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Prevention of depression and promotion of resilience in
Europe
12.11.2015
An expert paper for the EU Group of Governmental Experts on Mental Health and Wellbeing, prepared
under the EC Compass Tender.
Prof. Kristian Wahlbeck, The Finnish Association for Mental Health
Prof. Pim Cuijpers, Vrije Universiteit Amsterdam
Prof. Arne Holte, Norwegian Institute of Public Health
Loss of productivity due to depression is of growing concern in Europe. Implementing effective measures to
promote resilience and prevent depression will potentially result in huge societal savings. A major
reduction in the incidence of depression throughout Europe is feasible using existing prevention methods.
The burden of depression
Depression is a common mental disorder in Europe, causing unnecessary human suffering and an
enormous loss of productivity. Major depressive disorder is estimated to affect 13% of EU citizens at some
point in their lives. Every year around 30 million European citizens suffer from depression. Depression
affects women almost twice as often as men, i.e. one in six women in Europe.1,2
Depression makes a major contribution to the burden of disease because of the typically early onset of the
disorder, unlike many physical disorders which may begin later in life. Depressive disorders are a major
public health concern, constituting 11 % of all years lived with disability (YLD) in the WHO European Region.
According to WHO projections, depression will be the single most important cause of burden of illness in
the EU by 2030, hence draining Europe of large resources of mental capital.
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This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
1
Depressive disorders incur high social and economic costs (approximately 1% of the GDP), and constitute a
major threat to Europe’s productivity and sustainable development. The majority of these costs arise from
loss of productivity.3
Depression is characterised by sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
disturbed sleep or appetite, tiredness, and poor concentration, and can be long-lasting or recurrent.
Depression is frequently comorbid not only with other psychiatric disorders such as anxiety or substance
use disorders, but also with somatic disease such as coronary heart disease, diabetes, obstructive lung
disorders and cancers. 4
Depression substantially impairs the ability to function at work or school, as well as the ability to cope with
daily life. Two-thirds of individuals with depression report severe interference with normal function.5
European data indicate that mood disorders markedly reduce quality of life.6 At its most severe, it can lead
to suicide.
Depression is associated with excess mortality, with depressed people having a 1.5 times higher risk of
dying in the next year in comparison with people who do not have depression.7 This excess mortality is
presumably multifaceted and not only relates to lifestyle factors and higher suicide rates, but also relates to
stigma and insufficient access to health services.8 Depression is a predictor of premature death from noncommunicable somatic disease, of similar strength as tobacco smoking, alcohol abuse, physical inactivity
and malnutrition.9
Risk factors and resilience
Resilience is the ability to cope even in times of hardship, and supports positive development under stress.
The quality of emotional, social and community relationships as well as cognitive factors are influential in
forming resilient individuals and communities. 10
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This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
2
The foundation of adult resilience is built in childhood, hence child-friendly policies and mental health
promotion in child care settings and schools will promote population resilience in the long run.11 Turning
point effects across the lifespan increase opportunities and enhance coping when associated with positive
experiences.
Resilience is dependent on the social context and availability of social support. Thus, resilience is a function
of the interaction between an individual and the social environment. A supportive environment promotes
protective factors and increases resilience.12 Social capital, i.e. social support and trust in others, is a
protective factor against depression and suicide.
The single most important risk factor for depression is adverse childhood events, which increase the risk of
depression in adult life two- to fourfold.13,14,15 Poor parenting, e.g. low level of care and high level of
control, increases the risk for depression in adulthood two- to threefold.16 Childhood sexual and physical
abuse is linked with an approximately twofold risk of adult depression,17 the more severe the abuse, the
higher the risk of major depression.
Bereavement, unemployment, financial insecurity, high level of debt, and lack of social support are all risk
factors for depression in adulthood. A high level of alcohol consumption can also lead to a more serious
course of depression, including earlier onset of the disorder, more episodes of depression and more suicide
attempts.18
Structural societal determinants play a major role in the occurrence of depression, being linked to gender,
poverty, employment status and social exclusion. Exposure to war and armed conflicts, being a refugee as
well as the loss of family, can induce post-traumatic consequences such as depression. Mental health is also
compromised by living in deprived neighbourhoods surrounded by a poor environmental quality, with high
unemployment, poor quality housing and limited access to services. Improved housing conditions can
promote mental health and increase social and community participation.19
Targeting socio-economic disadvantage and inequality may assist in reducing depression. Policy measures
in education, employment and social sectors are important, as socioeconomic deprivation often has longreaching consequences over generations.
