Advances in Psychiatric Treatment (1995), vol. 1, pp.94-Wl

Prevention of depression:psychological and social measures

Jan Scott

The role of pharmacotherapy in the managementof depressive disorders is well-established andfrequently reviewed. This paper focuses on theprospects for reducing the incidence, prevalenceand morbidity of depression through psychosocialinterventions. A central requirement in preventionis a knowledge of the epidemiology of the disorderbeing investigated. This data can be used to identifyhigh-risk groups. By comparing the number ofknown cases with population levels of morbidity,it allows comment on help-seeking behaviour andaccessibility of services. Also, differences inincidence and prevalence rates give some indicationof the chronicity of the disorder.

This article begins with a brief review of theepidemiology of depressive disorders and thenexamines key concepts in prevention. Research onprimary, secondary and tertiary preventivestrategies is then discussed.

The risk of depression

Epidemiology

About 3% of GP attenders have a recogniseddepressive disorder, while an equal number ofsufferers go unrecognised. The median age of onsetof affective disorders is early adulthood (about 23years). Unipolar disorders are twice as common inwomen as men. Marital history is a powerfulinfluence on depression rates with continuouslymarried subjects, cohabitees and never marriedsubjects demonstrating the lowest morbidity. Thereis an inverse relationship between depression andsocial disadvantage. When the latter is controlledfor, there is minimal evidence of racial or ethnicdifferences in the prevalence of depression. Eightyper cent of individuals who experience a minorepisode later suffer a major depression.

Associated psychobiosocial factorsBipolar disorder and severe unipolar disorders arethe most familial forms of affective disorder.However, even where genetic influences are strong,environmental factors are important in determiningwhether a depressive disorder occurs and the formit takes. Psychosocial factors influencing vulnerability to depression include life events, socialsupport networks, early environment and pre-morbid personality. Key risk and protective factorsare summarised in Box 1.

Life events

In comparison with the general population,depression sufferers experience a significant excessof independent undesirable life events in the sixmonths prior to episode onset, or they reportchronic difficulties (Paykel & Cooper, 1992). Anincrease in such events may also be implicated inrecurrence or maintenance of depression (Scott &Paykel,1994). However, in the community, onlyabout 10% of individuals who experience an exitevent develop a clinical depression. Hence,mediating factors need to be explored.

Social support

Many depressives demonstrate premorbid deficitsin interpersonal relationships. However, researchsuggests that lack of support does not directlypredispose to depression. Social support reducesdepression risk by buffering individuals against theimpact of adversity (Alloway & Bebbington,1987).A specific form of support, namely the presence ofa confidante, is known to reduce vulnerability toonset and may also protect against recurrence ofdepression. Other characteristics of effectivesupport are that it has to be perceived by theindividual as adequate, and it has to be availableto them at times of crisis.

Professor Jan Scott is Professor of Community Psychiatry at the University of Newcastle School of Neurosciences, The Royal VictoriaInfirmary, Queen Victoria Road, Newcastle upon Tyne NEI 4LP

APT (1995), vol. 1, p. 95

Level of expressed emotion (EE) in a key relativeat the time of a depressive episode is a significantpredictor of outcome in unipolar and bipolarpatients.

Box 1. Risk factors and protective factors

Risk factors include:Close biological relative with depression

(due to genetic or depressive effect)Severe StressorsLow self-esteemFemale genderSocial disadvantage

Protective factors include:Presence of a confidanteCoping skills - problem-solving ability;

personal resilience

Early adversity

Brown (1989) suggested that a loss of mother beforethe age of 11 years was associated with increasedrisk of adult depression because of the adverseeffect on the individuals self-esteem. There is noevidence from recent reviews (Parker,1992) thatchildhood bereavement or parent-child separationsspecifically predispose to adult depression. Whilesuch events may be associated with a number ofdisorders, any negative effects are probably aconsequence of inadequate post-loss parenting.Childhood exposure to a parental style of 'affection-less overcontrol' is associated with an increased riskof neurotic disorders, particularly non-melancholicdepression, in adult life. Physical or sexual abusein childhood also increases the risk of adultdepressive and other mental disorders.

Premorbid personality and coping strategies

While personality factors may affect the course ofan affective disorder, no personality characteristicshave been found to be specifically associated withonset of depression. Individuals who develop a firstdepressive episode differ from never-ill controls inshowing higher levels of neuroticism, lower levelsof emotional stability, less resilience and higherlevels of interpersonal dependency (Hirschfeld &Shea, 1992). Cognitive theory highlights that highlevels of neuroticism are associated with chroniclow self-esteem, global negative affect andenhanced recall of negative self-related material.This may partly explain the role of this trait in thedevelopment of depression.

