Factsheet Prevention
Preventing Depression
Universal prevention
Universal prevention consists of
interventions, often of a psychoeducational nature, directed at the whole
population, regardless of risk status.
The aim of universal prevention is to
inform the general public about the
disorder, how to recognize it, what people
can do to prevent it and what treatments
are available.
1. Depression: definition and prognosis
Definition of depression
Depression is characterized by an abnormal depressed mood (dysphoria) and a
loss of pleasure in nearly all activities (anhedonia). This blunted affect is exhibited
throughout most of the day nearly every day for at least two weeks. The resulting lack
of motivation can be crippling. In addition, other symptoms cause marked functional
impairment, e.g. sleep disturbances (insomnia or hypersomnia), a lack of energy
(anemia), poor concentration, a lack or increase in appetite, inappropriate feelings of
self-reproach, recurrent morbid thoughts about death and suicidal ideation. In young
people, depression can be associated with agitation and risk-taking behaviour and in
older people with motor retardation, paranoid delusions and physical pain. Depressive
episodes can become recurrent and even chronically remittent. A relatively mild but
chronic form of depression is called dysthymia.
Prognosis of depression
The natural course of depression is unfavourable.
• On average a depressive episode lasts six months, but 20% of the people remain
depressed over a period of at least two years.
• People can experience several episodes of depression. Recurring depression has a
major and negative impact on a person’s life. In the five years following recovery,
there is a 70% probability that the patient will be confronted with a new depressive
episode. Every additional episode raises the likelihood of yet another episode: a
person with a history of two episodes has a 80% probability of a third one, and
there is a 90% probability of a fourth episode if a person has a history of three
previous episodes.
• People with depression have a higher risk of dying prematurely. This risk is higher
by a factor of 1.65 than in people without depression.
In short, depression is associated with an unfavourable prognosis in terms of course
and outcome.
2.Depression: epidemiology and health economics
One-year prevalence: 738,000 people
www.trimbospreventie.nl
In the Netherlands some 738,000 people in the 12-75 age group are affected by
depression every year. Depression can occur at any point in the life-course.
• First onsets of depression usually occur in late adolescence and early adulthood.
About 15% experience an episode of depression before the age of 18. Early onset is
likely to have detrimental impacts on academic and professional careers.
• Among adults (18-65) the one-year prevalence of depression is 5.8%. Depression is
slightly more prevalent in the 35-45 age bracket and drops when people get older.
• The one-year prevalence of depression in the non-institutionalized elderly is
between 2% and 3%. With dysthymia included, this prevalence is 4% to 5%.
Among the residents of homes for the aged and nursing homes, the prevalence of
depression and dysthymia is about 11%, and closer to 15% among the residents of
nursing homes.
In all age groups, women are twice as apt to have a depression as men.
Selective prevention
Disease burden: 157,000 DALYs
Selective prevention is aimed at
individuals or segments of the population
with a significantly higher risk of
developing a particular disorder. The
persons or groups are identified on the
basis of biological, psychological and/or
social risk factors.
Mental disorders such as depression, anxiety disorders and alcohol-related disorders
are high in the top ten most disabling diseases all across the globe. The same holds
for the Netherlands, where depression is one of the most disabling illnesses. Every
year 157,000 disability adjusted life years (DALYs) are lost due to depression in
the Netherlands. The reasons are clear: depression is highly prevalent, induces a
formidable disease burden at the individual level (comparable to near-blindness), has
a poor prognosis and is associated with premature death.
Economic burden: an annual € 1.3 billion
By a conservative estimate, the economic burden of depression in the 18-65 age group
is in excess of an annual € 1.3 billion. These costs are partly related to health care and
production losses in paid and unpaid work. The actual economic costs of depression
to society are more substantial because adolescents and people above 65 are not
included in these figures.
3.Prevention of depression: why we need it
The annual influx of new cases is substantial
The epidemiology of depression is characterized by a substantial influx of new cases
(first-ever incidence). In the Netherlands there is an influx of 357,000 new cases
annually, equivalent to 47% of the prevalent cases. In other words, nearly every other
person with depression is a new case. It would thus be wise to make every effort to
curb this influx. To do so, preventive measures are required.
Treatment can only partially avert the disease burden
Studies by Gavin Andrews and Dan Chisholm (see British Journal of Psychiatry, 2004,
184) demonstrate that the current treatment regimes can only avert 10-20% of the
disease burden of depression. By implication, a staggering 80-90% of the disease burden
remains in tact, leading to individual suffering, loss of quality of life, and economic
ramifications. Again, the conclusion is that we need prevention in addition to treatment.
