ev_20091210_co02_en
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Depression
Public Health Priority of the21st Century
Hans-Ulrich Wittchen
Institute of Clinical Psychology and PsychotherapyCenter of Clinical Epidemiology and Longitudinal Studies
(CELOS)Technische Universitt Dresden.
Lecture 10/12/2009: Prevention of Depression and Suicide - Making it happen (Budapest)
25% of the EU population has been suffering or will sufferfrom depression at some point in life!
In any given year, 9%* of the EU population suffers fromdepressive disorders
This corresponds to 20 8 million women and men suffering
Depression a frequent and serious illness
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1,9
6,46,8
5,8 6,15,4
2,3
13,5
10,5
13,412,5 12,4
0
5
10
15
20
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Depression is treatable!
Effective drug and psychological treatments exist (e.g. cognitive-behavioralpsychotherapy, interpersonal psychotherapy, various types of drug treatments)
Effective secondary preventive interventions exist (e.g relapse prevention)
Effective preventive methods for complications exist (e.g. suicide prevention) If applied (accessible, early enough, comprehensive, adequately) these methods
should result in a lower prevalence (reduction of length and number of episodes)
Wittchen & Hoyer 2008
Ultimate goal of prevention is lowering the incidence (=prevent new cases)
Equally effective primary preventive measures are still lacking Yet a wide range of highly promising approaches are available
More research on causal mechanisms and targets needed (public health perspective)
Depression is treatable - but is it preventable?
The societal burden of depression has onlyrecently been fully appreciated
Years Lived with Disability (YLD) and Disability Adjusted Life Years (DALY) aretwo time-related metric indicators to quantify the burden of diseases allowing fordirect comparisons between diseases
In the 90ies, the Global Burden of Disease experts estimated that:
disorders of the brainaccount for
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These past burden of disease estimations (1990 data)were problematic, and do not adequately reflect the
situation in the EU!
Disease burdenDepression (1990)
Years lived withdisability (1990)
Massive direct and indirect burden of depression:
Individual (e.g. high distress, disrupts social roles, work productivity, sickness days,disability, premature mortality)
Family (e.g. high emotional distress, economic consequences, malignant effects ondependent family members
Society (direct and indirect health and social costs)
I. The future has arrived - depression burden in EU ranks already No 1
The burden of depression in the EU has already becomethe most challenging public health burden: Reasons?
disability
due to any
somatic
disorder
53%
disability due
to disorders
of the brain
44%
1. Improved data on disability burden, revealingthat disorders of the brain account for about40% of the total burden
15
Proportion (%)
depression
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0
27,6
16,8
24,7
29,9
23,1
5,4
2,20
34,2
30,9
60,1
63
34,5
10,1
3,5
0
10
20
30
40
50
60
70
0-4 5-14 15-29 30-44 45-59 50-69 70-79 80+
Males
Females
II. The burden is not equally distributed
Among all Disorder of the brain depression is responsible forthe largest disability burden - particularly for females!
Proportion (%)of all neuropsychiatric DALYS
Age groups
Wittchen et al, in press; European Health Report 2005
Estimates after age 65* remaincontradictory and problematic!
High disability burden even inearly years
Women carry by far the greatestdepression burden
For women in the reproductiveyears, depression accounts for17-19% of all causes DALYs!
All brain disorders: 386.176 billion Health care costs: 135.446
Direct non-medical 72.201 Indirect costs: 178.529
Mental disorders 294.719(w.o depression: 176.053)
Health care costs: 110.061Direct non-medical 51.673Indirect costs: 132 985
Mental disorders
Depression accounts for almost 1/3 of all direct andindirect costs of disorders of the brain
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7
8
32
2
3
11
12
8
17
0 10 20 30 40 50
premature death
early retirement
sick leave (absenteeism)
other direct costs
informal care
social services
outpatient care
medication
hospitalization
Distribution of depression cost is characterized byhigh indirect costs
Direct costs in EuroHealth care costs: 42.000- outpatient care 22.000
- hospitalisation 10.000- drug cost 9.000
Resource items depression
Proportion (%) of total costs
Indirect costs in EuroIndirect costs: 74.389
Relatively low direct costsVersus
High indirect costs
Jacobi & Wittchen 2007
The largest economic burdenassociated with depression is
carried by the employers and thesocial health system
Depression Diabetes CVD
Distribution of depression cost is markedly different from othertreatable diseases: A comparison with two other common
somatic illnesses
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Depression is already now Europe`s most costly anddebilitating illness (9.2% of all DALYs)
Why has the burden of depression persisted or evenincreased?
