1

Depression
Public Health Priority of the 21st Century
Hans-Ulrich Wittchen
Institute of Clinical Psychology and Psychotherapy Center of Clinical Epidemiology and Longitudinal Studies (CELOS) Technische Universitt Dresden.

Lecture 10/12/2009: Prevention of Depression and Suicide - Making it happen (Budapest)

Depression a frequent and serious illness

25% of the EU population has been suffering or will suffer from depression at some point in life! In any given year, 9%* of the EU population suffers from depressive disorders This corresponds to 20.8 million women and men suffering from depression* each year Little evidence for major systematic variation in prevalence (+/- 2%) by EU region and country (when controlled for methodological
differences (time of study, sampling, diagnostic standards, instruments, analyses)

* Remains conservative, data in 65+ still lacking!

Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76 European Brain Council: Size and burden of Mental Disorders in Europe 2006 Kessler & Wittchen in press: World Mental Health Survey Variation in Europe in press

Depression is an illness of all ages,

birth Old age

12-months rates (%)

20

Males
15
13,5

Females
13,4 12,5 12,4

10,5

Range of findings

10
6,4 6,8 5,8 6,1

?
5,4

5
1,9 2,3

0 <15 15-25 26-35 36-45 46-55 56-65 66+

.. and affects Europeans particularly frequent during peak developmental and earning years and among women during the reproductive years!

Depression a complex disorder of brain and body

Depressive illnesses can occur in milder or very severe forms, are often
episodic (about 1/3); and can be recurrent (1/3) or even chronic (1/3)

age

single episode Recurrent episodes Chronic

age age 50% of episodes remit within 3 months, comorbid depression: 7 months the longer the episode - the lower the probability of remission

Depression challenges

women more frequently than males (hormonal cycle, caregiver/multiple roles, trauma?) Comorbidity: most depression patient suffer from several disorders Disability: Academic/work failure/underperformance, early retirment and disability Suicide attempts, suicide, other reasons of premature mortality (somatic illnesses)

Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76. Spijker et al 2001, Wittchen & Kessler 2002)

Depression is treatable!
Effective drug and psychological treatments exist (e.g. cognitive-behavioral
psychotherapy, 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)

Depression is treatable - but is it preventable?

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)

Wittchen & Hoyer 2008

The societal burden of depression has only recently been fully appreciated

Years Lived with Disability (YLD) and Disability Adjusted Life Years (DALY) are two time-related metric indicators to quantify the burden of diseases allowing for direct comparisons between diseases In the 90ies, the Global Burden of Disease experts estimated that: disorders of the brain account for over 31% of all YLDs worldwide and depression alone for 11% In terms of DALYS, they ranked depression as no. 4 worldwide, contributing 3.7% of all DALYS. It is projected that depression will become number 1 in the year 2020
A= lived in full health B= lived not in full health C=time lost to premature mortality
Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76.

These past burden of disease estimations (1990 data) were problematic, and do not adequately reflect the situation in the EU!
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 on dependent family members

Society (direct and indirect health and social costs)

Years lived with disability (1990)

Disease burden Depression (1990)

I. The future has arrived - depression burden in EU ranks already No 1

The burden of depression in the EU has already become the most challenging public health burden: Reasons?
1. Improved data on disability burden, revealing that disorders of the brain account for about 40% of the total burden
Proportion (%) depression
15 1990 2000 2005 2030

disability due to any somatic disorder 53%

disability due to disorders of the brain 44%

10 7,8

9,2

9,8

other 3%

2. Higher depression estimates

5,2 5

Markedly higher DALY proportions due to depression! Depression DALY ranks number 1 in 17 EU-states

0 1990 2000 2005 2030

Proportion (%) vary by country (5.2% to 12.1%)

Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76.

