why is prevention of depression important?
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Why is prevention of depression important?
• Huge burden of disease (fourth)• Highest burden of disease in 2030 in
developed countries• High prevalence• High incidence (almost 50% of
prevalence)• Huge economic costs• Treatments can reduce burden of disease
with not more than 35% (currently 15%)
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Illnesses with highest disease burden (Netherlands)
Illness % of disease burdenCoronary heart disease 7.6Anxiety disorders 5.1Stroke 4.9Depression / dysthymia 3.9COPD 3.2Diabetes mellitus 3.2Lung cancer 3Alcohol dependence 2.5Artrosis 2.5Dementia 2.3
Source: RIVM, 2006
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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 handicaps
Anxiety Depres- sion
Anxiety Stroke Stroke
3 Privat accidents.
Depres- sion
Alcohol Lung cancer
COPD Dementia
4 Bronchial infections
Traffic accidents
Suicide Depres- sion
Lung cancer
COPD
5 Asthma Mental handicaps
Traffic accidents
Diabetes Diabe- tes
Diabetes
Top 5 of diseases in The Netherlands with the highest disease burden, in different age groups
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Currently averted Years Lived with Disability (Andrews et al., 2004)
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 coverage 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%
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Averted YLD (current coverage and with EBMH)
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%
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Consequences
• Currently avoided in major depression (MDD): 16%, maximum 34%
• Consequences:– Better treatments– Dissemination (low-income countries!)– Prevention!
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Epidemiology of depression in The Nederlands
Prevalence: 738.000 Influx:
357.000 recovery
mortality
relapse
TreatmentPrevention
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Costs of depression• €132 million per milion adults (210 AU$)• Of which 47% is related to the incidence• About the same costs in minor depression• About twice as much in dysthymia• Total costs about € 600 million (AU$ 975),
per million adults
• Smit et al. (2006) Journal of Mental Health Policy and Economics
• Cuijpers et al. (2007). Acta Psychiatrica Scandinavica
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So why is prevention necessary?
• Because of high– Prevalence– Incidence– Costs– Burden of disease
• Limited possibilities of treatment
• But: Prevention for whom?
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Is it possible to prevent the onset of depressive disorders?
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Prevention of incidence of new cases of mental disorders
• Meta-analytic review: statistical integration of all available studies
• 19 controlled studies• Results:
– IRR = 0.78 (95% CI: 0.65~0.93)– Universal prevention is not effective– No significant subgroups (type, target population)– IPT may be somewhat more effective than CBT
Cuijpers et al., Am J Psychiatry 2008
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Effects of prevention of depression
-100 -80 -60 -40 -20 0 20 40
%
Depression: –22%IPT: –86%
chance of getting a depressive disorder
CBT: –16%
School: –17%PPD: –35%
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Trimbos-instituut 2007 19
Cost-effectiveness plane
More costs,Less health
More costsMore health
Less Costs Less Health
Less costs,More health
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Trimbos-instituut 2007 20
-7.500
-5.000
-2.500
0
2.500
5.000
7.500
10.000
-0,40 -0,20 - 0,20 0,40 0,60 0,80
Additional effects
Add
ition
al c
osts
Smit F, Willemse G, Koopmanschap M, Onrust S, Cuijpers P, Beekman A. (2006) Cost-effectiveness of preventing depression in primary care patients: randomised trial. British Journal of Psychiatry 188: 330-336
21 %
59%
5 %
10 %
Guided self-help as prevention of major depression
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How can depression be prevented?
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Different methods
• By offering “Coping with depression” course to those with subthreshold depression
• Through the Internet• In primary care• To patients with somatic disorders• To pregnant women• At schools
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Interventions
• Cognitive behavior therapy• Problem-solving therapy• Interpersonal psychotherapy
• Based on evidence-based treatments
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The “Coping with depression” course
• Available for 80% of Dutch population• Psychoeducation in groups of 8-12 participants• Mood management skills
– Learn to think differently– More pleasant activities– Social skills
• Reduction of incidence with 38% (Cuijpers et al., Clin Psychol Rev 2009)
• Specific versions for adolescents, older adults, minority groups, guided self-help, internet
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Internet-interventions
• Indicated prevention• No studies examining the effects on the
incidence of depressive disorders yet• Easy acces, low threshold, less stigma• Effective in reducing depressive symptoms• In Australia: Moodgym, e-couch are very
promising
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In primary care
• Stepped-care for older adults with subthreshold depression
• 4 steps: watchful waiting, guided self-help, brief psychotherapy, medication
• 1 study: 50% reduction of incidence• Van ‘t Veer et al., Arch Gen Psychiatry
2009
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To patients with somatic disorders
• Increased risk for depressive disorders• Several studies show that prevention of
depressive disorders is possible:– Age-Related Macular Degeneration (Rovner et al.,
2007)– Stroke patients (Robinson et al., 2008)– Rheumatology/diabetes (de Jonghe et al., 2009)– Head and Neck Cancer patients (Lydiatt et al., 2009)
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Pregnant women
• Prevention of Postpartum depression• Several studies, few examined prevention
of depressive disorders• In our meta-analysis: trend that it may be
effective
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At schools
• Universal interventions have small effects on depressive symptoms
• No evidence that prevention of MDD is effective
• Individual prevention through the Internet is very promising
• Indicated prevention
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Conclusion
• Prevention of depressive disorders is important
• It is possible• More research is needed to examine
methods and target groups in which it is effective
• Implementation!
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