5,2
7,8
9,29,8
0
5
10
15
1990 2000 2005 2030
Individuals do not seek treatment! Prevention and Early intervention is not provided or effective!
Treatment is not effective, too expensive, unavailable or unacceptable!
DALY proportions (%) of all causes
Artefact of methods and statistics Disease is difficult to detect or diagnose
Increasing depression rates? Overwhelmingcauses?
Changes in the constitution of risk groups
Effective treatment and prevention is not orcan not been provided
year
Artefact of methods and statistics
Disease is difficult to detect or diagnose
Increasing depression rates? Epidemic?Overwhelming causes?
Why has the burden of depression persisted or evenincreased?
5,2
7,8
9,29,8
5
10
15 1990 2000
2005 2030
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0
2
4
6
8
10
12
14
16
18
20
0 50
1940
1950
19601970
1980
10 20 30 40
Birth cohort
Age of onset depression
Cum. Incidence %
(Kaplan Maeier)
60
Cross-National Group, JAMA
Mauz & Jacobi 2008
Strong evidence for asubstantial increase indepression risk since the 60iesin industrialized countries.
Strong evidence for increasedrates in the young! Age of onsetshifted forward Earlier andmore frequent!
These effect seem to haveweakened though in the past 15years.
No evidence for epidemicNor overwhelming causes!
Evidence for increasing depression rates in the past?Probably yes but little evidence for continued increases!
3.6
3.2
Risk associationdepression (RR)
Parkinsons Disease 2
Alzheimer dementia 1
Disease 3
Age-related disorders, associated with increased risk for depression
4,4
6,2
6
8
10
RR for Depression
Selected diseases among subjects aged 65+by their depression risk elevation (ref.:
persons w.o. condition)
Effect of comorbidity
Increase due to longer life expectancy? Population 65+ is increasing!
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Increasing proportions of the elderly contribute to increaseddepression rates among the physically ill and neurodegenerativedisorders
Neurodegenerative disease Somatic diseases associated with pain Other disabling comorbid somatic diseases
The situation and trend monitoring in the elderly remainsunderstudied!
Other high risk populations:
Substance abuse population: Little evidence of major effects Economic crises and unemployed populations?
Conflict and disaster populations?
low income groups (the poor)?
Increase due to the size of high riskpopulations?
Despite lower overall estimates of
depression in old age evidence ofincreased rates when other illnesses
are present and when ability tofunction becomes limitedThe Elderly Paradox!
Did we fail to reduce the burden, because treatment fordepression is unavailable, difficult, ineffective and expensive?
Not ( or only partly) true!
Effective first-line treatments are available
Effective treatment delivery is not difficult given appropriatetraining
Cost-effectiveness is robustly established
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Examples for room for improvement
51
94
78
90
51
29
21
0 20 40 60 80 100
Asthma
Diabetes
Heart disease
High bloodpressure
athritis
Depression
Social phobia
Treatment (%) among selected conditions
Ormel et al 2008; WMH-survey EU data
35
48
43
41
29
52
49
0 20 40 60 80 100
USA
Belgium,
France
Germany
Italy
Netherlands
Spain
% of cases with depression in the community
with treatment in the year of onset
1. Increase treatment rates of depression! 2. Initiate treatment sooner!
Wang et al 2007
Action:Ensuring access to adequate treatment!
Screening is not enough!
Rates of adequate
treatment fordepression in the EU:
< 10% of all affected
Depression increases
risk for cardio-vascular disease (Pieper et al 2007)
risk for worse outcomes in heart failure(Blumenthal et al 2009)
risk of premature mortality (DETECT 2008)
Designing and providing early targeted treatment in physically ill
Example: Depression and cardiovascular disease
4
5
Odds ratio
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Targeted interventions for anxiety and depression parents cansubstantially reduce these risks
Focus on gender-specific risk groups - providing early targetedtreatment
Pregnancy, motherhood and the anxiety -depression link
Martini et al 2008
Anxiety (as an early onset primary disorder), depression and
suicidality run in families
Children of mothers and/or fathers with anxiety ordepression are at increased risk for anxiety and depression
Examples for risks for mother and child Pregnancy and perinatal complications Postnatal depression in mothers
Early anxiety and depression onset in children Adverse childhood development and neurocognitive dysfunctions
0,5
Cum
Incidence
no parental anxiety
parental anx & depAnxiety or depression
in parents Abuse/Dep.MajorOR = 2.0 *OR = 2.6 *
Psychopathology inoffspring
You cannot be too careful in choosing your parents!
