Prevention of the onset of Depression
Methods for preventing the onset of new cases of depression are manifold. The most researched prevention methods are:
- Cognitive Behavioral Therapy, the number of sessions can vary from 6-15 sessions. It can be given in a group or individual treatment.
- Problem Solving. In short: Problem solving treatment has three main steps: patients’ symptoms are linked with their problems, problems are defined and clarified, and an attempt is made to solve the problems in a structured way. See also BMJ. It is usually done by primary physicians and nurses.
- Psychoeducation emphasizes instruction not therapy and promotes relaxation, positive thinking, pleasant activities, and social skills. It can be done in a group or with individuals, the number of sessions can vary between 4-12.
- Interpersonal therapy is a time-limited psychotherapy that focuses on the interpersonal context and on building interpersonal skills. IPT is based on the belief that interpersonal factors may contribute heavily to psychological problems. It is commonly distinguished from other forms of therapy in its emphasis on the interpersonal rather than the intrapsychic. Individual and/or group sessions varying from 6-15.
- Social support is the physical and emotional comfort given to us by our family, friends, co-workers and others. In this form of treatment these forms of support are clarified and expanded or improved.
- Any combination of these treatments
Prevention has been examined in a considerable number of intervention studies, but only a small proportion of these have focused on possibilities for actually preventing the onset of new cases of mental disorders. In a recent meta-analysis 19 studies could be included.
The number needed to treat to prevent one case of depressive disorder was 22. This means that 22 individuals have to be treated with a prevention treatment before 1 won’t have an onset of a depressive disorder.
There are three types of prevention:
- Universal prevention, such as school programs and mass media campaigns, aimed at the general population or segments of the general population, regardless of whether they have a higher-than-average risk of developing a disorder
- Selective prevention, aimed at individuals in high-risk groups who have not yet developed a mental disorder such as post partum women, stroke patients.
- Indicated prevention, aimed at individuals who have some symptoms of a mental disorder but do not meet diagnostic criteria.
In this systematic review
Two of the 21 contrast groups we included in our meta-analysis examined universal prevention, 11 examined selective prevention, and eight examined indicated prevention. Fifteen interventions were cognitive-behavioral therapy (CBT), three were interpersonal psychotherapy,
and the remaining were other types of intervention (one-session debriefing; problem-solving; and
mutual support).
Not the type of prevention but prevention based on interpersonal psychotherapy may be more effective than prevention based on cognitive-behavioral therapy. Target population such as post partum women or adolescents did not influence the outcome of a prevention strategy.
The authors state in their article:
………the numbers needed to treat seem to be rather high (22 in the overall analysis). On the other hand, there are no clear guidelines for what is a high number needed to treat and what is not. For example, the regular use of aspirin to reduce the risk of heart attack has become common practice, and the number needed to treat has been found to be 130. The number needed to treat associated with the use of cyclosporine in the prevention of organ rejection has been found to be 6.3 and is considered a medical breakthrough of considerable practical importance.
What do you think is treating 22 individuals with a prevention program to prevent the onset of depression in one of them worth the time and money? Selective- and indicated prevention have lower numbers of needed to treat respectively 16 and 17.
Limitations of this study:
- Small number of studies (19)
- Quality of studies not all optimal
- Limited follow-up, max 2 years
Pim Cuijpers, Ph.D., Annemieke van Straten, Ph.D., Filip Smit, Ph.D., Cathrine Mihalopoulos,, B.B.Sc.(Hons), Aartjan Beekman, M.D., Ph.D. (2008). Preventing the Onset of Depressive Disorders: A Meta-
Analytic Review of Psychological Interventions American Journal of Psychiatry, 165, 1272-1280 DOI: 18765483
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December 5, 2008 @ 2:44 pm
Whether a NNT of 22 is worthwhile depends on what kind of depression we’re talking about preventing. If you’re preventing the onset of recurrent, difficult-to-treat depression in a 20 year old, that’s one thing, if you’re preventing a 40 year old from having a single mild depressive episode which would be easily treatable, that’s quite another thing.
December 6, 2008 @ 3:08 pm
What would happen if schools taught all children self-hypnosis? No one would ever again have to feel pain. Sales of analgesics would collapse, and the time that doctors now spend helping their patients to control pain would be much reduced. A good thing? Probably not. Pain has a purpose. It alerts us to conditions that need treatment, inhibits further damage, and gives an indication of how serious things are. Without pain, treatment would sometimes be delayed, further damage would sometimes occur, and serious conditions would be sometimes be taken too lightly.
In the case of depression, there is some wordplay at work. The word “depression” means a mental state that warns and protects in a similar way to pain. A period of depression prevents us from attempting complex tasks or making big decisions while our minds are fully engaged in making sense of some difficult event or situation. “Freedom” from depression would have dire consequences, just like “freedom” from pain.
The word “depression” also refers to depressive illness, or clinical depression, which is a state in which the depression mechanism has gone wrong and is overactive. Treating depressive illness is not the same thing as preventing depression.
There is more wordplay around the term “Cognitive Behavioral Therapy”. The focus of cognitive therapy is on inappropriate “automatic” thoughts and beliefs. Whatever treatment is being given to people who do not yet have any inappropriate automatic thoughts or beliefs, it is certainly not any form of cognitive therapy. If we train people to suppress thoughts and beliefs willy-nilly, then they will sometimes suppress perfectly appropriate thoughts and beliefs, causing problems that might be more difficult to unravel than depressive illness (and that will not show up in the “depression” statistics).
Also, people who have the “prevention” and still become clinically depressed might be more resistant to cognitive therapy because they feel they already know all that stuff. They might require more intensive treatment and remain ill for longer.
Merely contemplating the number 22 seems unlikely to resolve these issues.
December 9, 2008 @ 11:31 am
I agree with cbtish’s post, particularly since I’ve experienced a LOT of inappropriate CBT. Telling someone with a psychologically abusive partner that they need to suppress any thoughts of mistrust for that person–without any attempt to determine *why* they have those thoughts about a relatively new partner–is just plain negligent.
However, two of the “prevention” methods identified as helping prevent depression can be generally useful–such as having a social network and good problem-solving skills. Promoting these for everyone, not just identifying some people as pre-depressive and helping them, could have positive effects on society as a whole. Instead of considering this NNT=22, think of it as having a healthy society instead of an unhealthy society that affects some people more than others.