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Submitted Abstracts

Panel 1. Prevention of Depression. State of the Art.

Do we need a wider concept of prevention of depression?

Arne Holte  

Department of Psychology, University of Oslo. Norway

The current concept of prevention of mental illness is largely based on the work of Muñoz (1993) and Mrazek and Haggarty (1994). This concept contains three points: initiatives initiated prior to initial onset of a clinically diagnosable disorder, which reduces the rate of new disorders (incidence), during a follow-up period that extends into a period of risk for the condition, given the population. This modernization of the concept was strongly needed scientifically as well as politically to differentiate more clearly between investments in prevention and in treatment. Since then, several authors have tried to refine the concept, e.g. redefining “disorder” into “high symptom levels or a variety of behaviors and problems” (Gillham et al., 2000). Yet, scientific researchers (e.g. Cuijpers et al., 2009) and journal referees have to a large degree endorsed the original definition. In this paper, I ask whether such a strict definition may hamper practical initiatives for a mentally healthier population and leave an impression that we have less knowledge about how we can achieve a mentally healthier population free of depression than we actually have. I discuss whether we should expand the concept of prevention to include mental health promotion, reduction or maintenance of symptom levels in populations with already low levels of symptoms (e.g. general populations), strengthening of known positive determinants of mental well-being, reduction of risk factors of mental distress and mental disorders, and increasing the emphasis on impairment rather than diagnosis and symptom levels.

 

A to-do list for the Global Consortium for the Prevention of Depression: Implementing what we know, specifying what we still need to learn

Ricardo F. Muñoz, Blanca Pineda and Jazmin Llamas 

Palo Alto University, Palo Alto, California. USA

I would like to suggest two goals for the GCPD: 1) Concerted efforts to reduce incidence of major depressive episodes by 50% and 2) Systematic delineation of what we need to learn to tackle the remaining 50%. We now have sufficient evidence to claim that, with current psychological interventions, we can reduce the annual incidence of new episodes of major depression by 50% in individuals at risk. Using Internet interventions, we can provide worldwide access to such interventions. I propose that we harness the combined energy of our membership to implement what we already know and reduce incidence in our communities by 50%. But we still need to learn how to prevent the remaining 50% of major depressive episodes. I propose that we create a work group to specify the most promising areas that we need to study to prevent the remaining cases of major depression. Such areas would include genetic and epigenetic research, the potential of focused brain training on mood regulation, the crucial role that the beginning of life plays on risk of depression (from preconception, through pregnancy, the first weeks and years of life, and the major risk period of adolescence), the role of individual and family processes, and the impact of the social and physical environment, including the protective role of nurturing environments. I propose that the GCDP set up a ten-year plan to pursue these two goals in a concerted manner and use our future meetings to determine how far we have progressed.

 

Panel 2: Moderators and mediators of Depression Prevention

 

Be a Mom, a web-based intervention to prevent postpartum depression: An exploratory study on the mechanisms that explain the treatment response

Ana Fonseca, Fabiana Monteiro, Stephanie Alves, Ricardo Gorayeb and Maria Cristina Canavarro

CINEICC - Center for Research in Neuropsychology and Cognitive-Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal

Introduction: Be a Mom is a self-guided web-based intervention, grounded on CBT principles and including acceptance and compassion-based approaches, delivered at postpartum women (at-risk women or with early-onset depressive symptoms) to prevent Postpartum Depression. The pilot trial results provided preliminary evidence of the program’s feasibility, acceptability and efficacy. This exploratory study aimed to examine the role of changes in self-regulatory processes (experiential avoidance, self-compassion and emotion regulation difficulties) on the changes in depressive symptoms. Methods: A pilot randomized, two-arm controlled trial was conducted (intervention group-Be a Mom vs. control group). Participants in both groups completed baseline and post-intervention (8-weeks after) assessments, including depressive symptoms, experiential avoidance, self-compassion and emotion regulation difficulties. This study focused on data of the intervention group (n=98 at-risk/early-onset symptoms women). Two-wave Latent Change Score Models were conducted with Mplus. Results: Latent Change Scores analyses showed that, from baseline to post-intervention assessment, women presented a significant decrease in depressive symptoms, as well as in the levels of experiential avoidance and emotion regulation difficulties, and a significant increase in the levels of self-compassion (all p<.001). A decrease in the levels of emotion regulation difficulties (B=0.078, p=.032) and an increase in self-compassion levels (B=-0.089, p=.09 was (marginally) significantly associated to a decrease in the levels of depressive symptoms. Discussion: Although exploratory, these results provide preliminary evidence of the mechanisms that explain women’s treatment response to Be a Mom program and are congruent with the therapeutic principles underlying the design of the program (e.g., third-wave CBT acceptance and self-compassion-based approaches).

                          

Physician Training as a Model to Identify Predictors and Preventative Interventions for Depression under Stress

Srijan Sen, Yu Fang and Connie Guille 

University of Michigan. USA

A critical barrier to identifying and efficiently targeting prevention strategies is the unpredictable onset of depressive episodes. Here, we use the first year of professional physician training, medical internship, as an unusual situation where the onset of stress can be reliably predicted. In a prospective annual cohort study including over 17,000 medical interns across 80 US medical institutions, we find that the prevalence of major depression increases 5-6 fold during internship, with 46% of physicians reporting at least one episode of depression during their first year of training (Archives of General Psychiatry 67 (6), 557. 2010; JAMA. 2015;314(22):2373-2383). We have identified a series of psychological, demographic and genetic factors that predict the development of depression during internship stress (PloS One 8(7), e67395. 2013; Archives of General Psychiatry 67 (6), 557. 2010). Further, we have shown pre-training through web-based CBT substantially prevents the development of depression and suicidal ideation during internship (JAMA Psychiatry. 2015 Dec;72(12):1192-8). With recent cohorts, we have piloted the use of wearable and smartphone technology to identify real-time, objective predictors of mood (J Gen Intern Med. 2018 Jun;33(6):914-920). Going forward, we hope to utilize mobile technology and genomics to more precisely target depression interventions to the right person and the right time.