4.Prevention of depression: where to start
Risk groups and risk factors
It is generally assumed that depression is caused by a combination of risk factors. The
following risk groups can be identified on the basis of social and psychological factors:
• People whose parents or close relatives have a history of depression, anxiety
disorder, or drinking problems
• People with a prior history of depression or dysthymia (likelihood of recurring
depression)
• People with minor depression (depressive symptoms that do not yet meet the
diagnostic criteria of full-blown depression)
• People with prolonged anxiety disorders who are at an increased risk of developing
a secondary depression
• People who experienced traumatic events in their youth (abuse, neglect before the
age of 16)
• Vulnerable personalities (highly neurotic, low self-esteem, high degree of
interpersonal sensitivity, children with learning difficulties)
• Vulnerable people facing stressful life-events (serious illness, sudden
unemployment, death of a spouse)
• People with a chronic physical illnesses (e.g. neoplasm, cardiovascular disease,
chronic obstructive lung disease, lower back pain) or a handicap (e.g. visual
impairment)
• People with a low level of education and a low income
• Women (one-year prevalence for depression is 7.5% in women and 4.1% in men)
• Single people (limited social support, loneliness, can apply to the widowed and to
vulnerable groups such as the homeless and asylum-seekers).
Factsheet
Preventing depression
It is understood that an accumulation of risk factors in one and the same individual
substantially increases the risk of depression. Targeting these ultra-high risk groups
may result in substantial health gains at the lowest costs.
Protective factors
The following factors may help keep people from developing depression and can
perhaps be used in preventive strategies to foster resilience, promote health and
increase the likelihood of favourable outcomes:
• High intelligence
• Self-awareness, realistic self-appraisal, improving self-esteem
• Understanding depression and knowing what can be done about it
• An easy-going personality, improving interpersonal relationships
• A sense of mastery, strengthening internal locus of control
• Scheduling and engaging in pleasurable activities
• Physical activities, sports.
Protective factors in children include:
• At least one supportive parent
• A good understanding of the parent’s psychological problems (if any).
Indicated prevention
Indicated prevention is aimed at high-risk
groups that are identified on the basis
of a limited number of symptoms that
predate the disorder, but do not yet meet
the criteria of the particular diagnosis.
5.Prevention of depression: organizational aspects
Universal and selective prevention
Keeping in mind the risks and protective factors, several important target points
appear suitable for universal and selective prevention, e.g. promoting and
strengthening
• various coping styles
• cognitive and social skills
• social participation.
In part this can be done via psycho-education at schools and via the media.
Interventions to improve the living situation (healthy school, healthy neighbourhood,
positive parenting) are also likely to help reduce the number of people affected by
depression. Several settings appear suitable for depression prevention activities, e.g.
schools, GP practices and nursing homes.
Indicated prevention
We define sub-clinical depression as depressive symptoms that do not yet meet the
diagnostic criteria of a full-blown depression. Prevention measures against sub-clinical
depression are important for a number of reasons:
• Sub-clinical depression occurs in 17% of adolescents, 16% of adults and about
13% of everyone in the 55-85 age group. The prevalence of depressive symptoms
among elderly people who live at home is about 15%, and about 21% among
residents of nursing homes.
• Sub-clinical depression is accompanied by considerable role limitations and is
thus likely to induce a willingness to address problems and accept preventive
interventions.
• A person with a sub-clinical depression is six times as likely to develop full-blown
depression as a person without sub-clinical depression.
• Sub-clinical depression is amenable to change, e.g. via preventive interventions.
Early depressive disorder detection and intervention by general practitioners, teachers
and nursing staff based on initial symptoms is thus an important prevention strategy.
Relapse prevention
The high likelihood of depression recurrence requires relapse prevention. The target
group is people with a prior history of depression, especially if the first episode
occurred early in life, if the previous episodes were severe, and if there are residual
symptoms. Relapse prevention can be organized as cognitive behavioural therapy in
the final treatment phase and as booster sessions after treatment, and is aimed at
the long-term enhancement and maintenance of the acquired skills. Periodic contact
(telephone calls, providing written material) can also be helpful in this respect.