II. The burden is not equally distributed

Among all Disorder of the brain depression is responsible for the largest disability burden - particularly for females!
Proportion (%)of all neuropsychiatric DALYS
70
63 60,1

High disability burden even in early years Women carry by far the greatest depression burden For women in the reproductive years, depression accounts for 17-19% of all causes DALYs! Estimates after age 65* remain contradictory and problematic!
10,1

60 50 40
34,2 30,9 34,5 29,9 24,7 23,1

Males Females

30 20 10
0 0

27,6

16,8

5,4 2,2

3,5

0 0-4 5-14 15-29 30-44 45-59 50-69 70-79 80+

Age groups
Wittchen et al, in press; European Health Report 2005

Depression accounts for almost 1/3 of all direct and indirect costs of disorders of the brain
All brain disorders: Health care costs: Direct non-medical Indirect costs: 386.176 billion 135.446 72.201 178.529

Mental disorders

Mental disorders
(w.o depression:

294.719
176.053)

Health care costs: Direct non-medical Indirect costs:

110.061 51.673 132.985

Neurosurgical disorders Health care costs: 4.099 Direct non-medical 269 Indirect costs: 3.155

Depression 118.000
Neurological disorders Health care costs: 21.286 Direct non-medical 20.259 Indirect costs: 42.389

Depression Health care costs: Direct non-medical Indirect costs:

42.000 2.259 74.389

The total cost of brain disorders and depression in Europe by disease area ( PPP billion) Andlin-Sobocki et al 2005

Distribution of depression cost is characterized by high indirect costs

Resource items depression
hospitalization medication outpatient care social services informal care other direct costs sick leave (absenteeism) early retirement premature death
0
7 8 2 3 8 17

12

Direct costs in Euro Health care costs: 42.000 - outpatient care 22.000 - hospitalisation 10.000 - drug cost 9.000

11

Relatively low direct costs Versus High indirect costs

32

Indirect costs in Euro Indirect costs: 74.389

10

20

30

40

50

The largest economic burden associated with depression is carried by the employers and the social health system

Proportion (%) of total costs Jacobi & Wittchen 2007

Distribution of depression cost is markedly different from other treatable diseases: A comparison with two other common somatic illnesses

Depression

Diabetes

CVD

directhealth care indirect

indirect directhealth care

indirect direct other directhealth care

direct other

direct other

We should increase direct costs (treatment and prevention) for depression to decrease the indirect costs due to disability burden!

Depression is already now Europe`s most costly and debilitating illness (9.2% of all DALYs) Why has the burden of depression persisted or even increased?
15

Artefact of methods and statistics Disease is difficult to detect or diagnose Increasing depression rates? Overwhelming
causes?

DALY proportions (%) of all causes

10 7,8

9,2

9,8

5,2 5

Changes in the constitution of risk groups Effective treatment and prevention is not or
can not been provided

0 1990 2000 2005 2030

Individuals do not seek treatment!

year

Prevention and Early intervention is not provided or effective! Treatment is not effective, too expensive, unavailable or unacceptable!

Why has the burden of depression persisted or even increased?

15 1990 2005 2000 2030

Artefact of methods and statistics Disease is difficult to detect or diagnose Increasing depression rates? Epidemic? Overwhelming causes?
5 10 7,8 9,2 9,8

5,2

Changes in the constitution of risk groups (eg increase in elderly or high risk groups) Effective treatment and prevention is or can not been provided
0 1990 2000 2005 2030

DALY estimates

Individuals do not seek treatment! Prevention and Early intervention is not provided or effective! Treatment is not effective, too expensive, unavailable or unacceptable!

Evidence for increasing depression rates in the past? Probably yes but little evidence for continued increases!
Cum. Incidence % (Kaplan Maeier)
20

Birth cohort
18 16 14 12 10 8 6 4 2 0
0
10 20 30 40

1940 1950 1960 1970 1980

Strong evidence for a substantial increase in depression risk since the 60ies in industrialized countries. Strong evidence for increased rates in the young! Age of onset shifted forward Earlier and more frequent! These effect seem to have weakened though in the past 15 years. No evidence for epidemic Nor overwhelming causes!
50
60

Age of onset depression

Cross-National Group, JAMA Mauz & Jacobi 2008

Increase due to longer life expectancy? Population 65+ is increasing! Age-related disorders, associated with increased risk for depression
Selected diseases among subjects aged 65+ by their depression risk elevation (ref.:
persons w.o. condition)
RR for Depression

Effect of comorbidity
10

Disease 3
Alzheimer dementia 1 Parkinsons Disease 2 Stroke Other neurological dis. Cardio-vascular dis. Cancer Musculo-skeletal dis.

Risk association depression (RR)

8 6,2

3.2 3.6 4.6 2.9 2.5 1.9 2.1

6 4,4 4 2,5 2 1 0 no one two three four five 6+ 1,6

OR
2,8

Number of diseases 1 Riedel et al 2005 2 Riedel et al 2008 3 Jacobi et al 2005 4 Pieper et al 2008 DETECT)

The risk for major depression increases steadily by number of diseases (Pieper et al 2008; DETECT)

Increase due to the size of high risk populations?