COUPLING: preventing parentification of children of depressed parents

Frederike Jörg, Henriette Hoving, Dolinda van der Meer and Robert Schoevers

University Medical Center Groningen, The Netherlands

Children of parents with a mental disorder (COPMI) are at increased risk of developing depression. Parentification is a strong risk factor: children take over the role and responsibilities of parents. They run the household and take care of siblings, which impedes their own socio-emotional development. A strong and supporting social network is protective. However, depressed parents are often reluctant to ask their network to help, professionals lack tools to activate the parent’s social network and the network itself wants to help but does not know how. A network that can temporarily take over parental tasks while the sick parent recovers would unburden the children, enabling a healthy development. We developed a tool for social workers called COUPLING: coupling parental tasks and responsibilities to persons from the parent’s network. First, social workers and patient make a list of tasks and responsibilities that he or she can no longer fulfil due to the illness. Next, the tool helps them to work out who’s in the social network: family, friends, neighbours, colleagues, parents of their children’s classmates. Then they “couple” tasks to persons from their network, who use WhatsApp and Google Diary to get involved. Evidently, parents need coaching in overcoming reluctance to ask their network, and the network needs information about depression. In a pilot study among five families, we investigate social workers’, parents’, the network’s and the child’s experiences with COUPLING. Results will help prepare for an RCT into the (cost)effectiveness of the tool.

 

Effects and moderators of preventive psychological interventions on health-related quality of life in adults with subthreshold depression: An individual participant data meta-analysis of randomized controlled trials

Claudia Buntrock1, David Daniel Ebert1, Jo Annika Reins2, Johannes Zimmermann3, Pim Cuijpers4 

1 Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany; 2 Leuphana Universität Lüneburg, Germany; 3 Psychologische Hochschule Berlin, Germany; 4 VU University Amsterdam, The Netherlands

Introduction The effectiveness of psychological interventions on health-related quality of life in adults with subthreshold depression is unclear and effects vary among subgroups of patients indicating that not all patients profit from such interventions. Randomized clinical trials are mostly underpowered to examine adequately subgroups and moderator effects. The aim of the present study is, therefore, to examine the short- and long-term as well as moderator effects of psychological interventions compared to control groups in adults with subthreshold depression on health-related quality of life using an individual participant data meta-analysis approach. Methods for the identification of potential studies for inclusion, we will use a database of papers on the psychological treatment of depression. For this database, studies have been identified from Pubmed, PsychInfo, Embase and the Cochrane Central Register of Controlled Trials. Multilevel models with participants nested within studies will be used. Missing data will be handled using a joint modeling approach to multiple imputation. A number of sensitivity analyses will be conducted in order test the robustness of our findings. Results The study is ongoing. Results will be presented at the conference. Discussion This study will summarize the available evidence on effects of preventive psychological interventions on health-related quality of life in adults with subthreshold depression. Identification of subgroups of patients in which those interventions are most effective will guide the development of evidence-based personalized interventions for patients with subthreshold depression.

 

Depression prevention strategies in adulthood

Terry Brugha 

University of Leicester. UK

Much thinking on prevention of depression in adulthood draws on the medical disease model defined in terms of onsets, episodes, recurrences. What if that medical model is simplistic and inappropriate? Evidence on the course of depression (and anxiety) symptoms in adulthood suggests that they fluctuate considerably over time, possibly like some chronic, complex non infectious disease processes such as musculoskeletal conditions (pain, stiffness etc). Indicated prevention approaches that involve the extension of psychological therapy principles (1:1 with an adult [or digitally], group based, or as in the teen years, classroom based) have shown the most promise by in effect extending treatment models to a lower threshold of case inclusion. Indicated approaches require the identification of a threshold level of depression for selecting into intervention from a wider or from a selected population (e.g. subpopulations at high risk). But evidence also shows that tests used for selection (i.e. depression status measures) have poor sensitivity and specificity with respect to reference or so called 'gold standard' measures of depression. Accordingly, by the time intervention begins, many who agree to take part have likely 'fluctuated back' to being in the low symptom group (but seemingly must benefit in some way if the prevention intervention is effective). And many who are symptomatic at the time the intervention is ready to begin are excluded as their test had been negative, which is wasteful, a lost opportunity. Universal approaches to prevention in which an 'entry test' is not required are viewed as high cost and have rarely been evaluated. But if we were to accept depressive symptoms as fluctuating and difficult to capture reliably we would have to begin to think 'out of the box'. The global burden of disease model shows that in spite of remarkable increases in access to mental health care, particularly in high income countries, there has been no decline in rates of these conditions. Breaking away from the medical disease model, seemingly a flawed approach, requires a different way of thinking about the kinds of interventions that might be acceptable to the wider population ('stigma free'), which are affordable (linked to other desirable processes and outcomes), and which could alter the course of depressive symptom variation over time. The case for new strategic thinking requires us to open our eyes to these uncomfortable facts.

 

 Specific and Nonspecific Change Mechanisms as Mediators of a Cognitive-Behavioral and a Nonspecific Program of Adolescent Depressive Symptoms

Patrick Pössel, Nina C. Martin, Judy Garber, & Martin Hautzinger

University of Louisville, Vanderbilt University, University of Tuebingen


To examine change mechanisms of cognitive-behavioral depression prevention programs, a cognitive-behavioral (CB) and a nonspecific (NSp) prevention program were compared with each other to assess their effects on depressive symptoms, on specific (i.e., cognitive errors, dysfunctional attitudes), and nonspecific change mechanisms (i.e., group cohesion, working alliance). Further, we examined whether specific and nonspecific change mechanisms mediated the effects of the CB prevention program on adolescents’ depressive symptoms. This randomized, controlled trial included 340 high-school students (mean age = 15.09 years) from a moderate sized city in the United States. Students participated in either a 10-week CB program (n = 166; 61.4% girls) or NSp program (n = 174; 62.1% girls). Measures included the Children’s Depression Inventory, Children’s Negative Cognitive Error Questionnaire, and Dysfunctional Attitude Scale assessed at baseline, post-intervention, and at 4-, 8-, and 12-month follow-ups and Group Cohesiveness Questionnaire and Working Alliance Inventory administered after half of the group sessions. The CB program showed positive effects on adolescents’ depressive symptoms with and without subsyndromal depression at baseline (Hedge’s g = 0.35 and 0.24, respectively) at the 4-month follow-up. Further, at post-intervention, adolescents in the CB program showed significantly fewer cognitive errors than youth in NSp (g = 0.51). Finally, cognitive errors at post-intervention mediated the relation between the intervention and depressive symptoms at the 4-month follow-up. The CB program evidenced a short-term effect. Possible explanations for the lack of long-term differences are delayed effects of the NSp and cross-over effects caused by interactions between adolescents in both conditions.