Depression prevention
Depression prevention programmes are effective, and can work at multiple levels – individual level, family
level, caregiving level, the larger community level, and the policy level. Effectiveness has been established
for children and adults, yet preventive public health programmes to reduce incidence of depression are not
widely used. 20
The earlier in life initiatives and interventions are implemented, e.g. infancy, pre-school, and early school
age, the better is the return on investments in human capital.21
Technological advances pave the way for increased use of e-health applications for the prevention of
mental disorders and promotion of mental health.22 The role of social media in depression prevention
should not be underestimated. Strengthening and nurturing civic society will create social capital and
cohesion, and promote mental health.
Good urban planning and creating safe and inviting environments is especially important for children. The
focus of such planning includes the safe expansion of zones that foster children’s opportunities for socio______________________________________________________________________________________
This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
3
emotional development. Urban shape and regeneration using zoning strategies, reducing noise levels,
community initiatives to reduce social isolation and public amenities (such as community centres) can
promote urban health, community cohesiveness creating social capital, and helping to reduce stress, social
dislocation and violence.
Alcohol is a major mental health determinant and a leading cause of mental health inequality. Mental
health can be promoted by regulating the alcohol market, despite the fierce opposition and lobbying by the
alcohol industry.
Preventing depression requires combining structural initiatives (e.g. reduce poverty and social inequality),
universal interventions (e.g. mental health literacy) and targeted target interventions (e.g. addressing
school children with enhanced symptoms levels). In order to prevent depression arenas of everyday life
such as the family, child care centres, schools, work places, culture and sports should provide their
members with a “sense of identity and self-respect”, i.e. the feeling of being something, of being something
worth; a “sense of meaning in life” – the feeling of being part of something larger than oneself, that there
are somebody that needs you; a “sense of mastery” – that there is at least something that you are good at;
a “sense of belonging” - the feeling of belong somewhere, that there are somebody that you feel attached
to; a “sense of security” – being able to think, feel and act without being afraid; a “sense of social support”
– that there are somebody that you can share thoughts and feelings with, that knows you, and you know
that cares about you; a “sense of participation and involvement” – that it matters to somebody else what
you do or do not do.
Expert recommendations for prevention of depression in Europe:
1. Adopt a “Mental Health in All Policies” approach
Prevention of depression needs to be mainstreamed into the non-health sectors. For example, involving
child day-care and school settings is a key objective.
Effective public health action to prevent depression requires an intersectoral policy framework at all levels.
A “Mental Health in All Policies” approach acknowledges that causes of depression are numerous, and
predominantly not amendable by the healthcare sector alone. Thus, a successful battle against depression
requires continued willingness to work across sectors, and a readiness to address determinants such as
parent-child interaction, child abuse, bullying, loneliness, alcohol consumption, gender and health
inequalities, over-indebtedness, work-life problems, deprived neighbourhoods and poor social protection.
This approach includes the systematic use of Health Impact Assessment (HIA) to promote intersectoral
healthy policies and equity.
Recommended actions:
• Initiate mental wellbeing assessment as a regular part of public policy and decision making
processes
2. Monitor indicators and set targets
Regular and repeated monitoring of determinants, protective factors and risk factors for depression, as well
as the monitoring of mental health policies is necessary. Benchmarking between countries is possible using
comparative European data from e.g. Health Behaviour in School Children (HBSC) survey, Eurofound
surveys and the European Social Survey. Figure 1 presents an example of existing wellbeing data. On a
national or regional level, measures of depression determinants and protective and risk factors, as well as
mental wellbeing measures can be incorporated into already existing health and wellbeing surveys.
______________________________________________________________________________________
This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
4
Recommended actions:
•
•
Define a set of indicators for monitoring depression, as well as determinants and protective and
risk factors of depression based on available data
Increase policy accountability by publishing monitoring data on a regular basis
Figure 1: Company performance and workplace wellbeing: indices by country (Source: European Company
Survey 2013, Eurofound)
3.
Promote population mental wellbeing
Investing in building mental capital will benefit the whole population universally. Increased resilience and a
reduction of risk factors associated with depression will not only prevent depression but will simultaneously
be of universal benefit for society at large.