Children of anxiety and depression parents are at high forprimary anxiety and secondary depression at early ages
Increased risk of child onset byparental disorder
Parental disorders increased therisk many disorders
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Focus on the risk group with the highest burden
Pregnancy, parenthood, childhood and the anxiety -depression link
Martini et al 2008
The familial transmission of anxiety and depression and suicidality can beprevented (prenatal interventions in mothers, parent training, early child interventions)
Reducing the burden of parents pays off for the children as well
Anxiety is the most powerful risk factor for depression
Targeting anxiety and depression is particularly promising
Remember! 64% of all with suicide attempts have also anxiety disorders
The most powerful and effective interventions exist for anxiety
Preventing anxiety prevents depression and reduces morst effectively the overall burden
Awareness/screening campaigns are necessary, but not enough
It is not enough and effective to: offer just one or two encounters and deliver a prescription Leave the job largely on overly busy primary care doctors or rely on self-help structures
Improve treatment adequacy and continuity across the cycle of illness
Conclusionit is already worse than we thought! but we can make a change!
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(it is already worse than we thought!) Depression = public health challenge No 1 Depression treatment and prevention demands qualified personel
Depression is not mereley a psychological problem!
Need for evaluating medical, psychological, and social interventions on all levels
Understanding how they work, when they fail and how to optimize
From general prevention to targeted early interventions
Prioritize measures and programs to reduce the burden
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Depression and suicide
Fact sheet I: Depression in Europe
Every given year, about 9% of population suffers from a depressive disorder (21millions)
About 7% meet criteria for major depression (approx 18 million)
The lifetime risk for depression is considerably higher: Every 4th person in the EU hasor will suffer a depression in the course of their life (24%)
F l h id bl hi h lif i i k d b i hi h
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Fact sheet II: Depression in Europe
Special features and depression subtypes remain understudied:
1/3 take a chronic course (with no full remission)
1/3 a recurrent course (at least 2 episodes, mean 4.8 episodes lifetime)
Among those with single episodes the average duration of a depressive episode is 11.8 weeks
Bipolar depression is estimated with a 12-month prevalence of 1%
Melancholic depression 1.2%, seasonal depression 0.2%
Depression in the community is highly comorbid with all other mental disorders
Comorbid conditions typically affect course and outcome, precding comorbid disorder can bepowerful risk factors (anxiety disorders, substance use disorders)
About 1/3 of all depression cases have or will attempt suicide
Suicide attempt rates are highly elevated among highly comorbid cases
In all countries treatment rates are low! At best about 50% of depression cases
receive any professional attention
Primary care is the most frequent provider (21-43%)
Specialist care varies by country, but rarely exceeds 30%
Treatment typically occurs late in the illnes progression
The burden of depression children of depressed parents
Pregnancy, birth and depression
The depressed child increseaed risk for adverse social and mentaldevleopmental unless treated
Facets of Burden
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depression across the life span
patients needs (age, gender, risk groups)
burden (individual, societal, cost)
Mental health system characteristics (diversity, fragmentation)
Fragmentation of health care (lack of continuity)
Costs and cost benefits
causal prevention and therapy
Identifying the most promising targets
Filling the research gaps
there is no health without mental health!
Conclusion
Depression, number 1 as the most debilitating diseases in the EU
Depression, the most costly of all disorders of the brain in the EU
The high burden is mainly attributable to the indirect costs
Because of low recognition and low treatment rates the directt t t t ti l l
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Depression a frequent and serious illness
Lifetime risk: one out of four person in the community In any given year: 7-8% suffer from depression
Depression may affect the young and the old
Increasing rates particularly among the young
Leading cause of suicide
Major source of premature mortality in physical diseases
Ranks as number 1 among the most disabling diseases Underrecognized and undertreated in helathj care systems
The Situation
Only 50% of all 12-month depression cases receive treatment! Even in themost developed health care system
21,5
18,8
24,6
psychologists
other mental health
primary care
Health care sectorNote!Treatment rates within EU froma low of 24% to a high of 51.6%
Although primary care is in allcountries the most frequentprovider, rates vary from 21%t 43%!