 

Cognitive Reactivity as a predictor of depressive relapse

Caroline A. Figueroa, Henricus G. Ruhé, Maarten W. Koeter, Philip Spinhoven, Willem Van der Does, Claudi L. Bockting, and Aart H. Schene 

University of Amsterdam, The Netherlands

Objective: Major depressive disorder (MDD) is a burdensome disease that has a high risk of relapse/recurrence. Cognitive reactivity appears to be a risk factor for relapse. It remains unclear, however, whether dysfunctional cognitions alone or the reactivity of such cognitions to mild states of sadness (ie, cognitive reactivity) is the crucial factor that increases relapse risk. We aimed to assess the long-term predictive value of cognitive reactivity versus dysfunctional cognitions and other risk factors for depressive relapse. Method: In a prospective cohort of 116 outpatients who had experienced ≥2 previous major depressive episodes (MDEs) and were in remission at the start of follow-up, we measured cognitive reactivity, with the Leiden Index of Depression Sensitivity (LEIDS), and dysfunctional cognitions, with the Dysfunctional Attitudes Scale, simultaneously. Course of illness (with the primary outcome of MDE) and time to relapse were monitored prospectively for 3.5 years. Results: Cognitive reactivity scores were associated with time to relapse over the 3.5-year follow-up and also when corrected for the number of previous MDEs and concurrent depressive symptoms. Rumination appeared to be a particularly strong predictor of relapse. Dysfunctional cognitions did not predict relapse over 3.5 years. Every 20-point increase on the cognitive reactivity scale resulted in a 10% to 15% increase in risk of relapse. Conclusions: Cognitive reactivity—and particularly rumination—is a long-term predictor of relapse. Future research should address whether psychological interventions can improve cognitive reactivity scores and thereby prevent depressive relapses.


Panel 3: Prevention depression efforts in different countries.

 

Attitude change with a one-semester curriculum in the psychology and philosophy of happiness for high school students in China: a cluster randomized trial

Paul H. Desan1, Mark K. Setton2, Allison A. Holzer3, Kevin KC4 Young, Yan Sun and Xiaoling Yu5.

1Department of Psychiatry, Yale School of Medicine. New Haven,USA. 2Department of Religion and Politics, College of Public and International Affairs, University of Bridgeport. Bridgeport USA. 3InspireCorps. Hartford, USA. Department of Psychology, George Mason University. Alexandria, USA. 4University of Kansas Medical Center. Kansas City, USA. 5Department of Psychology, Beijing Normal University, Beijing, China

Objective: While much research on depression prevention has taken a cognitive-behavioral approach, research on happiness and well-being in recent decades has explored a wide range of factors. Pursuit of Happiness.org is an international consortium of educators and has developed a 7-part curriculum on the science and philosophy of happiness. The curriculum emphasizes active learning and life skill acquisition, and was tested in a cluster-randomized trial at an urban high school in Beijing, China (High School #19). Method: The intervention curriculum was presented to 9 classrooms (n = 252 students) at the 10th grade level, while a traditional psychology curriculum was taught to 9 control classrooms (n = 263). Primary outcome measure was a composite measure of positive attitudes (PAS) including relatedness, competence, autonomy, gratitude, calmness, mindfulness, hope, with secondary outcome measures of depression (CES-D), positive and negative affect (PANAS), life satisfaction (LS), and subjective happiness (SHS). Students completed questionnaire measures before and after the semester. Results were analyzed by a hierarchical linear model with effects of baseline score, treatment, semester, classroom, and gender. Results: PAS scores were significantly higher in the intervention group than the control group, including significantly higher scores on all subscales except Anxiety. PANAS balance scores were more significantly more positive in the intervention group. CES-D, LS, and SHS change scores were improved in the intervention group, but not significantly so. Conclusions: A one-semester curriculum demonstrated meaningful changes in attitudes which research has linked to psychological wellbeing, and may offer a novel and fundamental approach to depression prevention. 

 

Preventing Maternal Depression and Promoting Early Childhood Development in Kenya and Tanzania

Huynh-Nhu Le, Hembling J, Kapiyo M, McEwan E, Nyanza E, Jahanpour Ol and Shannon Senefeld.

George Washington University and Catholic Relief Services. USA

Maternal depression is estimated to be two-to-three times higher in low- and middle-income countries versus high-income countries and is associated with negative consequences on maternal and infant health. Catholic Relief Services and George Washington University adapted the Mothers and Babies Course (MBC) to the African rural context and implemented this innovation as part of an early childhood development (ECD) project. The MBC, originally developed by Ricardo Muñoz and Huynh-Nhu Le, is a cognitive behavioral intervention that teaches women mood regulation skills to decrease depression and increase uptake of key ECD behaviors. Using a non-equivalent control group design, data from 505 mothers of children who were 18 months old or younger at baseline (intervention: MBC + ECD, n=235; control: ECD only, n=270) in Kenya and Tanzania were collected at baseline and at 6 and 12 months post-intervention. Preliminary results from multivariate analyses indicate that the intervention group had a lower incidence of depression than the control group at 6 months post-intervention (6.8% vs. 13.5%; p <.05). Women in both conditions reported increased rates of engaging in early child stimulation behaviors between baseline and the 6-month follow-up, with rates higher in the intervention than control group (59% vs. 50%, p <.05). Subsequent analyses will look at the effects of the MBC at one year period (data available August 2018). Overall, this study indicates the potential of integrating a maternal mental health intervention into a community-based behavior change project to promote the uptake of ECD behaviors and prevent symptoms of maternal depression.