Increasing proportions of the elderly contribute to increased
depression rates among the physically ill and neurodegenerative disorders Despite lower overall estimates of

Neurodegenerative disease Somatic diseases associated with pain Other disabling comorbid somatic diseases

depression in old age evidence of increased rates when other illnesses are present and when ability to function becomes limited The Elderly Paradox!

The situation and trend monitoring in the elderly remains

understudied!

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)?

Did we fail to reduce the burden, because treatment for depression is unavailable, difficult, ineffective and expensive? Not ( or only partly) true! Effective first-line treatments are available Effective treatment delivery is not difficult given appropriate
training

Cost-effectiveness is robustly established Successful EU- (Prevention of Depresion and Suicide Making it Happen) and national programs (eg EAAD)

However, there is still tremendous room for improvement! Providing proactive and earlier treatment Designing and providing early trageted treatment Prevention

Examples for room for improvement

1. Increase treatment rates of depression!
Rates of adequate treatment for depression in the EU: < 10% of all affected
29

2. Initiate treatment sooner!

Spain
49

Social phobia

21

Depression

Netherlands

52

athritis High blood pressure Heart disease

51

Italy

29

90

Germany

41

78

France

43

Diabetes

Action: Belgium, 94 Ensuring access to adequate treatment! 48 Screening is not enough!

51

Asthma
0 20 40

USA
60 80 100

35

20

40

60

80

100

Treatment (%) among selected conditions

Ormel et al 2008; WMH-survey EU data

% of cases with depression in the community with treatment in the year of onset
Wang et al 2007

Designing and providing early targeted treatment in physically ill

Example: Depression and cardiovascular disease Depression increases

5

Odds ratio
(Pieper et al 2007)

risk for cardio-vascular disease

(Blumenthal et al 2009)

risk for worse outcomes in heart failure risk of premature mortality (DETECT 2008)

Bi-directional relationsship?
2

Depression as powerful as traditional risk

factors (cholesterol, hypertension, etc; Eichler 2009)
1
2,5 2,7 1,7

Yet lack of screening programs, treatment

rates in CVD samples with depression < 10%!
DETECT - Pieper et al 2009

0 Premature mortality heart failure CVD

Risk elevation by depression

10

Focus on gender-specific risk groups - providing early targeted treatment

Pregnancy, motherhood and the anxiety depression link

Anxiety (as an early onset primary disorder), depression and
suicidality run in families

Children of mothers and/or fathers with anxiety or

depression 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 substantially reduce these risks

Targeted interventions for anxiety and depression parents can

Martini et al 2008

You cannot be too careful in choosing your parents! Children of anxiety and depression parents are at high for primary anxiety and secondary depression at early ages

Cum Incidence
0,5

Increased risk of child onset by parental disorder

Parental disorders increased the risk many disorders

Psychopathology in offspring

0,4

no parental anxiety parental anx & dep no parental disorder parental depression

OR = 2.6 *

Major Depression

Anxiety or depression in parents

OR = 2.0 *

OR = 3.3 *

OR = 1.5 *

Abuse/Dep. illicit drugs

0,3

Dysthymia
OR = 2.0

OR = 1.5

Nicotinedependence Alcohol

0,2

Panic

OR = 2.3 OR = 1.7 OR = 1.5

OR = 3.1 * dependence OR = 3.1 *

0,1

Agorapho bia Social Phobia Specific Phobia GAD

PTSD

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Age of onset of childs disorder

Odds Ratios are controlled for age and sex of the respondents and comorbid disorders in the parents; no IA * sex; N = 2427;

11

Focus on the risk group with the highest burden

Pregnancy, parenthood, childhood and the anxiety depression link

The familial transmission of anxiety and depression and suicidality can be
prevented (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

Martini et al 2008

Conclusion
it

is already worse than we thought! but we can make a change!

