Baumeister

Clarke

Cuijpers

Mrazek

Muñoz

Rovner

Schoevers

Smit

Van‘T Veer-Tazelaar

Cuijpers, P.

Smit, H.F.E.

DSpace at VU

Editorial
Has time come for broad-scale dissemination
for prevention of depressive disorders?
It has long been thought that it is not possible to
prevent the onset of mental disorders such as
depression, because the processes involved in the
etiology are too complex and not yet sufﬁciently
understood. However, in the past 15 years, the
knowledge about identifying target groups for
prevention and about the effects of preventive
interventions has increased considerably. In the
1990s the ﬁrst studies were conducted which
examined the effects of preventive interventions
on the incidence of depressive disorders in people
who did not meet diagnostic criteria for a depres-
sive disorder (1, 2). In a recent meta-analytic
review, we found 19 studies examining the eﬀects
of preventive interventions on the incidence of
depression (3). This meta-analysis demonstrated
that preventive interventions reduce the incidence
of depressive disorders with 22% compared with
control groups who did not receive the interven-
tions. This is a statistically signiﬁcant ﬁnding
(P < 0.01), which supports the idea that preven-
tive interventions are actually capable of prevent-
ing the onset of depressive disorders in some cases.
Most researchers and practitioners deﬁne pre-
vention as interventions that are conducted before
people meet the criteria of a depressive disorder
according to the DSM-IV (4). Three types of
prevention can be discerned: universal prevention,
which is aimed at the general population or parts
of the general population, regardless of whether
they are at elevated risk of developing a disorder
(e.g. school programs or mass media campaigns);
selective prevention which is aimed at high-risk
groups, who have not yet developed a mental
disorder; and indicated prevention which is aimed
at individuals who have some symptoms of a
mental disorder but do not meet diagnostic criteria.
In our meta-analysis we found no indication that
universal prevention was effective in reducing the
incidence of depressive disorders. We did ﬁnd
indications that prevention, directed at people
presenting with subthreshold depression is effec-
tive. It could be argued that indicated prevention
may not be actual prevention at all, because these
symptoms could be a part of the prodromal phase
of the disorder, and prevention is in fact early
intervention in such cases, intervening in a process
which has already started. However, our meta-
analysis showed that selective prevention is also
effective, suggesting that prevention of new cases is
indeed possible. To be more speciﬁc, these preven-
tive interventions are aimed at high-risk groups,
such as pregnant women and general medical
patients (5).
Although preventive interventions have been
found to be effective in reducing the incidence of
depressive disorders, more research in this area is
clearly needed. One important challenge for future
research is to improve the interventions efﬁcacy. In
our meta-analysis, we found that preventive inter-
ventions reduce the incidence rate with 22%. We
found some indications that interventions based on
interpersonal psychotherapy may result in greater
reductions in incidence. Another possibility to
improve efﬁcacy is to use stepped-care approaches
in indicated preventive interventions (6). When
someone has a subthreshold depression, it seems
logical to monitor these symptoms regularly and
when they do not improve, a non-intrusive inter-
vention seems to be the best option. If such an
intervention is not suﬃcient to ameliorate the
symptoms, a more intensive intervention should be
used, and when that fails, full pharmacological and
psychological treatment can be applied. A series of
trials examining the possibility of stepped care in
prevention has recently started (6) and the out-
comes are impressive.
Another area where future research is necessary,
concerns deﬁning the best target populations for
preventive interventions. Methods to identify the
most optimal target populations for prevention
have been developed recently (7–9). In this line of
research, epidemiological cohort data can be used
to identify those target groups in which a maxi-
mum health gain can be generated against a
minimal eﬀort. To illustrate, it was shown in one
study that older adults with subthreshold depres-
sion, functional limitations, a small social network
and a female gender comprise only 8% of the total
population, while 25% of the total number of
Acta Psychiatr Scand 2008: 118: 419–420
All rights reserved
DOI: 10.1111/j.1600-0447.2008.01294.x
Copyright  2008 The Authors
Journal Compilation  2008 Blackwell Munksgaard
ACTA PSYCHIATRICA
SCANDINAVICA
419
incident cases stem from this group (7). The next
step in this line of research would be to conduct
preventive trials speciﬁcally directed at these ultra-
high-risk groups.
One other important way of identifying the
optimal target groups for preventive interventions
is to improve the deﬁnition of subthreshold
depression. Indicated prevention is directed at