Training General Practitioners in Bulgaria to Reduce Suicide Rate: A Controlled Trial

Mykletun A 1,3, Widding-Havnerås T 1,3, Zarkov Z3, Nakov V3and Hinkov H3

1 Norwegian Institute of Public Health, Norway 2 National Centre for Public Health and Analyses, Bulgaria 3Regional Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway

Aim: The aim of this study is to examine whether a training program for management of suicide and common mental disorders (CMDs) for general practitioners (GPs) in Bulgaria can reduce suicide and/or suicide attempts. Background: The World Health Organization (WHO) has recommended GP education in suicide and CMD management as one of several strategies to improve suicide prevention. There is evidence for the efficacy of this intervention, but evidence for the effectiveness applied in large scale naturalistic settings is lacking. The latter is the aim of this study. Method: This nationwide intervention in Bulgaria aimed to provide GPs and other health professionals (psychologists and social workers) (N = 1650) with practical knowledge and techniques to improve management of suicide risk and recognition and treatment of CMDs. The online web-based training module was well attended, whereas attendance rates of the two-day follow-up seminar was lower. The effectiveness of the training program was evaluated by comparing four regions of Bulgaria receiving the intervention, with the remaining two regions kept as controls. Results: We have recently received the data and these will be analysed in time for the GCDP meeting I 2018. The trail has 75 percent power to detect a significant effect (p < .05, 1-sided) if the number of suicides among health professionals being trained is reduced from approximately 800 to 700 during our two-year observation period. Suicide attempts will also be analyzed. Conclusion: This study will provide empirical evidence on the effectiveness of large scale suicide prevention by means of training GPs.

¡HOLA, amigos! Towards Preventing Anxiety and Depression in Older Latinos

Daniel Jimenez  

University of Miami, USA

Given the prevalence and morbidity of depression in later life, the inadequacies of current treatment approaches for averting years living with disability, the inequities in access to the mental health care delivery system, and the workforce shortages to meet the mental health needs of older Latinos, development and testing of innovative strategies to prevent depression and anxiety are of great public health significance and have the potential to change practice. The Happy Older Latinos are Active (HOLA) program is a community health worker–led, multicomponent, health promotion intervention. The diverse needs and circumstances of older Latinos (highly sedentary, culture-specific health beliefs, service disparities) were incorporated into the design of HOLA to reduce risk factors and improve health-related outcomes associated with common mental disorders in this group. Health promotion interventions like HOLA hold promise as effective, practical, and non-stigmatizing interventions for preventing common mental disorders in older Latinos.


Prevalence and Risk Factors for Prenatal Depression in Spain and Mexico. A prevention point of view

María de la Fe Rodriguez Muñoz1, Rosa Marcos- Nájera1, Asunción Lara Cantú2, Laura Navarrete2, Huynh-Nhu Lee3                                                            

1National University of Distance Education, SpainUNED (SPain). 2Instituto Psiquiátrico Ramón de la Cruz México, México. 3George Washington University, USA

Introduction: Studies on prenatal depression among Spanish-speaking women internationally are extremely limited. This study examined and compared the prevalence and the risk factors that are associated with prenatal depression through a cross-cultural study in Spain and Mexico. Material and Methods: The study utilizes secondary data from 563 participants who received prenatal care in Madrid (Spain, N = 283) and in Mexico City (N = 280). The Patient Health Questionnaire (PHQ-9) and the Postpartum Depression Predictors Inventory-Revised (PDPI-R) were used. Results: Spanish women reported a lower prevalence of depressive symptoms (10,0%) than Mexican (20.3%) women. Previous prenatal anxiety and lack of family emotional support were common risk factor found in both countries. In Spain, previous depression history was also a significant predictor of prenatal depression. In Mexico, unplanned pregnancy, lack of emotional support from others, marital dissatisfaction, and life stress due to financial problems and marital problems were significant risk factors. Conclusions: Data showed that cross-cultural and cross-national comparisons, rarely conducted in previous studies, provide a context to interpret the prevalence and relevance of specific risk factors given differences in the country level of development, sociocultural context, and endorsement of traditional gender roles. Studies between country comparisons may contribute to developing culturally sensitive preventive interventions.

 

Panel 4: Prevention depression efforts in different countries.

Preventing major depression in older adults living in low- and middle-income countries: a randomized controlled trial of problem solving therapy and care as usual

Amit Dias, Fredric Azariah, Stewart J. Anderson, Miriam Sequeira, Alex Cohen, Jennifer Morse, Pim Cuijpers, Vikram Patel, and Charles F. Reynolds III (corresponding author)

University of Pittsburgh. USA

Preventing depression in older adults living in low- and middle-income countries is important because of scarce treatment resources, depression-related disability and increased risk for suicide and dementia. We conducted a randomized, controlled trial of indicated depression prevention in 181 primary care and community-resident adults (aged 60 and older) living with subsyndromal depressive symptoms in Goa, India. Delivered by lay counsellors, the intervention (“DIL”: depression in later life; “heart” in Hindi) utilized problem solving therapy, brief behavioral treatment for insomnia, education in self-care of common medical disorders (e.g., diabetes), and assistance in accessing medical and social programs. The primary outcome was incidence of major depressive episodes (MINI 6.0) over 12 months. We also monitored symptoms change (GHQ-12), cognitive status (Hindi MMSE), functional status (WHODAS-II), blood pressure, and body mass index. Using Kaplan-Meier plots and Cox proportional hazards models, we observed significantly fewer depressive episodes in participants randomized to “DIL” (n = 91) compared to care as usual (CAU: n = 90).   Using mixed model approaches, we observed greater reduction in symptoms and systolic blood pressure and BMI improvement among DIL participants, but no significant change in cognitive performance or functional status. We conclude that indicated prevention of depression in older LMIC adults can be effectively implemented by lay counsellors and is potentially scalable to other LMIC’s.