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

manifestations (from primary prevention over treatment to secondary prevention)

Move from general prevention to early targeted intervention . .. within large-scale integrated regional preventive programs to avoid
fragmentation of care

.. With focus on interventions in high risk groups for which causal

pathways are established

Depression is not simply a psychological problem - treatment and

prevention demands an increase in qualified mental health providers

12

From general prevention to targeted early interventions

Prioritize measures and programs to reduce the burden

(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 This implies increases of direct costs (e.g. availability, access, quality) In order to lower the indirect cost mainly responsible for the disease burden

Focus on targeted interventions in high risk groups for which causal

pathways are established (e.g. antenatal, parents, children, comorbid elderly)

rather than broad general primary prevention trials

Focus on regional health structures to encourage concerted action and

fight fragmentation

there is no health without mental health!

13

Depression and suicide

Fact sheet I: Depression in Europe

Every given year, about 9% of population suffers from a depressive disorder (21 millions) About 7% meet criteria for major depression (approx 18 million) The lifetime risk for depression is considerably higher: Every 4th person in the EU has or will suffer a depression in the course of their life (24%) Females have a considerably higher lifetime risk and about two times higher rates as males Rates of depression differ by country (sociodemographic factors) however there is little variation between countries and regions when controlling for methodologcal factors The incidence of depression is low in childhood/adolescence and steeply and consistently increases over the life span (depression can occur at any point in life!) Prevalence of major depression in the elderly remains understudied! Overall - Depression ranks among the most frequent disorders of the brain and body

14

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 be powerful 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

Facets of Burden

The burden of depression children of depressed parents Pregnancy, birth and depression The depressed child increseaed risk for adverse social and mental
devleopmental unless treated

Depression and the heart: Depression and physical health Depression and the elderly Caregiver burden Burden reduction Cost

15

Filling the research gaps

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

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 direct treatment costs are comparatively low Challenges in fighting the burden of depression Increase direct costs (access, availability, quality of treatments and care) Lower indirect cost (earlier treatment, targeted treatment and prevention, etc) Changing the situation requires concerted action on all levels and prioritization

16

The Situation

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

Only 50% of all 12-month depression cases receive treatment! Even in the most developed health care system
Health care sector
primary care other mental health psychologists psychiatrist inpatient any treatment no treatment 0 10 20
11,1 49,1 50,1 24,6 18,8 21,5 18,0

Note! Treatment rates within EU from a low of 24% to a high of 51.6% Although primary care is in all countries the most frequent provider, rates vary from 21% to 43%! Any contact is counted irrespective of intensity or appropriateness

30

40

50

60
Wittchen & Jacobi 2005

% of all 12-month depressed patients with treatment contact

ECNP-Task Force Report 2005 : Size and burden of Mental Disorders in the EU

17

II. Prevalence and incidence: Special features

Mental Disorders and Depression Are Frequently Comorbid: 12-Month Comorbidities Among Mental Disorders
OR anxiety with Substance: 2.6 Depression: 6.9 Somatoform: 3.4

54.3% of anxiety disorders are comorbid

60.2% of affective disorders

OR depression with Anxiety: 7.0 Substance: 2.7 Somatoform: 3.5

41.2% of substance disorders 49.2% of somatoform disorders

OR substance with Anxiety: 2.5 Depression: 2.7 Somatoform: 1.9

OR somatoform with Anxiety: 3.5 Substance: 2.1 Depression: 3.5

Bittner et al. 2004. APS

(Wittchen & Jacobi, 2005; adapted from ESEMeD/ MHEDEA 2000 Investigators, 2004)

Ich brauche die DALY und oder YLD getrennt nach Altersgruppe und Geschlecht
6% no consultation only drug treatment 5% only psychological treatment 14% 63% drug and psychological treatment consultation but no treatment 12%

Treatment of mood disorders (12-month) in the EU

Bitte machen

And: Depression often under-recognized in primary care; e.g. Wittchen, 2000:

26% not recognized, 19% other diagnoses, 39% recognized as definite, 16% recognized as probable

18

I. Methods

Epidemiological approaches
Unselected sample of the general population (or
fractions thereof)
Epidemiological methods allow a representative description of patterns of morbidity and supplement and complement clinical research findings

Sample of persons at risk (i.e. with anxiety, after stressful events) Persons in primary care Persons in treatment settings

Treated patients
(adaequate/inadaequate)
Clinical research

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 Greece Germany Finland US Portugal Poland European Region Hungary Romania Russia 56 58 60 62 64 66 68 70 72 74 Japan Spain France Italy Sweden Finland Austria EU-15 average Germany Israel Netherlands Greece Portugal UK US Poland

* Only rounded data available for 2005

Males

European Region Hungary

Females
1995 2005
56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86

1995 2005
76 78 80 82 84 86

Romania Russia

UNECE Statistical Division Database, compiled from national and international official sources (WHO, EUROSTAT, UNICEF Transmonee) (www.unece.org/stats/data, accessed 9 August 2007). WHO Statistical Information System (WHOSIS) / World Health Statistics 2007.

