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

2. JAMA 2012;307:

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

5. What is prevention?

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

7. Why is prevention of common mental disorders important?

8. 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%)

9. 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

10. 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

11. 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

12. 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%

13. 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%

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

15. Epidemiology of depression in The Nederlands
relapse
Influx:
recovery
Prevalence:
Prevention
mortality
Treatment

16. 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

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

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

19. 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

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

21. Included studies
32 trials (6,214 participants; 3,312 prevention and 2,902 control); 34 comparisons
Publication year:
>
Type of prevention:
Universal: 2 studies
Selective: 15 studies
Indicated: 17 studies

22. 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

23. 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

24. Forest plot

25. 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

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

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

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