Trial registration: NCT02145429 Support: US National Institute of Mental Health (to University of Pittsburgh; C.F. Reynolds III PI)  Participating institutions: University of Pittsburgh, Sangath and Goa Medical College , London School of Hygiene and Tropical Medicine

Low tech self-help to prevent of depression in older people: the results of the UK SHARD trial of behavioural activation
Simon Gilbody, Dean McMillan - on behalf of the SHARD collaborativeMental Health and Addictions Research Group, University of York UK

In this presentation we will give the results of the UK Self Help for People at Risk of Depression (SHARD) trial (ISRCTN95270332). Older people with long term health problems and low-severity depressive symptoms represent a population at risk of developing case-level depression. Low intensity prevention strategies targeted at this group could prevent the onset of depression. Recent research interest has tended to focus on the delivery of evidence supported psychotherapy using technological self-help approaches, such as e-health or computerised CBT. Older people are subject to the 'digital divide' and do not always access the internet or use computer-delivered interventions. There is a need for low-tech delivery methods. We conducted a multi-centred randomised controlled trial to determine whether a specifically designed guided self-help workbook, using behavioural activation principles is more effective than usual primary care alone for older people with sub-threshold depression symptoms. The results are encouraging and this large scale trial was conduced in a population cohort of older people who have given prospective consent to participate in research. This is an innovative and efficient method of delivering large scale trial - known as 'trials within Cohorts - TWiCs'. We will give an overview of this method, using the SHARD trial as a motivating example [ref 1] 1. Relton C, Torgerson D, O’Cathain A, Nicholl J: Rethinking pragmatic randomised controlled trials: introducing the “cohort multiple randomised controlled trial” design. BMJ 2010, 340:c1066. SHARD trial protocol - http://www.isrctn.com/ISRCTN95270332

 

Effectiveness and cost-effectiveness of a personalized intervention to prevent depression in primary care: a clustered randomized trial.

Juan Ángel Bellón, Sonia Conejo-Cerón, Patricia Moreno-Peral, Ana Fernández, Michael King, Irwin Nazareth, Carlos Martín-Pérez, Carmen Fernández-Alonso, Antonia Rodríguez-Bayón, José Maria Aiarzaguena, Carmen Montón-Franco, Inmaculada Ibanez-Casas, Emiliano Rodríguez-Sánchez, Maria Isabel Ballesta-Rodríguez, Antoni Serrano-Blanco, Maria Cruz Gómez, LaFuente P, Muñoz-García M del M, Mínguez-Gonzalo P, Araujo L, Diego Palao, Bully P, Zubiaga F, Desirée Navas-Campaña, Mendive J, José Manuel Aranda-Regules, Alberto Rodriguez-Morejón, Luis Salvador-Carulla and Luna JD.

El Palo Health Centre (SAS), Dpt. Public Health & Psychiatry. University of Malaga. IBIMA. redIAPP
BACKGROUND: Not enough is known about universal prevention of depression in adults. OBJECTIVE: To evaluate the effectiveness and cost-effectiveness of a personalized intervention to prevent major depression in primary care. METHODS: Multicenter, cluster randomized trial with sites randomly assigned to usual care or an intervention. A random sample of 3326 non-depressed primary care attendees, belonging to 140 GPs and 70 Health Centres, consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual level and profile risk for depression and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. GPs were trained in a 10-h workshop. The primary outcome was incidence of major depression, assessed by every 6 months for 18 months, and incidence of anxiety and cost-effectiveness as secondary outcomes. RESULTS: At 18 months, 7.39% of patients in the intervention group developed major depression compared with 9.40% in the control group (absolute difference, -2.01%[CI, -4.18% to 0.16%]; P=0.070). For the 2998 patients without anxiety at baseline, 10.43% in the intervention group developed anxiety compared with 13.10% in the control group (absolute difference, -2.67[CI,-5.05 to -0.28 perce];P=0.029). With a willingness-to-pay threshold of €30,000, the probability of being considered cost-effective was 94%(societal perspective) and 96%(health perspective). CONCLUSION: Compared with usual care, an intervention based on personal predictors of risk of depression implemented by GPs is an effective and cost-effective strategy to prevent depression and anxiety. This type of personalized intervention in primary care should be further developed and evaluated.


Update on prevention of depression among children and adolescents

Arne Holte 

Department of Psychology, University of Oslo                                                                  

Most symptoms of common mental disorders start in childhood or adolescence. Interventions early in life give higher return to investment in human capital, than later interventions. Therefore, most RCTs on prevention of depression have been conducted with children and adolescents. During the past five years, ten systematic reviews or meta-analyses have been published. Five of them contain trials across different arenas. Three of them are limited to the school arena. One targets parents to improve outcomes in children. One is restricted to children of a depressed parent. Quality of the reviews are generally high, but quality of the single studies varies. All ten reviews use symptom level as outcome. Five of them also include incidence of depressive disorder (diagnosis). Nine of the ten reviews report significant reductions in symptom levels. Four of the five reviews assessing depressive disorder (diagnosis) report reduced incidence. The effect sizes are generally small. Targeted interventions tend to have larger effect sizes than universal interventions, but not in all reviews. When achieved by universal programs, even small effect sizes may be of great value in terms of bpyj well-being and human capital. Whether the program is more effective when delivered by an external (e.g. clinician) or internal (e.g. teacher) provider differ between reviews and types of preventive programmes. The few available studies that include economic evaluations indicate that prevention of depression among children and adolescents is cost-effective.

Prevention of depression: a joint endeavor of academics, municipality and health insurer
Frederike Jörg, Lonneke Kamp, Lotus van Nes, Anita Schnieder, Janine Groeneveld, Robert Schoever

University Medical Center Groningen, The Netherlands

The incidence of depression is high in adolescence with long-lasting consequences in terms of social, academic and societal functioning. COPMI (children of parents with a mental illness) are a specific risk group, as approximately two thirds of them will have developed a depression or anxiety disorder by the age of 35. Several evidence based preventive interventions target COPMI, such as peer groups, mother-child interaction and psychoeducation. However, these interventions are often not provided, due to professionals’ unawareness and parents’ reluctance. Most importantly however, players in the field (specialist adult and child mental health care, community services, school, work and income, housing) do not effectively cooperate and are unsure of their responsibility towards protection of the adolescent’s health. In Groningen (the Netherlands), the University Center Psychiatry, municipality and health insurer have started a joint endeavor to prevent depression in COPMI by focusing on a) effective cooperation in the chain, b) normalization and resilience and c) what is needed for healthy socio-emotional development of the child. We monitor 20 families with one or more COPMI and investigate, by using case narratives, the problems families are confronted with, the barriers and facilitators of effective cooperation between domains, and what is needed to achieve a healthy socio-emotional development and how this can best be organized, by professional or informal help.