people with subthreshold depression and identify-
ing those persons with the highest risk of develop-
ing a depressive disorder could possibly improve
the eﬀectiveness of preventive interventions. As we
have discussed earlier (10), there is little doubt that
people with subthreshold depression are at
increased risk of developing a depressive disorder.
However, how large that risk is depends very much
on how subthreshold depression is deﬁned. The
paper by Baumeister and Morar in this issue (11)
shows that the prevalence of subthreshold depres-
sion is much lower when clinical signiﬁcance
criteria are included in the deﬁnition. It seems
very well possible that the risk of developing a
depressive disorder in this subset is higher than in
other groups with subthreshold depression and,
accordingly, that preventive interventions are more
eﬀective in this group.
Now, has the time come to start disseminating
preventive interventions in routine practice? The
answer should be a cautious yes. Our meta-analysis
shows that it is possible to prevent the incidence of
depressive disorders. The next step then is to
examine how this knowledge can be applied in
routine practice. In the Netherlands, for example,
preventive services for depression are already
offered on a regular basis in most mental health
services. The Coping with Depression course,
which is a preventive intervention aimed at persons
with subthreshold depression, is currently available
for 80% of the general population in the Nether-
lands (12). At the same time, we must be cautious
about starting to disseminate preventive interven-
tions. As indicated, many research questions still
have to be answered. Furthermore, the preventive
interventions we have included in our meta-anal-
ysis have been examined in several settings, includ-
ing the school setting, prenatal health services and
general medical settings. In our meta-analysis we
did not ﬁnd evidence that interventions in each of
these settings were equally eﬀective. Only when we
pooled all studies together the results were statis-
tically signiﬁcant. So, it seems to be advisable to
start with pilot projects for dissemination, com-
bined with research on the eﬀectiveness in routine
practice settings.
It is encouraging, however, that prevention of
new cases of depressive disorders seems to be
feasible and effective. As an adjunctive to treat-
ment, prevention may play an important role in
public mental health to reduce the enormous
burden of depression. The development of evi-
dence-based prevention of depression and other
mental disorders should be an important scientiﬁc
and public health objective for the 21st century.
Acta Psychiatrica Scandinavica
Pim Cuijpers and Filip Smit
Invited Guest Editors
References
1. Mun˜oz RF, Ying YW, Bernal G et al. Prevention of
depression with primary care patients: a randomized con-
trolled trial. Am J Commun Psychol 1995;23:199–222.
2. Clarke GN, HawkinsW,MurphyM, Sheeber LB, Lewinsohn
PM, Seeley JR. Targeted prevention of unipolar depressive
disorder in an at-risk sample of high school adolescents: a
randomized trial of a group cognitive intervention. J Am
Acad Child Adol Psychiatry 1995;34:312–321.
3. Cuijpers P, Van Straten A, Smit F, Beekman A. Preventing
the onset of depressive disorders: A meta-analytic review of
psychological interventions. Am J Psychiatry 2008;165:
1272–1280.
4. Mrazek PJ, Haggerty R (Ed). Reducing risks of mental
disorder: Frontiers for preventive intervention research.
Washington, DC: National Academy Press, 1994.
5. Rovner BW, Casten RJ, Hegel MT, Leiby BE, Tasman WS.
Preventing depression in age-related macular degeneration.
Arch Gen Psychiatry 2007;64:886–892.
6. VanT Veer-Tazelaar PJ, Van Marwijk HWJ, Van Oppen P
et al. Prevention of anxiety and depression in the age
group of 75 years and over: a randomised controlled trial
testing the feasibility and effectiveness of a generic stepped
care programme among elderly community residents at
high risk of developing anxiety and depression versus usual
care. BMC Publ Health 2006;6:186.
7. Smit F, Ederveen A, Cuijpers P, Deeg D, Beekman A.
Opportunities for cost-effective prevention of late-life
depression: An epidemiological approach. Arch Gen Psy-
chiatry 2006;63:290–296.
8. Smit F, Comijs HC, Schoevers R, Cuijpers P, Deeg D,
Beekman A. Target groups for the prevention of late-life
anxiety. Br J Psychiatry 2007;190:428–434.
9. Schoevers RA, Smit F, Deeg DJH et al. Prevention of late-
life depression in primary care; do we know where to
begin? Am J Psychiatry 2006;163:1611–1621.
10. Cuijpers P, Smit F. Subthreshold depression as a risk indi-
cator for major depressive disorder: a systematic review of
prospective studies. Acta Psychiatr Scand 2004;109:325–
331.
11. Baumeister H, Morar V. The impact of clinical signiﬁcance
criteria on subthreshold depression prevalence rates. Acta
Psychiatr Scand 2008;118:443–450.
12. Cuijpers P. A psycho-educational approach to the treatment
of depression; a meta-analysis of Lewinsohns Coping with
Depression course. Behav Ther 1998;29:521–533.
Editorial
420



Has time come for broad-scale dissemination for prevention of depressive disorders?