Factsheet
Preventing depression
Relapse prevention and promotion
of participation
Relapse prevention and promotion of
participation is aimed at individuals
who have a disorder according to
the DSM-IV criteria. The preventive
interventions for these groups are focused
on relapse prevention, the prevention
of co-morbidity and the promotion of
participation in society.
6. Prevention of depression: current practice
Courses
In the Netherlands about forty specialized mental health facilities engage in
depression prevention. They help people who have a number of depressive symptoms
or a history of depression.
• Most prevention activities focus on adults and the elderly; e.g. courses on coping
with depression, which are structured courses based on social learning theory,
cognitive behavioural therapy, relaxation exercises, training in social skills and
learning how to have more pleasurable activities.
• In addition there are special courses for people with chronic illnesses, students
and young adults, and members of ethnic minorities. Various regions have widowto-widow visiting services.
• Family interventions (counselling, social support, improving parenting skills) focus
on parents with mental health problems and their children who may be at risk of
depression and other disorders.
New approaches
Colophon
Funding
Netherlands Ministry of Health, Welfare and Sports
Author
F. Smit
In collaboration with
I. Voordouw, E. Bohlmeijer, J. Blekman,
R. van der Zanden
Production coordination
F. Zolnet
Layout and design
Ladenius Communicatie BV
This factsheet is a publication of the Prevention
Department of the Trimbos Institute and the National
Consultancy on Prevention (LSP). The following
factsheets are available as a free download at
www.trimbos.nl:
- Alcohol Prevention (AF0757)
- Children of Parents with Psychological
Problems (AF0427)
- Preventing Depression (AF0426)
- Infectious Diseases (AF0755)
- Reminiscence and Life Review (AF0726)
- Prevention in Social Psychiatry (AF0429)
Dutch versions of these factsheets are also available.
ISBN 978-90-5253-400-8
@ 2007 Trimbos Institute, Utrecht
All rights reserved. Nothing from this publication may
be copied and/or published without the prior written
permission of the Trimbos Institute.
www.trimbos.nl
A number of studies were conducted to evaluate the effectiveness of alternative
interventions.
• Bibliotherapy is a form of self-help involving the independent study of a booklet. It
entails learning social and cognitive skills, doing relaxation exercises and engaging
in pleasurable activities. In GP patients with some depressive symptoms, this
approach effectively reduced the incidence of new cases of depression by 30% and
turned out to be cost-effective.
• A meta-analysis indicated the efficacy of structured life-review (e.g. the group
intervention “Stories we live”) in the early stages of late-life depression. This
promising approach is now being tested in several pilots in the Netherlands.
• The Internet is a new way to provide guided self-help interventions. A metaanalysis demonstrated the effectiveness of this approach to depression. Two
randomized clinical studies are currently being conducted on new Internet-based
guided self-help interventions in the early stages of depressive disorder in the
Netherlands. The initial results are very promising.
• The aim of the community approach is to improve the target group’s
neighbourhood cooperation and participation at an inter-sectoral level. A number
of studies are currently being conducted on integrated depression prevention. In
addition, a guideline is being produced for integrated depression prevention at the
local level. The aim is to create a chain of activities from mental health promotion
to universal, selective and indicated prevention within a network of organizations.
See the overview of all the depression prevention activities.
Activities for intermediaries
Intermediaries are professionals in such fields as special education, paediatrics, home
care, primary care and nursing. Training is available for primary care professionals
to improve their depression detection skills. There are folders and meetings for the
relatives of people with depression.
Due to space limitations, references have not been inserted in the text. Some of the
relevant literature is listed below:
• Honig A., Praag H. (eds). Depression: Neurobiological, psychopathological and
therapeutic advantages. Chichester: John Wiley & Sons, 1997.
• Jong A., Brink W. v. d., Ormel J., Wiersma D. (eds). Handboek psychiatrische
epidemiologie. Maarssen: Elsevier/De Tijdstroom, 1999.
• Mrazek P. J., Haggerty R. J. Reducing risks for mental disorders. Frontiers for preventive
research. Washington: National Academic Press, 1994.
• Meijers S., Smit F., Schoemaker C., Cuijpers P. Volksgezondheid Toekomst
Verkenningen. Gezond verstand: evidence-based preventie van psychische stoornissen.
De Bilt: RIVM, centrum VTV.
• Smit F. Prevention of Depression (PhD thesis). Faculty of Medicine, VU University,
Amsterdam, 2006. (Can be downloaded from www.trimbos.nl > “products” > key
word “depression”).