 

Depression prevention in routine orthopedic aftercare – final results from the PROD-BP trial: a nationwide pragmatic RCT in Germany.

Lasse Sander1, David Daniel Eber2, Sarah Paganini1, Sandra Schlicker2, Kerstin Spanhel1, Jiaxi Lin1, ClaudiaBuntrock2 and Harald Baumeister 3

1University of Freiburg, Institute of Psychology, Department of Rehabilitation Psychology and Psychotherapy. 2University of Erlangen-Nürnberg, Institute of Psychology, Department of Clinical Psychology and Psychotherapy. 3University of Ulm, Institute of Psychology and Education, Department of Clinical Psychology and Psychotherapy

Background: Within the group of medically ill persons, chronic back pain (CBP) is one of the most common conditions and is associated with a two to three-fold increased risk for major depressive disorder (MDD). Methods: This study is a multicenter pragmatic randomized controlled trial (RCT) of parallel design aiming to investigate the (cost-) effectiveness of an Internet- and mobile-based intervention for the PRevention Of Depression in chronic Back Pain patients (PROD-BP) with subthreshold depressive symptoms. 295 patients without a MDD at baseline (SKID-V) were recruited at discharge from 82 orthopedic care units across Germany and allocated to either intervention group (IG) or treatment-as-usual (control group, CG). Two distinct implementation strategies (personal recruitment and recruitment by letter) were applied. Results: A fairly gender-balanced, low educated sample with a mean age of 53 (SD:7.7) years could be recruited. Secondary outcome measures showed a significantly higher decrease of depressive symptoms (PHQ-9) in the IG post nine weeks (d= 0.39 95%CI: 0.16 – 0.62) and post 6 months (d= 0.31 95%CI: 0.04 – 0.58) after randomisation compared to the CG. Furthermore, pain related disability and quality of life improved significantly in the IG compared to the CG. Discussion: The embedment into routine orthopedic healthcare lead to results with a high external validity. The specific strengths and challenges of Internet-based depression prevention in this setting will be discussed contrasting two different recruitment approaches. The one year follow-up effects on the incidence of depression (SCID-V) will be revealed at the venue for the first time.

 

European Alliance against Depression: Community based 4-level interventions targeting depression and suicidal behaviour

Ulrich Hegerl and the EAAD consortium 

Department of Psychiatry and Psychotherapy, University of Leipzig, Germany

European Alliance against Depression e.V. The community based 4-level-intervention concept developed within the “European Alliance against Depression” (www.EAAD.net) combines the aims to improve the care and treatment of patients with depression and to prevent suicidal behavior. It has been shown to be effective concerning the prevention of suicidal behavior (1, 2, 3, 4) and has been implemented in more than 100 regions worldwide The 4-level intervention concept comprises training and support of primary care providers (level 1), a professional public relation campaign (level 2), training of community facilitators (teacher, priests, geriatric care givers, pharmacists, journalists) (level 3), and support for selfhelp of patients with depression and for their relatives (level 4). At level 4, digital self management tools such as the iFightDepression tool are gaining relevance. Implementation research and systematic process analyses have provided insights in mechanisms relevant for a successful implementation of the 4-level intervention concept in different cultures and health care systems. Becoming simultaneous active at 4 levels has been found to create strong synergistic and also catalytic effects. Via the EAAD and partners from 24 countries, the intervention concept and materials (available in many different languages) are offered to interested region in and outside of Europe. 1) Hegerl et al 2006; Psychol Med 36: 1225-1234 2) Hegerl et al 2010; Eur Arch Psychiatry Clin Neurosci 260:401-406. 3) Székely et al 2013; PLOS One 8: e75081 4) Hübner-Liebermann et al (2010): Gen Hosp Psychiatry 32: 514-518. 5) Hegerl et al 2013; Neurosci Biobehav Rev; 37: 2404-2409.

 

Panel 5: Future prevention depression strategies and research

 

The evolution and future of mental health digital prevention

Helen Christensen, Aliza Werner Seidler, Yael Perry, Bregje Van Spijker, Fiona Shand, Joe Tighe, Mark Larsen and Judy Proudfoot

Black Dog Institute, UNSW; Centre for Mental Health Research, Australian National University. Australia

The Global Consortium for Depression aims to conduct excellent research, leading to new solutions, which, when adopted, disseminated and scaled, are capable of lowering the burden of depression. Digital interventions form a key part of the vision to scale and extend reach. The important question we need to address now is the extent to which evidence-based digital interventions have been translated successfully into a service or product that creates value for which customers will pay (and/or governments and industry will pay). And, if not, how do we improve our dissemination and commercialisation activities. To address this issue, I trace the development of the digital prevention of depression and suicide ideation. Taking Black Dog’s Research over the last decade, I describe the type of prevention research work we have undertaken in terms of three types/phases: (1) Program-Based Interventions; (2) Systems-Based Services Research; and (3) Dynamic, scaled research, conducted “in the wild”. The failures and successes of these types/phases are considered. I conclude that research tackling our goal: “an idea or innovation that is translated into a services for which someone will pay” seems (almost) in reach. However, our research efforts need improvement. Our field may advance faster if we focus on the mechanisms underlying depression (thereby better understanding of the mechanisms to prevent depression, and the ages and timelines to introduce interventions), mount research trials that are sufficiently powered at a population level, focus on integration of our interventions into the relevant health and education systems that may support them, investigate potential new forms of early detection of the development of disorders (possibly through digital phenotypes), and consider how we can use organic or natural digital activities, such as social media and online communities to improve our prevention efforts.