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VU Research Portal

VU Research PortalHas time come for broad-scale dissemination for prevention of depressive disorders?Cuijpers, P.; Smit, H.F.E.published inActa psychiatrica scandinavica2008DOI (link to publisher)10.1111/j.1600-0447.2008.01294.xdocument versionPublisher's PDF, also known as Version of recordLink to publication in VU Research Portalcitation for published version (APA)Cuijpers, P., & Smit, H. F. E. (2008). Has time come for broad-scale dissemination for prevention of depressivedisorders? Acta psychiatrica scandinavica, 118(6), 419-420. https://doi.org/10.1111/j.1600-0447.2008.01294.xGeneral rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.E-mail address:vuresearchportal.ub@vu.nlDownload date: 23. May. 2021EditorialHas time come for broad-scale disseminationfor prevention of depressive disorders?It has long been thought that it is not possible toprevent the onset of mental disorders such asdepression, because the processes involved in theetiology are too complex and not yet sufficientlyunderstood. However, in the past 15 years, theknowledge about identifying target groups forprevention and about the effects of preventiveinterventions has increased considerably. In the1990s the first studies were conducted whichexamined the effects of preventive interventionson the incidence of depressive disorders in peoplewho did not meet diagnostic criteria for a depres-sive disorder (1, 2). In a recent meta-analyticreview, we found 19 studies examining the effectsof preventive interventions on the incidence ofdepression (3). This meta-analysis demonstratedthat preventive interventions reduce the incidenceof depressive disorders with 22% compared withcontrol groups who did not receive the interven-tions. This is a statistically significant finding(P < 0.01), which supports the idea that preven-tive interventions are actually capable of prevent-ing the onset of depressive disorders in some cases.Most researchers and practitioners define pre-vention as interventions that are conducted beforepeople meet the criteria of a depressive disorderaccording to the DSM-IV (4). Three types ofprevention can be discerned: universal prevention,which is aimed at the general population or partsof the general population, regardless of whetherthey are at elevated risk of developing a disorder(e.g. school programs or mass media campaigns);selective prevention which is aimed at high-riskgroups, who have not yet developed a mentaldisorder; and indicated prevention which is aimedat individuals who have some symptoms of amental disorder but do not meet diagnostic criteria.In our meta-analysis we found no indication thatuniversal prevention was effective in reducing theincidence of depressive disorders. We did findindications that prevention, directed at peoplepresenting with subthreshold depression is effec-tive. It could be argued that indicated preventionmay not be actual prevention at all, because thesesymptoms could be a part of the prodromal phaseof the disorder, and prevention is in fact earlyintervention in such cases, intervening in a processwhich has already started. However, our meta-analysis showed that selective prevention is alsoeffective, suggesting that prevention of new cases isindeed possible. To be more specific, these preven-tive interventions are aimed at high-risk groups,such as pregnant women and general medicalpatients (5).Although preventive interventions have beenfound to be effective in reducing the incidence ofdepressive disorders, more research in this area isclearly needed. One important challenge for futureresearch is to improve the interventions efficacy. Inour meta-analysis, we found that preventive inter-ventions reduce the incidence rate with 22%. Wefound some indications that interventions based oninterpersonal psychotherapy may result in greaterreductions in incidence. Another possibility toimprove efficacy is to use stepped-care approachesin indicated preventive interventions (6). Whensomeone has a subthreshold depression, it seemslogical to monitor these symptoms regularly andwhen they do not improve, a non-intrusive inter-vention seems to be the best option. If such anintervention is not sufficient to ameliorate thesymptoms, a more intensive intervention should beused, and when that fails, full pharmacological andpsychological treatment can be applied. A series oftrials examining the possibility of stepped care inprevention has recently started (6) and the out-comes are impressive.Another area where future research is necessary,concerns defining the best target populations forpreventive interventions. Methods to identify themost optimal target populations for preventionhave been developed recently (7–9). In this line ofresearch, epidemiological cohort data can be usedto identify those target groups in which a maxi-mum health gain can be generated against aminimal effort. To illustrate, it was shown in onestudy that older adults with subthreshold depres-sion, functional limitations, a small social networkand a female gender comprise only 8% of the totalpopulation, while 25% of the total number ofActa Psychiatr Scand 2008: 118: 419–420All rights reservedDOI: 10.1111/j.1600-0447.2008.01294.xCopyright  2008 The AuthorsJournal Compilation  2008 Blackwell MunksgaardACTA PSYCHIATRICASCANDINAVICA419incident cases stem from this group (7). The nextstep in this line of research would be to