A core objective is to promote population mental health literacy, including socio-emotional skills, coping
skills and stress management skills. Acquisition of these skills can be strengthened in childhood by good
parenting and mental health promotion in child-care, pre-school and school settings. Providing access to
good quality affordable childcare centres available for all protects against internalising problems associated
with intra-family socio-economic disadvantage.23
Prior to this, child health clinics and health visitor services have an important role in preventing depression
in women after childbirth. Adequate prenatal care including prevention of postpartum depression
strengthens not only wellbeing in mothers, but also promotes the wellbeing of the child. 24
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This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
5
Intergenerational transmission of mental ill health is well documented, although evidence demonstrates
that parenting support interventions can reduce this risk by 40 %.25 Offspring of people with depression
have a high risk of developing depression, which can be offset by effective family interventions.26 Such
psychoeducational programmes have been successfully implemented even on country-wide basis.27
Recommended actions:
• Train all staff in antenatal and child health clinics in the promotion of mental wellbeing of mothers
before and after childbirth
• Train all staff in child health clinics to support early interaction between parents and child
• Establish a system of affordable, available and accessible parent training courses for new parents
and parents-to-be.
• Provide access to good quality child-care centres for all children
• Train all staff in social and health care to provide psychoeducational support to all families with a
depressed parent
4. Integrate mental health promotion in promotion of healthy lifestyles
A healthy lifestyle can assist in improving or maintaining good mental health. Risk factors related to lifestyle
are established early in life, and follow a socio-economic gradient.
A healthy lifestyle is often associated with higher levels of income and higher levels of education. Also
healthy levels of sleep are important in preventing depression. Studies have repeatedly found a strong link
between regular physical activity and a sense of wellbeing and lower levels of depression, stress and
anxiety.28 29 30 31 Excessive alcohol use is strongly linked with depression, and limiting the availability of
alcohol promotes a healthier lifestyle and prevents depression.
Recommended actions:
• Support everyday physical activity by healthy urban planning
• Free access for all to evidence-based e-mental health interventions to promote healthy sleep
• Restrict availability of alcohol by e.g. age limits, pricing, and sales hours
5. Prevention of depression: Provision of immediate access to psychological support
Data indicates that 20-40 % of new cases of depression can be prevented by evidence-based methods, such
as early low-intensity psychological support. 32,33 Easy access to early support on a local level can be scaled
up by increased involvement of civil society, i.e. experts by experience providing peer support and by lay
people being trained to deliver Mental Health First Aid training courses to the public.34
Free availability of preventive e-mental health interventions is at the core of large scale implementation of
depression prevention and is highly cost-effective. Promising e-interventions based on a cognitivebehavioural framework include components such as healthy sleep, self-acceptance and behavioural
activation.35
Recommended actions:
•
Free access for all to low threshold psychological support including psychoeducation (e.g. Mental
Health First Aid) at a local level
______________________________________________________________________________________
This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
6
•
Free access for all to evidence-based e-mental health interventions to promote wellbeing and
prevent depression
6. Prevention of depression in pre-schools and schools: supporting skills and reducing risk factors
Evidence suggests that training and empowering gatekeepers, both professional and peer based, in preschools and schools is effective for the prevention of depression.36 A core strategy is the “whole school
approach”, i.e. developing pre-schools and schools into mental health promoting organisations.
Automated or assisted internet-based programmes, based on a cognitive behavioural therapy framework,
are successful in preventing depression among adolescent school students.37
Recommended actions:
• Educate all pre-school and school leaders in providing good mental health leadership and in
developing their institutions into mental health promoting organisations in a whole school
approach
• Ensure that training in socio-emotional skills, problem solving, stress management and healthy
lifestyle skills always are included throughout the curriculum
• Ensure that all school staff are trained to support the mental health skills of all students, as well as
to justify focus on mental wellbeing in school
• Provide all students with free access to evidence-based e-mental health interventions to prevent
depression
• Obligate all schools to use evidence-based programmes to eradicate school bullying
7. Prevention of depression in the work place: early detection and intervention
To most people the workplace is a major source of mental wellbeing. However, the workplace may also be
a source of depression. Evidence suggest that both progammes to promote wellbeing and programmes to
early detect, reduce, and prevent depression at the work place are highly cost effective to the companies
that apply them.38,39 Yet, most companies have no such programmes.
Recommended actions:
• Provide all work place leaders with at least a minimum education in good mental health leadership
• Ensure that all larger companies and most medium size companies have a progamme to promote
employee mental wellbeing
• Ensure that all larger employers offer employees enrolment in programs of early detection,
reduction, and prevention of depression at the work place
Acknowledgments: The authors are grateful to Johanna Cresswell-Smith and Johannes Parkkonen for
comments and assistance and Pauliina Mäntyvaara for infographs.
______________________________________________________________________________________
This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
7
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This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
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This report has been prepared under a tender contract with the European Commission (contract 2014-7103), led by the Trimbos Institute in collaboration with The Finnish Association for Mental Health (FAMH),
Universidade NOVA de Lisboa and EuroHealthNet.
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