Interventions and their benefits Prof. Dr. Pim Cuijpers Presidency Conference “Mental Health: Challenges and Possibilities “ Vilnius, 10-11 October, 2013 Interventions and their benefits Evidence-based actions to prevent mental disorders Department of Clinical Psychology Prof. Dr. Pim Cuijpers

JAMA 2012;307:1033-1034

Overview What is prevention? Why is prevention of common mental disorders important? Is it possible to prevent new incident cases? Conclusions

What is prevention?

Intervention spectrum for mental disorders (Mrazek & Haggerty, 1994) Treatment Prevention Standard treatment Maintenance Case identification Indicated Long term treatment Selective After-care Universal

Why is prevention of common mental disorders important?

Why is prevention important? Huge burden of disease Highest burden of disease in 2030 in developed countries High prevalence High incidence (almost 50% of prevalence) Huge economic costs (130 million euros per million inhabitants, 47% incidence) Treatments can reduce burden of disease with not more than 35% (currently 15%)

Illnesses with highest disease burden % of disease burden Coronary heart disease 7.6 Anxiety disorders 5.1 Stroke 4.9 Depression / dysthymia 3.9 COPD 3.2 Diabetes mellitus Lung cancer 3 Alcohol dependence 2.5 Artrosis Dementia 2.3 Source: RIVM, 2006

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 2 Mental handicaps Depres-sion Stroke 3 Privat accidents. Lung cancer COPD Dementia 4 Bronchial infections Traffic accidents Suicide 5 Asthma Diabetes Diabe-tes

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

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%

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%

Consequences Currently avoided in MDD: 16%, maximum 34% Currently avoided in anxiety disorders: 13%, maximum 49% Consequences: Better treatments Dissemination (low-income countries!) Prevention!

Epidemiology of depression in The Nederlands relapse Influx: 357.000 recovery Prevalence: 738.000 Prevention mortality Treatment

Costs of depression €132 million per milion adults 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 Estimated costs in EU: €136.3 billion Smit et al. (2006) Journal of Mental Health Policy and Economics Cuijpers et al. (2007). Acta Psychiatrica Scandinavica

So why is prevention necessary? Because of high Prevalence Incidence Costs Burden of disease Limited possibilities of treatment But: Is prevention possible?

Is it possible to prevent the onset of common mental disorders?

First meta-analysis Inclusion: 19 trials met inclusion criteria RCT comparing prevention with control No depressive disorder at baseline (diagnostic interview) Incidence at follow-up (another diagnostic interview) Any target group 19 trials met inclusion criteria Results: IRR = 0.78 (95% CI: 0.65~0.93) Universal prevention is less effective No significant subgroups (type, target group) IPT may be more effective than CBT Cuijpers et al., Am J Psychiatry 2008

An updated meta-analysis Kim van Zoonen, Claudia Buntrock, David Daniel Ebert, Filip Smit, Charles F. Reynolds III, Aartjan T.F. Beekman, Pim Cuijpers

Included studies 32 trials (6,214 participants; 3,312 prevention and 2,902 control); 34 comparisons Publication year: 1995-2000 5 2001-2005 5 2006-2010 20 >2011 2 Type of prevention: Universal: 2 studies Selective: 15 studies Indicated: 17 studies

Included studies (continued) Most studies did not report history of depressive disorders (n=20); 4 included only no depression history Target groups adolescents/students: 14 adults in general: 8 pregnant women: 6 (new) mothers: 3 adults with diabetes: 1 Intervention based on CBT: 15 studies IPT: 5 studies PST: 2 studies

Results N=32 IRR=0.79 (95% CI: 0.69~0.91); NNT=20 Most results for 1 year follow-up (2 for 24 months, one longer); Trend (p<0.1) of decreasing effect over time No significant differences between subgroups (type of prevention; age group; type of intervention; number of sessions; country, quality) when using IRR

Forest plot

Type N IRR 95% CI NNT Indicated 17 0.74 0.62~0.89 14 Selective 15 0.81 Type of prevention Type N IRR 95% CI NNT Indicated 17 0.74 0.62~0.89 14 Selective 15 0.81 0.64~1.02 20 Universal 2 1.01 0.66~1.53 -1000

Prevention in different settings Schools/adolescents Postpartum depression Primary care General medical settings Older adults Internet

Conclusions Prevention of common mental disorders is important It is possible to prevent the onset of common mental disorders Stepped care models Implementation!

Thank you for your attention! Contact: p.cuijpers@vu.nl