conductpreventive trials specifically directed at these ultra-high-risk groups.One other important way of identifying theoptimal target groups for preventive interventionsis to improve the definition of subthresholddepression. Indicated prevention is directed atpeople with subthreshold depression and identify-ing those persons with the highest risk of develop-ing a depressive disorder could possibly improvethe effectiveness of preventive interventions. As wehave discussed earlier (10), there is little doubt thatpeople with subthreshold depression are atincreased risk of developing a depressive disorder.However, how large that risk is depends very muchon how subthreshold depression is defined. Thepaper by Baumeister and Morar in this issue (11)shows that the prevalence of subthreshold depres-sion is much lower when clinical significancecriteria are included in the definition. It seemsvery well possible that the risk of developing adepressive disorder in this subset is higher than inother groups with subthreshold depression and,accordingly, that preventive interventions are moreeffective in this group.Now, has the time come to start disseminatingpreventive interventions in routine practice? Theanswer should be a cautious yes. Our meta-analysisshows that it is possible to prevent the incidence ofdepressive disorders. The next step then is toexamine how this knowledge can be applied inroutine practice. In the Netherlands, for example,preventive services for depression are alreadyoffered on a regular basis in most mental healthservices. The Coping with Depression course,which is a preventive intervention aimed at personswith subthreshold depression, is currently availablefor 80% of the general population in the Nether-lands (12). At the same time, we must be cautiousabout starting to disseminate preventive interven-tions. As indicated, many research questions stillhave to be answered. Furthermore, the preventiveinterventions we have included in our meta-anal-ysis have been examined in several settings, includ-ing the school setting, prenatal health services andgeneral medical settings. In our meta-analysis wedid not find evidence that interventions in each ofthese settings were equally effective. Only when wepooled all studies together the results were statis-tically significant. So, it seems to be advisable tostart with pilot projects for dissemination, com-bined with research on the effectiveness in routinepractice settings.It is encouraging, however, that prevention ofnew cases of depressive disorders seems to befeasible and effective. As an adjunctive to treat-ment, prevention may play an important role inpublic mental health to reduce the enormousburden of depression. The development of evi-dence-based prevention of depression and othermental disorders should be an important scientificand public health objective for the 21st century.Acta Psychiatrica ScandinavicaPim Cuijpers and Filip SmitInvited Guest EditorsReferences1. Muñoz RF, Ying YW, Bernal G et al. Prevention ofdepression with primary care patients: a randomized con-trolled trial. Am J Commun Psychol 1995;23:199–222.2. Clarke GN, Hawkins W, Murphy M, Sheeber LB, LewinsohnPM, Seeley JR. Targeted prevention of unipolar depressivedisorder in an at-risk sample of high school adolescents: arandomized trial of a group cognitive intervention. J AmAcad Child Adol Psychiatry 1995;34:312–321.3. Cuijpers P, Van Straten A, Smit F, Beekman A. Preventingthe onset of depressive disorders: A meta-analytic review ofpsychological interventions. Am J Psychiatry 2008;165:1272–1280.4. Mrazek PJ, Haggerty R (Ed). Reducing risks of mentaldisorder: Frontiers for preventive intervention research.Washington, DC: National Academy Press, 1994.5. Rovner BW, Casten RJ, Hegel MT, Leiby BE, Tasman WS.Preventing depression in age-related macular degeneration.Arch Gen Psychiatry 2007;64:886–892.6. VanT Veer-Tazelaar PJ, Van Marwijk HWJ, Van Oppen Pet al. Prevention of anxiety and depression in the agegroup of 75 years and over: a randomised controlled trialtesting the feasibility and effectiveness of a generic steppedcare programme among elderly community residents athigh risk of developing anxiety and depression versus usualcare. BMC Publ Health 2006;6:186.7. Smit F, Ederveen A, Cuijpers P, Deeg D, Beekman A.Opportunities for cost-effective prevention of late-lifedepression: An epidemiological approach. Arch Gen Psy-chiatry 2006;63:290–296.8. Smit F, Comijs HC, Schoevers R, Cuijpers P, Deeg D,Beekman A. Target groups for the prevention of late-lifeanxiety. Br J Psychiatry 2007;190:428–434.9. Schoevers RA, Smit F, Deeg DJH et al. Prevention of late-life depression in primary care; do we know where tobegin? Am J Psychiatry 2006;163:1611–1621.10. Cuijpers P, Smit F. Subthreshold depression as a risk indi-cator for major depressive disorder: a systematic review ofprospective studies. Acta Psychiatr Scand 2004;109:325–331.11. Baumeister H, Morar V. The impact of clinical significancecriteria on subthreshold depression prevalence rates. ActaPsychiatr Scand 2008;118:443–450.12. Cuijpers P. A psycho-educational approach to the treatmentof depression; a meta-analysis of Lewinsohns Coping withDepression course. Behav Ther 1998;29:521–533.Editorial420

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Has time come for broad-scale dissemination for prevention of depressive disorders?

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