19

II. Prevalence

12-month prevalence (%, 95% CI) and estimated number of subjects affected 12 affected in 12-month the EU
eating disorders ill. subst. dep. OCD psychotic disorders bipolar disorder agoraphobia GAD panic disorder social phobia alcohol dependence somatof. disorders specific phobias major depression 0
Note:
Numbers add up to more than 27% and 82 million subjects because subjects can have more than one disorder (comorbidity)

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)
18.9 Mio. (12.6-21.1) 18.4 Mio. (17.2-19.0) 18.5 Mio. (14.3-18.6)

Wittchen & Jacobi (2005), Neuropsychopharmacology

II. Prevalence

The Lifetime risk up to age 60 is even higher!

DSM-IV mental disorders
Any mental disorder Nicotine dependence Drug dependence Alcohol dependence Psychotic disorders Any mood disorder Any anxiety disorder Eating disorders 0
Any mood disorder includes: Major depression, bipolar, dysthymia

12-month lifetime risk

Because only full threshold depressive disorders are assessed in the 12month prevalence (blue), parally remitted, prodromal, and lifetime cases add to the overall lifetime estimate (orange)

10

20

30

40

50

12-month prevalence and lifetime risk

Wittchen & Jacobi 2005

ECNP-Task Force Report 2005 : Size and burden of Mental Disorders in the EU

20

The lifetime risk of depressive disorders of males and females in the community up to age 65
Cumulative hazard rate (%) 35 Incidence Major depression and Dystymia
Lifetime risk estimate Females: 35%

30 25 20 15 10 5 0 0
NGS: Wittchen et al (1999),

depression - total depression females depression males

Total: 24%

Males 21%

10

15

20

25

30

35

40

45

50

55

60

Age of onset (years)

Wittchen & Jacobi 2005

Prevalence estimates of depression in community studies

Age of subject when examined, eg 45

Point prevalence3 mean: 3.4% (range: 1.2-6.5) 12-month prevalence2,3 mean: 6.9% (IQR: 4.8-8.0) Lifetime prevalence1 MD: 11.1% (IQR = 7.9-13.8) Lifetime risk for MDE (up to 75)4 16.3%

Point prevalence

12-Months prevalence

Lifetime prevalence

Lifetime risk

Age 75

Based on epidemiological evidence, we estimate that 20.8 million women and men in the EU suffer each year from depression
1. Wittchen et al. Arch Gen Psychiatry. 1994;51(5):355-64. 2. Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76. 3. Lieb et al. Eur Neuropsychopharmacol. 2005;15(4):445-52. 4. Kessler et al 2005. Arch Gen Psychiatry. 2005;62(6):617-27.

21

IV. Is depression increasing?

Is this trend continuing? Most current German examination in birth cohorts

0.00 0.05 0.10 0.15 0.20 0.25 0.30

Cumulative lifetime incidence of Major Depression

Shifting forward of age of onset

Proportion

10

20

30

40

50 1965-1974 1945-1954

60

65

Age
Birth cohorts
1974-1981 1955-1964 1935-1944

Evidence for Increasing Rates of depression in succeivly younger birth cohorts

Comorbid secondary depression

cumulative lifetime probability in % 20
Birth cohorts

Pure and primary MD

cumulative lifetime probability

0,090 0,080 0,070 0,060 0,050 0,040 0,030 0,020 0,010

Any depressive disorder
Birth cohorts

15

Chi-2 (df=3)= 71,6; p<0.05 Any depressive disorder

15-14 25-34 35-44

15-14 25-34 35-44 45-54

10

45-54 55-64

0 0 5 10 15 20 25 30 35 Alter 40 45 50 55 60 65

Age of onset in years

0,000 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Alter

Age of onset in years

Kessler et al NCS 2002 Kessler et al (1996)