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60.2% of
affectivedisorders
54.3% of anxietydisorders arecomorbid
49.2% ofsomatoform
disorders
41.2% of substancedisorders
OR anxiety withSubstance: 2.6Depression: 6.9
Somatoform: 3.4
OR substance withAnxiety: 2.5Depression: 2.7Somatoform: 1.9
OR depression withAnxiety: 7.0
Substance: 2.7Somatoform: 3.5
OR somatoform withAnxiety: 3.5Substance: 2.1
Depression: 3.5
Bittner et al. 2004. APS
Mental Disorders and Depression Are Frequently Comorbid:12-Month Comorbidities Among Mental Disorders
II. Prevalence and incidence: Special features
Ich brauche die DALY und oder YLD
getrennt nach Altersgruppe und Geschlecht Bitte machen
Treatment of mood disorders (12-month) in the EU(Wittchen & Jacobi, 2005; adapted from ESEMeD/ MHEDEA 2000 Investigators, 2004)
6%
12%
5%
no consultation
only drug treatment
only psychological
1
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Epidemiological approaches
Unselected sample of thegeneral population (or
fractions thereof)
Sample of persons at risk (i.e. with anxiety, after stressful events)
Persons in primary care
Persons in treatment settings
Treated patients
(adaequate/inadaequate)
Clinicalresearch
Epidemiological methods allow a representative
description of patterns of morbidity and supplementand complement clinical research findings
I. Methods
Life expectancy continues to grow! 3-4 years per decade in the EU!Proportion of population aged 65+ is increasing!
Japan
Sweden
Israel
Italy
Spain
Netherlands
UK
France
EU-15 average
Austria
Japan
Spain
France
Italy
Sweden
Finland
Austria
EU-15 average
Germany
Israel
1
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1,1 Mio (0,9 - 1,7)
2,0 Mio (1,4 - 2,1)
2,6 Mio (2,4 - 3,0)
3,6 Mio (2,8 - 5,3
2,4 Mio (1,7 - 2,4)
3,9 Mio (3,3 - 4,7)
5,8 Mio (5,2 - 6,1)
5,2 Mio (4,3 - 5,3)
6,6 Mio (5,4 - 9,2)
7,1 Mio (5,8 - 8,6)
0 1 2 3 4 5 6 7 8 9
major depression
specific phobias
somatof. disorders
alcohol dependence
social phobia
panic disorder
GAD
agoraphobia
bipolar disorder
psychotic disorders
OCD
ill. subst. dep.
eating disorders
18.9 Mio. (12.6-21.1)
18.5 Mio. (14.3-18.6)
18.4 Mio. (17.2-19.0)
12-month prevalence (%, 95% CI) and estimated number of subjects affected inthe EU
1212--month prevalence (%, 95% CI) and estimated number of subjects afmonth prevalence (%, 95% CI) and estimated number of subjects af fected infected in
the EUthe EU
Note:Numbers add up to more than 27% and 82 million subjects because subjects can havemore thanone disorder (comorbidity)
Wittchen & Jacobi (2005), Neuropsychopharmacology
II. Prevalence
The Lifetime risk up to age 60 is even higher!
Alcohol dependence
Drug dependence
Nicotine dependence
Any mental disorder
12-month
lifetime risk
DSM-IV mental disorders
Because only full threshold depressivedisorders are assessed in the 12-month prevalence (blue), parally
remitted, prodromal, and lifetime
cases add to the overall lifetime
II. Prevalence
1
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The lifetime risk of depressive disorders of males and females in thecommunity up to age 65
Cumulativehazardrate (%)
0
5
10
15
20
25
30
35
0 5 10 15 20 25 30 35 40 45 50 55 60
depression - total
depression females
depression males
Age of onset (years)
Incidence Major depression andDystymia
NGS: Wittchen et al (1999),
Lifetime riskestimate
Females: 35%
Total: 24%
Males 21%
Wittchen & Jacobi 2005
Prevalence estimates of depression in community studies
Point prevalence3
mean: 3.4% (range: 1.2-6.5)
12-month prevalence2,3
mean: 6.9% (IQR: 4.8-8.0)
