Preventing the onset of new cases of depressive disorders Possibilities and challenges

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1 Prof. Pim Cuijpers Preventing the onset of new cases of depressive disorders Possibilities and challenges 6 th European conference on mental Health Berlin, October 6 th, 2017

2 JAMA 2012;307: Faculty of Psychology and Education

3 OVERVIEW What is prevention? Why is prevention important? Is prevention effective? Identifying target groups for preventive interventions 3 examples of prevention trials Comparing prevention and treatment Conclusions 3 Faculty of Psychology and Education

4 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 4 Faculty of Psychology and Education

5 INTERVENTION SPECTRUM FOR MENTAL DISORDERS (Mrazek & Haggerty, 1994) Treatment Case identification Standard treatment Universal After-care 5 Faculty of Psychology and Education

6 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 6 Faculty of Psychology and Education

7 WHY IS PREVENTION IMPORTANT? High prevalence (30.3 million Europeans) High incidence (almost 50% of prevalence) Huge burden of disease Highest burden of disease in 2030 in developed countries Treatments can reduce burden of disease with not more than 35% (currently 15%) Huge economic costs 7 Faculty of Psychology and Education

8 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 cancer 3 Alcohol dependence 2.5 Artrosis 2.5 Dementia 2.3 Source: RIVM, Faculty of Psychology and Education

9 TOP 5 OF DISEASES IN THE NETHERLANDS Innate anomalies 2 Mental handicaps 3 Privat accidents. 4 Bronchial infections Alcohol Anxiety Coron. Heart dis Anxiety Traffic accidents 5 Asthma Mental handicaps Alcohol Suicide Traffic accidents Coron. Heart dis Coron. Heart dis Anxiety Stroke Stroke Lung cancer Depression Depression Depression COPD Lung cancer Diabetes Diabetes Dementia COPD Diabetes 9 Faculty of Psychology and Education

10 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 Faculty of Psychology and Education

11 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 Faculty of Psychology and Education

12 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 Faculty of Psychology and Education

13 CONSEQUENCES Currently avoided in MDD: 16%, maximum 34% Currently avoided in anxiety disorders: 13%, maximum 49% Consequences: Better treatments Dissemination (low/middle-income countries!) Prevention! 13 Faculty of Psychology and Education

14 IN A POPULATION OF 10M (PER YR) Prevalence (N= ) Recovery (N= ) Chronicity (N=60.000) Mortality (N=1.000) Courtesy Filip Smit 14 Faculty of Psychology and Education

15 IN A POPULATION OF 10M (PER YR) Minor Dep ( ) Incidence (N= ) Prevalence (N= ) Recovery (N= ) Chronicity (N=60.000) Mortality (N=1.000) Courtesy Filip Smit 15 Faculty of Psychology and Education

16 IN A POPULATION OF 10M (PER YR) Minor Dep ( ) Recurrence (N= ) Incidence (N= ) Prevalence (N= ) Recovery (N= ) Chronicity (N=60.000) Mortality (N=1.000) Courtesy Filip Smit 16 Faculty of Psychology and Education

17 COSTS OF DEPRESSION 132 million per milion adults for MDD 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, per million adults Smit et al. (2006) Journal of Mental Health Policy and Economics Cuijpers et al. (2007). Acta Psychiatrica Scandinavica 17 Faculty of Psychology and Education

18 COSTS OF DEPRESSION 2.2% - 4.4% of Gross Domestic Product (GDP) in OECD Member States 610 billion per year across 27 Member States Absenteism/presenteism: 270 billion Lost output: 240 billion Health care: 60 billion Disability benefit payments: 40 billion 18 Faculty of Psychology and Education

19 SO WHY IS PREVENTION NECESSARY? Because of high Prevalence Incidence Costs Burden of disease Limited possibilities of treatment But: Is prevention possible? 19 Faculty of Psychology and Education

20 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 20 Faculty of Psychology and Education

21 WHAT DO WE NEED FOR EFFECTIVE PREVENTION? Low specificity of most risk indicators Most people with a risk indicator do not develop a disorder Most epidemiologal studies report OR or RR Other methodology is needed 21 Faculty of Psychology and Education

22 NEW STATISTICS Exposure rate: prevalence of risk group among the population Population attributable fraction: the percentage of the incident cases that are accounted for by the risk indicator 22 Faculty of Psychology and Education

23 METHOD LASA data At t1: N=3056; at t2: N=2200 (72%) Age: Incidence of depression: CES-D>16 at t2 Risk indicators: vulnerability-stress theory Smit et al., Arch Gen Psychiatry Faculty of Psychology and Education

24 RISK INDICATORS Risk indicator Exposure Rate Female Low education >2 chronic diseases Functional limitations Depressive sympt Small network Total AF 82.8 Attributable Fraction 24 Faculty of Psychology and Education

25 COMBINATIONS OF RISK INDICATORS Attributable Fraction Exposure Rate 5 0 dep sympt Depressive &impaired Functional &alone Small &female Female symptoms limitations network 25 Faculty of Psychology and Education

26 ANOTHER STUDY Amstel study N=2244 (pre + post) MDD: AGECAT Risk factors CART-analyses Lowest NNT Highest AF Smallest ER Schoevers et al., Am J Psychiatry Faculty of Psychology and Education

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28 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 28 Faculty of Psychology and Education

