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Depressive disorders erode quality of life, productivity in the workplace, and fulfillment of social and familial roles. In today's knowledge- and service-driven economies, the population's mental capital (ie, cognitive, emotional, and social skills resources required for role functioning) becomes both more valuable and more vulnerable to the effects of depression. Depressive disorders, severe mental illnesses that should not be confused with normal mood variations, are part of a vicious circle of poverty, discrimination, and poor mental health in middle- and low-income countries.1 These realities also have major economic ramifications: treatment costs of depression are soaring but are only a fragment of the costs of reduced productivity due to depression.2
More than half of those with depression develop a recurrent or chronic disorder after a first depressive episode and are likely to spend more than 20% of their life-time in a depressed condition. With a 12-month prevalence rate of more than 5% in most high-, middle-, and low-income countries and its occurrence at almost any age,3 depression generates substantial loss of quality of life and personal morbidity and despair. But it also leads to considerable additional damage through biological sequelae and maladaptive illness behaviors, thus increasing risk of cardiovascular disease, dementing illnesses, and early death while amplifying disability, complications, and health services use in those with coexisting chronic illnesses. Depression ranks third among disorders responsible for global disease burden, with all the concomitant economic costs to society, and will rank first in high-income countries by 2030.4
Even if it were possible to provide evidence-based treatment to all persons affected by a depressive disorder, the effect on averting years lived with disability would be limited because of the steady influx of new patients and the limited efficacy of currently available treatments.5 Prevention may offer new possibilities to reduce the disease burden of depressive disorders. A report of the Institute of Medicine defined prevention as any intervention aimed at preventing the onset of new cases of mental disorders in people who do not yet meet criteria for such a disorder.6 Prevention may be directed toward the whole population (universal prevention), high-risk groups (selective prevention), or those with subsyndromal symptoms (indicated prevention). More than 30 randomized trials have demonstrated that preventive interventions can reduce the incidence of new episodes of major depressive disorder by about 25% and by as much as 50% when preventive interventions are offered in stepped-care format.7 Methods with proven effectiveness involve educational, psychotherapeutic, pharmacological, lifestyle, and nutritional interventions.
Cost-effectiveness ratios for preventive interventions are attractive,2 with numbers needed to treat to prevent 1 case of depression ranging between 8 and 10,7 an effect size comparing favorably with established preventive interventions for other conditions (eg, number needed to treat=21 using statins for 5 years to prevent another myocardial infarction).8 In addition, the financial costs of averting 1 year lived with depression-related disability is below the current ceiling of $30 000 to $50 000 generally accepted by policy makers as cost-effective.
The positive findings of selective and indicated prevention trials are of great public health significance, but full use of evidence-based depression prevention strategies has yet to be realized. This gap between what is known and implementation of these strategies requires attention, action, and the strengthening of research and dissemination efforts. The Global Consortium for Depression Prevention, which convened in Utrecht, the Netherlands, in September 2011, compared progress made in depression prevention with that in cardiovascular disease. Cardiovascular morbidity and mortality have declined, reflecting combined effects of improvements in treatment and prevention. In comparison, the consortium advocates integrating prevention of depression with improvements in diagnosis and treatment with the aim of decreasing the global illness and economic burden of depression. Research priorities identified by the consortium are listed in the Box.
Depression prevention research and practice have progressed from a pioneering stage to one in which evidence-supported and cost-effective interventions can be disseminated on a larger scale and prevention can help to lessen the global disease burden.
Funding/Support: The conference Shaping the Research Agenda for Depression Prevention was financially supported by the Fonds Psychische gezondheid, the HSK Groep, and Zorgonderzoek Nederland and by grant P30 MH090333 from the National Institute of Mental Health to Dr Reynolds.
Role of the Sponsor: The conference's funding organizations had no role in the preparation, review, or approval of the manuscript.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Beekman reports receiving grants to his institution from Lilly, Janssen, AstraZeneca, and Shire and payment for lectures from Lilly and Lundbeck. Dr Reynolds reports receiving pharmaceuticals for research studies from Bristol-Myers Squibb, Forest, Pfizer, and Lilly. No other disclosures were reported.
Additional Information: The conference Shaping the Research Agenda for Depression Prevention was organized and hosted by the Trimbos Institute (Netherlands Institute of Mental Health and Addiction) in its role of World Health Organization Collaborating Center for Mental Health. Filip Smit, PhD, Trimbos Institute, was responsible for obtaining funding, organizing, and hosting this meeting of the Global Consortium for Depression Prevention. Supplementary information and a list of the members of the Global Consortium for Depression Prevention are available at http://www.preventionofdepression.org.
Additional Contributions: Filip Smit, PhD, contributed to this article by writing parts of it and reading all versions critically. All consortium members read the text of the manuscript and provided suggestions for improvement.