Lifetime prevalence1
Age of subject when examined, eg 45
Point prevalence
12-Months prevalence
1
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0.0
0
0.0
5
0.1
0
0.1
5
0.2
0
0.2
5
0.3
0
Proportion
10 20 30 40 50 60 65
Age1974-1981 1965-1974
1955-1964 1945-1954
1935-1944
Cumulative lifetime incidence of Major Depression
Is this trend continuing? Most current German examination in birth cohorts
Shifting forward of age of onset
Birth cohorts
IV. Is depression increasing?
Evidence for Increasing Rates of depression in succeivly youngerbirth cohorts
20umulative li etime pro a ility in
Bi th h t
0,090cumulative lifetime probability
Pure and primary MDComorbid secondarydepression
1
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Rates of abuse or dependence; ** Epidemiologic Catchment Area study; National Comorbidity Study, ages 18-64 years
Suicide attempts in cross national study standardised bypsychological disorder
Suicide attempt Rate/100 (SE) among
Major depression Any anxiety Alcohol/drug*
US
ECA (1980s)**
3.13 (0.19) 3.13 (0.19) 3.13 (0.19)NCS (1990s), - - -Edmonton, Canada 3.12 (0.36) 4.33 (0.42) 3.76 (0.39)Puerto Rico 6.08 (0.69) 6.38 (0.71) 7.05 (0.82)Savigny, France 3.27 (0.59) 4.23 (0.65)West Germany 3.08 (0.91) 3.39 (0.95) 3.50 (0.97)Taiwan 1.32 (0.12) 1.22 (0.12) 1.92 (0.19)Korea 3.81 (0.28) 3.80 (0.29) 3.69 (0.30)New Zealand 3.56 (0.57) 4.75 (0.65) 4.35 (0.62)
Weissman et al (1999)
II. Prevalence and incidence: Special features
Across studies 1/3 of all cases of major depression attempt suicideHowever due to comorbidity rates are also high in anxiety and addictive disordersComorbidity increases the risk of suicide attempts and suicide two- to threefold
15%
Conclusion: Estimates for depression are considerably differentdepending on what we are interested in
Lifetime riskestimate
Total: 24%
Lifetimeprevalence
Total: 15%
24%
Note! 6 9%
1
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In Western countries depressive disordersin the community are increasing
Consistent evidence for successively higher incidence in young cohorts; age ofonset for fisrt episode of depression is decreasing
Subjects born after 1934 have twice the risk, those born after 1964 almostthree times the risk for MDE
There is little evidence that these effects are artefactual (different methods,willingnes to speak about symptoms etc)
Increases are due to higher incidences of comorbid secondary depressions
Projecting to beyond the year 2000
if increases continue, the prevalence of depression will double
.. making major depression the second most costly and disabling(DALY) single disease worldwide
ICPE, SHO, World Bank, HMS: The Global Burden of Disease
IV. Is depression increasing?
Depression may occur at any point in life in females twice asoften as in males
13,5 13,4
12,5 12,4
15
20males
females
cumulative incidence (%)of MDE (Kaplan-Meier) 12-months prevalence of MDE
Fewdata
childhood
0,25
0,30
0,35
Males
Females
1
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Depression 2000
Point prevalence of depression in primary care by age group
9,4
11,9
10,9
0
2
4
6
8
10
12
14
16
16-19 20-29 30-39 40-49 50-59 60-69 >70 Total
Males Females Total
Point-Prevalence in %
Age groups
N=20.304 primary
care patients
Year 2001
Point prevalenceICD-10 depressionaccording to DSQ
As compared to thecommunity (4%)2-3 times higher
rates!
Wittchen et al JCP 2004
III. Prevalence in primary care
In in the EU fairly convergent estimates of number of persons affected
Evey year 7-8% (males females?)
Little evidence for cultural and regional effects
Fact sheets
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The burden of depression as a proportion of all causesand neuropsychiatric conditions by age
(GBD 2004: Projected DALYs by cause for the year 2008, optimistic scenario Europe)
More recent and more sophisticated global burden of diseasefindings supported this projection
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8,9
11,9
10,4
5,5
36,3
15,3
0 10 20 30 40 50
Inpatient
outpatient
medication
suicide relatedcosts
absenteeism
reducedproductivity
The largest economic burden associated with depressionis carried by the employers and the social health system
proportion (%) of depression costs
Kessler & Wittchen 2007
Work place
costs:51,5%
Direct treatmentcosts:
31%
Evidence for an epidemic?
Increases are relatively small not due to larger proportions of the elderly
Increase in depression rates has slowed down over the past 15 years
Definitely not!
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This paper was produced for a meeting organized by Health & ConsumersDG and represents the views of its author on the
subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of
the Commission's or Health & ConsumersDG's views. The European Commission does not guarantee the accuracy of the data
included in this paper, nor does it accept responsibility for any use made thereof.
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