29 META-ANALYSIS OF RANDOMIZED TRIALS 32 trials (6,214 participants) Universal: 2 studies Selective: 15 studies Indicated: 17 studies Different target groups adolescents/students: 14 adults in general: 8 pregnant women/young mothes: 9 Other: 1 Intervention based on CBT: 15 studies IPT: 5 studies PST: 2 studies Cuijpers et al., Am J Psychiatry 2008; Van Zoonen et al., Int J Epidem Faculty of Psychology and Education

30 TYPE OF PREVENTION Type N IRR 95% CI NNT Indicated ~ Selec6ve ~ Universal ~ With new improvements (stepped-care; Internet-based) IRR approaches 50%, with NNT=8 Growing evidence for cost-effectiveness Van t Veer-Tazelaar et al., Arch Gen Psychiatry 2009; Buntrock et al., JAMA Faculty of Psychology and Education

31 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 31 Faculty of Psychology and Education

32 1. GUIDED SELF-HELP IN PRIMARY CARE Screening of GP patients (N=5276) CIDI in screen-positive patients Those with increased symptoms, but no depressive disorder were included Randomized to: Guided self-help (n=107) usual care (n=109) Willemse et al., Br J Psychiatry Faculty of Psychology and Education

33 INTERVENTION Self-help book Coping with Depression course: Cognitive restructuring Behavioral activation Social skills 6 weekly telephone calls no therapy, only support in working through materials Max 15 minutes 33 Faculty of Psychology and Education

34 RESULTS AT 12 MONTHS IRR =0.66 (p<0.05) Incidence: 0.12 (13/107) for self-help 0.18 (20/109) for the usual care P<0.05 NNT= Faculty of Psychology and Education

35 More costs, Less health More costs More health Less Costs Less Health Less costs, More health 35 Faculty of Psychology and Education

36 GUIDED SELF-HELP AS PREVENTION OF MAJOR DEPRESSION % % Additional costs ,40-0,20-0,20 0,40 0,60 0, % Additional effects 59% Mean saved costs per patient: 1849 Smit et al., British Journal of Psychiatry Faculty of Psychology and Education

37 2. PREVENTION OF DEPRESSION IN OLDER ADULTS Aimed at older adults in primary care Stronger effects: stepped-care Depression and anxiety Van t Veer et al., Arch Gen Psychiatry Faculty of Psychology and Education

38 INCLUSION OF PATIENTS Part of larger project of GP group Screening of patients 75 years or older (N=5207) Those scoring above cut-off on CES-D, but had no DSM-IV depressive disorder were included Randomized to: Stepped-care (N=86) Care-as-usual (N=84) 38 Faculty of Psychology and Education

39 STEPPED-CARE Four steps Watchful waiting Guided self-help (Coping with depression and anxiety) Brief psychotherapy (PST) Referral to GP for medication Steps of 3 months Screening every 3 months 39 Faculty of Psychology and Education

40 RESULTS Stepped care: incidence of 11.6% (10/86) Control group: incidence 23.8% (20/84) RR=0.49 (95% CI: 0.24~0.98) NNT= Faculty of Psychology and Education

41 3. PREVENTION OF MAJOR DEPRESSIVE DISORDERS THROUGH WEB-BASED GUIDED SELF-HELP Buntrock et al., Journal of the American Medical Association (JAMA) Faculty of Psychology and Education

42 DESIGN AND OUTCOMES 406 participants with subthreshold depression (no MDD) Randomized to guided web-based prevention (PST + behavioral activation) or care as usual Incidence of MDD was 27% in the prevention group compared with 41% in the control group Hazard ratio: 0.59 (95% CI: 0.42~0.82) at 12 months NNT=6 42 Faculty of Psychology and Education

43 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 43 Faculty of Psychology and Education

44 REDUCING INCIDENCE OF MDD: INDICATED PREVENTION Assumptions Per 1 million adults: 1-year incidence of ~3% = cases 7.5% or people had subclinical depression Participants in indicated prevention have 25% chance of developing MDD, and that is reduced to 15% by prevention Estimated reductions of incidence: 10% participation => 7,500 participants => 750 less incident cases = 2.5% 40% participation => 30,000 participants => 3,000 less incident cases = 10% 50% participation => 37,500 participants => 3,750 less incident cases = 12.5% 44 Faculty of Psychology and Education

45 REDUCING PREVALENCE OF MDD: PSYCHOTHERAPY Assumptions: Per million adults, prevalence of MDD: ~6.5% = 65,000 patients ~50% is treated: ~32,500 patients After psychotherapy (and other treatments): 62% no longer has MDD (20,150 patients) In control groups (CAU): 48% no MDD Contribution of treatment: 14% (optimistic estimate) = ~4,500 less cases Data based on: Cuijpers et al., J Affect Dis Faculty of Psychology and Education

46 COMPARISON PER 1 MILLION PEOPLE Prevention Intervening in 30,000 people for 3,000 less (incident) cases At one-year follow-up Less intensive treatment Treatment Treatment of 32,500 patients for 4,500 less cases After treatment (probably smaller effects at 1-year follow-up Traditional treatment 46 Faculty of Psychology and Education

47 OVERVIEW What is prevention? Why is prevention important? Identifying target groups for preventive interventions Is prevention effective? 3 examples of prevention trials Comparing prevention and treatment Conclusions 47 Faculty of Psychology and Education

48 CONCLUSIONS Public health challenge of depression: high prevalence, disease burden, economic costs, limited effects of treatments Prevention can reduce incidence with ~22%, and possibly up to 50% Is a viable option compared to treatment Best option is to focus on specific groups Focus on implementation 48 Faculty of Psychology and Education

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50 THANK YOU FOR YOUR ATTENTION! CONTACT: 50 Faculty of Psychology and Education

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