22

II. Prevalence and incidence: Special features

Suicide attempts in cross national study standardised by psychological disorder

Suicide attempt Rate/100 (SE) among Major depression Any anxiety
US ECA (1980s)** NCS (1990s), Edmonton, Canada Puerto Rico Savigny, France West Germany Taiwan Korea New Zealand 3.13 (0.19) 3.12 (0.36) 6.08 (0.69) 3.27 (0.59) 3.08 (0.91) 1.32 (0.12) 3.81 (0.28) 3.56 (0.57) 3.13 (0.19) 4.33 (0.42) 6.38 (0.71) 4.23 (0.65) 3.39 (0.95) 1.22 (0.12) 3.80 (0.29) 4.75 (0.65) 3.13 (0.19) 3.76 (0.39) 7.05 (0.82) 3.50 (0.97) 1.92 (0.19) 3.69 (0.30) 4.35 (0.62)

Alcohol/drug*

Across studies 1/3 of all cases of major depression attempt suicide However due to comorbidity rates are also high in anxiety and addictive disorders Comorbidity increases the risk of suicide attempts and suicide two- to threefold
Rates of abuse or dependence; ** Epidemiologic Catchment Area study; National Comorbidity Study, ages 18-64 years

Weissman et al (1999)

Conclusion: Estimates for depression are considerably different depending on what we are interested in
Lifetime risk estimate

24%
Total: 24%

15%
Note! The true prevalence of 1month and 1-year might be higher. This is because subthreshold depression (prodromal or residual) and successfully treated depression patients without current symptoms are not considered!

Lifetime prevalence Total: 15% 12-month prevalence Total: 6.9% 1-month prevalence Total: 4.1%

6.9% 4.1%

Wittchen & Jacobi 2005, BGS Wittchen et al 2005

23

IV. Is depression increasing?

In Western countries depressive disorders

in the community are increasing
Consistent evidence for successively higher incidence in young cohorts; age of onset for fisrt episode of depression is decreasing Subjects born after 1934 have twice the risk, those born after 1964 almost three 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

Depression may occur at any point in life in females twice as often as in males cumulative incidence (%)
of MDE (Kaplan-Meier)
childhood

12-months prevalence of MDE

20

0,35

males females
15
13,5 13,4 12,5

0,30

Males Females

Few
12,4 data

0,25

0,20

10
6,8

9,5

0,15
6,4 5,8 6,1 5,4

0,10

0,05

0 1524
10

26-35

36-45

34-55

Old age 56-65 65

0,00

Age at onset of 1st depressive episode

Wittchen et al. Arch Gen Psychiatry. 1994;51(5):355-64. Wittchen & Jacobi. Eur Neuropsychopharmacol. 2005;15(4):357-76.

24

III. Prevalence in primary care

Depression 2000

Point prevalence of depression in primary care by age group

Point-Prevalence in %
16
Males Females Total
11,9 10,9 9,4

14 12 10 8 6 4 2 0 16-19 20-29 30-39 40-49 50-59 60-69 >70 Total

N=20.304 primary care patients Year 2001 Point prevalence ICD-10 depression according to DSQ As compared to the community (4%) 2-3 times higher rates!

Age groups

Wittchen et al JCP 2004

Fact sheets

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 Indications for increasing rates in the past and levelling off more recently

Data about depression in children are deficient And data about the elderly 65+ are largely lacking EU action: MentDis 65+ on ist way!

25

The burden of depression as a proportion of all causes and 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 disease findings supported this projection

26

The largest economic burden associated with depression is carried by the employers and the social health system

reduced productivity absenteeism suicide related costs medication outpatient Inpatient

0
8,9 5,5

15,3

36,3

Work place costs: 51,5%

10,4

11,9

Direct treatment costs: 31%

10

20

30

40

50
Kessler & Wittchen 2007

proportion (%) of depression costs

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!

Overwhelming causes for depression?

In the EU, there is little evidence that we are overwhelmed by the putative causes of depression (increases in risk groups,, environmental stress, genes etc) or the provision of treatment In contrast - selected evidence that we have effectively reduced the burden in some areas (for example reduction of suicide rates)

Probably not!

27

Evidence in the consititution of risk groups? Life expectancy continues to grow in the EU! Proportion of population aged 65+ is increasing!

Males 1995-2005: 76,8in the Increase in life expectancy EU-15 from 1995 to 2005: Increase

Males: Females:

73,7 to 77.7 80.0 to 82.7

The risk of depression in the Elderly does not seem to increase in general, but only when other illnesses are present and when ability to function becomes limited The Elderly Paradox!

28

This paper was produced for a meeting organized by Health & Consumers DG 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 & Consumers DG'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.