 

Utility of Current Insights in the Genetic Architecture of Depression for Prevention

Johan Ormel

University Medical Center Groningen. The Netherlands

The recent successful genome wide association studies (GWASs) for depression have now yielded more than 50 loci and have returned the excitement and optimism of the early 2010’s that had evaporated during the years of negative GWAS findings. The identified loci provide the anchors to explore their relevance for the treatment and prevention of depression, but this comes with new challenges on the horizon. In addition, genome editing has become more feasible thanks to recent developments in CRISP/Cas technology. Using the watershed model of genotype-phenotype relationships as a conceptual aid as well as recent genetic findings on "easier" phenotypes (e.g. height), I will discuss some implications of these recent developments in genetic epidemiology and genome editing pertinent to prevention of depression. These include: how to detect the true cause of the association between depression and genetic variants? What does the probably genetic architecture of depression implies for prevention? My preliminary conclusion: The small effect sizes of common variants seem detrimental to their utility for prevention. Rare variants with larger effect may represent better targets for risk estimation and genome-editing. Because rare variants are rare (<1%), editing will have at best a tiny impact on the population prevalence. However, their significance for the development of antidepressant profylaxe in families that carry these rare variants may be substantial. Nonetheless, the best strategy to reduce the prevalence of depression remains structurally embedment of prevention in educational and child health care institutions targeting the big person(ality) and environmental determinants of risk.

 

Six-Month Outcomes from a Randomized Clinical Trial of an Internet-based Adolescent Depression Prevention Intervention in Primary Care

Tracy RG Gladstone, Sarah A. de Forest, Miae Lee, Lauren O. Thomann, David Aaby, Linda Schiffer, Marian Fitzgibbon, Hendricks Brown and Benjamin Van Voorhees.

Wellesley Centers for Women, Wellesley College and University of Illinois at Chicago. USA

Objectives: Few innovative and adaptable interventions targeting adolescent depression in primary care are available. We compare CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training), an internet-based prevention intervention, with a general health education (HE) attention control on depression onset in adolescents over 6 months. Method: We conducted a multisite, single-blind randomized control trial of CATCH-IT to prevent depression in adolescents with depression risk as defined by subsyndromal depressive symptoms and/or history of depression. Participants were 369 adolescents aged 13-18 (68% female, 46% non-White) recruited from primary care. The primary outcome was time to depression onset, as measured by the Depression Symptom Rating, at 6 months. Results: The outcome of time-to-event favored CATCH-IT but was not significant with intention-to-treat analyses (N=369; HR=0.59; 95% CI 0.27, 1.29; p=0.18) but was significant in the per protocol survival analysis (≥2/20 modules completed) (N=245; HR=0.41; 95% CI 0.17, 0.99; p=0.047). In addition, CATCH-IT showed a significant impact on time-to-event for higher levels of baseline depressive symptoms as compared to lower levels of baseline depressive symptoms (p<0.05). For both the CATCH-IT and HE groups, depression symptoms declined and functional scores increased across 6 months. Conclusion: Technology mediated interventions implemented in primary care settings may be efficacious for adolescents who, with their families, are motivated to engage in the program at a modest level, and for adolescents with elevated levels of depressive symptoms. Dissemination of CATCH-IT should target adolescents with current depressed mood and ensure completion of at least 2 modules.

 

What’s up? Towards an early-warning system for children and adolescents with depression based on the joint analysis of their WhatsApp communication, smartphone usage and wearable sensors. Technological aspects and first results from a pilot study.

Stefan Lüttke1, Martin Hautzinger1, Jamie Ward² and Julian Schmitz³

1University of Tübingen, Germany, ²University College London, UK, ³University of Leipzig, Germany

The high incidence of depressive disorders demands effective interventions. Although there has been substantial progress, the incidence of major depression (MD) remains high. Here, we argue that further progress can only be achieved through prevention. Importantly, prevention has to be individual and feasible in each patient’s everyday life. Since early onset MD is significantly associated with recurrent MD (Pössel et al., 2009), prevention ideally starts in childhood and adolescence taking into account developmental psychological aspects. The interdisciplinary What’s up? project aims to create an early-warning system that is capable to detect depressive relapses in young patients automatically in their everyday life. The core of the system is an algorithm that integrates different depression markers and is able to adapt and respond to changes in the user’s behaviour. Should the system detect a behavioural change that might indicate the onset of MD, a stepped-care intervention (self-help > online-therapy > preferred face to face appointments) would follow. Firstly, we seek to establish depression markers that can be measured automatically in daily routine. These include, among others, language use in dyadic WhatsApp chats (e.g. use of pronouns and absolutist words), quantity of smartphone usage (e.g. day times of usage) and the extent of distance travelled (GPS signal). Other markers of interests are, e.g. body motions (accelerometer) and adaptation to stress (EDA and HRV). The talk presents the theoretical rationale and technology of the project as well as first results from a recent pilot study with a non-clinical sample of students.

 

Evaluation of a German project “with us in balance” for the prevention of psychological stress and depression in green professionals with internet- and tele-based treatments

Ingrid Titzler, Harald Baumeister, Claudia Buntrock, Matthias Berking, David Daniel Ebert Friedrich-Alexander University Erlangen-Nürnberg, Germany

Background: The social insurance agency for farmer, gardener and forester (SVLFG) is conducting a model project “with us in balance” to prevent the occurrence of depression and to strengthen psychological health in their insured people (employer, family workers and retired farmer). The project is running from 1th of June 2017 to 31th May 2021. Evaluation partner are the Friedrich-Alexander University Erlangen-Nürnberg (FAU) und University Ulm (UULM) in Germany with experience in research in the context of e-mental health services. Two external service provider are delivering either guided iCBT (GET.ON) or tailored tele-based services, e.g. intensive coaching, socio-economic counseling (IVP). Referral and recruitment paths to the prevention services include field workers with on-site visits at the workplace of the insured people and call center agents who guide the green professionals to the offered services. The aim of this model project is to implement these digital solutions on a nationwide basis to strengthen wellbeing and mental health. Method: The evaluation of this project will take place within six work packages: WP1: Pilot implementation in two federal states WP2: Implementation study for the evaluation of the national rollout (two federal states) WP3: Two randomized-controlled trials for the evaluation of the clinical and cost-effectiveness of seven guided online-trainings for the prevention of depression (PROD-A) and the prevention of psychological stress through chronic pain (PACT-A) WP4: Randomized-controlled trial for the evaluation of the clinical and cost-effectiveness of a tele-based intensive coaching WP5: Epidemiological survey to access the prevalence, uptake, acceptance and barriers of preventative services. WP6: Studies for the evaluation of acceptance-facilitating-interventions (AFI) and experimental tests of recruitment strategies and to improve uptake rates Results and current stage of work: WP 1, 3, 6 are in progress and have already started WP 2, 4, 5 are in preparation The work packages as evaluation strategies and the implementation concept will be presented.

 

Teaching Behavior: An Opportunity for a Context Based Prevention Approach?

Patrick Pössel

University of Louisville, KY. USA

For multiple theoretical and practical reasons schools can be an appropriate setting for prevention of depression. However, basically all existing prevention programs are content based, meaning students need to gain knowledge and/or train new or develop existing skills. This requires instructional time which has to be taken away from other school subjects. Further, one has to wonder who is qualified to facilitate these prevention programs. Teachers seem to be the natural choice but studies examining them as facilitators find programs implemented by teachers are not particularly effective. Both issues raise the question how else depression in students can be prevented in the school setting. Empirical data to parenting programs demonstrate that behavioral parenting strategies can contribute to youths’ mental health. Based on this research and Cole’s Competence-Based Model of Depression four types of teaching behaviors (instructional, organizational, negative, social-emotional) were identified and their associations with students’ depressive symptoms and positive and negative affect examined. The findings of HLMs in multiple cross-sectional studies with elementary (n = 777), middle (n = 763), and high (n = 822 & 976) students from U.S. private and public schools will be presented. The individual associations differ based on type of teaching behavior, outcome variable (depressive symptoms vs. affect), and grade level, but overall each type of teaching behavior contributes to students’ mental health. Implications for a potential prevention approach based on teaching behavior will be discussed.

 

‘…and how are the kids?’ Integrated family-focused care for adult patients with depressive and/or anxiety disorders: a pilot study

Marieke R. Potijk, Louisa M. Drost, Petra Havinga, Catharina Hartman, Robert A. Schoevers

University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, The Netherlands

Depressive and anxiety disorders are highly prevalent and form a substantial burden for individuals and their family members. A recent study showed that approximately two-thirds of the children of patients with severe depressive and/or anxiety disorders develop one of these disorders themselves before 35 years of age. In the Netherlands, various preventive interventions are available for children of parents with mental illnesses. However, local referral options are often limited and the actual reach of interventions is small (<1% of all children participate). A major barrier appeared to be parents’ hesitancy to let children participate in preventive programs. In order to address this barrier, we designed a pilot study to implement a psychoeducation program on parenting and mental illnesses. Currently, guidelines for addressing patients’ roles as parents are lacking. Therefore, the aim of this study was to implement a preventive, family-focused approach that addresses patients’ roles as a parent, during routine treatment for depressive and/or anxiety disorders. The pilot started in April 2017 and will end in September 2018, and was conducted in the University Center Psychiatry (UCP) in Groningen, The Netherlands. This presentation describes the implementation process so far. The main intervention was a monthly organized group-psychoeducation called ‘parenting and a mental illness’, which could be attended by parents currently treated in the UCP. In 18 months, implementation activities were divided in four phases; 1. Creating awareness, 2. Adoption of the intervention, 3. Implementation and evaluation, and 4. Continuation phase. The implementation was evaluated using both qualitative and quantitative data.


Community pharmacies mood intervention study (CHEMIST): a pilot and feasibility trial
David Ekers, Dean McMillan, Simon Gilbody
University of York. UK
About 30% of the UK population has long term physical health problems. Many of those people also suffer from depression, which can end up making their physical health problems worse, lowering their quality of life and doubling healthcare costs. Mild/Sub-Threshold depression often goes undetected and untreated despite the fact it also can worsen a person’s health and functioning and is a major risk factor for depression. A previous study found that a treatment called collaborative care and behavioural activation reduced depression symptoms and nearly halved the number of people who developed major depression in older adults with sub-threshold depression. To enhance the uptake and coverage of this work, we sought to test whether behavioural treatments to prevent depression could be delivered in novel settings. Community pharmacies may provide an excellent setting for this type of program for people with health problems and sub-threshold depression. The aim of this study is to look at whether the treatment can be adapted and if it can be delivered by suitably trained community pharmacy staff to adults with mild depression and long term health problems. All participants receive the Enhanced Pharmacy Support Intervention (ESI). The ESI will be adapted for use with individuals with sub-threshold depression and long-term conditions, and will consist of four elements: Behavioural Activation focused self-help support; Proactive follow-up; Symptom monitoring; and Decision supported signposting. It will be delivered by suitably trained pharmacy support staff experienced in delivery of extended pharmacy roles (such as smoking cessation behavioural change approaches) over 4-6 sessions in a 4 month period either over the phone or face-to-face in the privacy of pharmacy consulting rooms. Participants are followed up at 4 months post-recruitment. This is a pilot RCT to test the feasibility of recruitment and delivery of the intervention prior to conducting a large scale trial Intervention group: Participants receive the Enhanced Pharmacy Support Intervention (ESI) over 4-6 sessions in a 4 month period either over the phone or face-to-face in the privacy of pharmacy consulting rooms, as in the feasibility study. Control group: Participants receive usual primary care management of sub-threshold depression offered by the GP or other local community provision. Participants in both groups are followed up at 4 months post-randomisation to test whether case level depression emerges. We will present some initial findings of the pilot trial and reflect on the experience of preventing depression in a high risk population (and in a novel setting). We will also present the rationale for conducting pilot trials of novel interventions. More about CHEMIST at http://www.isrctn.com/ISRCTN11290592