Alternative models of vulnerability to depression

focus on perceived self-efficacy, coping andproblem-solving strategies. Coping consists notonly of what an individual does but also of whatpsychological and social resources are available.Individuals differ in the extent and efficacy of theircoping responses. For example, those who generatefewer and less effective alternative solutions toproblems may be at increased risk of depressionand deliberate self-harm.

Key concepts in prevention

Epidemiological data are used initially to identifythose people at greatest risk of affective disorder(the target population). Historically, three forms ofprevention have been defined :

(a) Primary : aimed at reducing the incidence ofthe disorder

(b) Secondary : aimed at reducing prevalence(c) Tertiary : aimed at reducing associated

disabilities.The strategies used in secondary and tertiary

prevention are essentially those employed in goodclinical practice. Primary preventive interventionsare less well defined, but may be categorised as'pro-active' or 'reactive' (Jenkins, 1994).

Box 2. Issues for cliniciansA sound knowledge of epidemiology helps

clinicians understand which psycho-social factors may predispose to, orprotect against, the onset of depressivedisorder.

The introduction of self-rating questionnaires is an inexpensive way of improving the detection of depressive disordersin community settings. To be trulyeffective this strategy probably needs tobe linked to training that improvestreatment.

Even where genetic or biological influencesare strong, taking a psychosocial (distressed person), as well as a biomdical(diseased organ) approach improvespatient outcome.

For example, improving parenting skills whichmay in turn enhance a child's self-esteem andreduce the risk of depression in adulthood, is a proactive intervention. Counselling recently bereavedindividuals to reduce the risk of abnormal griefreactions is a reactive intervention. Selecting

APT (1995), vol. 1, p. 96

candidates for such approaches is a criticalconsideration. Three targeting strategies arerecognised :

(a) Universal: measures regarded as desirable forall members of the community (e.g. healthpromotion, improved housing)

(b) Selective: measures appropriate to high-riskgroups within the community (e.g. youngfemale single parents)

(c) Indicated: measures targeting an individualat very high risk (e.g. someone with a stronggenetic predisposition).

These preventive interventions operate atdifferent levels within the social order. Macro levelinterventions are aimed at changing the society andculture. Psychiatrists may seek to operate at amacro level by trying to influence governmentpolicies to reduce poverty, unemployment and poorhousing. Micro level interventions are aimed atindividuals, primary groups or social networks. Itis easier to show the efficacy of micro levelinterventions with individuals in their immediateenvironment, particularly if the strategy is highlytargeted as in selective or indicated measures(Jenkins,1994; Scott & Leff,1994).

Specific psychosocial preventive strategies maycomprise individual or family therapy or may focuson general behavioural change in the individual(e.g. social skills training) or significant others. Thesocial environment may also be modified either byenhancing existing support systems or creating anew more protective environment (e.g. throughchanges in lifestyle).

Systematic research on psychosocial aspects ofthe prevention is limited. In the biological field,there is a small literature on primary prevention(regarding the role of genetic counselling) whilesecondary and tertiary preventive strategies aredescribed in the detailed research on the benefitsof different drugs in the acute, continuation andmaintenance phases of depression treatment. Theincreasing awareness of psychosocial factorsassociated with onset and maintenance of depression means the development of preventionprogrammes is likely to expand in the next decade.Potential strategies are reviewed below.

Preventive strategies indepressive disorder

Primary prevention

Primary prevention strategies may target earlyaspects of the lifespan (genetic or constitutionalvulnerability or childhood adversity), or may focuson individuals experiencing specific life events (seeTable 1).

Interventions in parent-child relationships

The impact of poor parenting may not specificallypredispose a child to depression in adulthood.However, if parental care could be improved, orself-esteem of the child at risk enhanced, it mighthave a long-term primary preventive effect. Rutter(1985) highlights how problems experienced by oneindividual may adversely affect another individualin the immediate environment, which may furtherworsen the interaction and problems of bothpeople. Strayhorn & Weidman (1991) attempted tointervene in this vicious cycle by targetingdistressed mothers who were having difficultymanaging children who had identified behaviourproblems. Support for the mothers was associatedwith reduced levels of behavioural disturbance inthe offspring.

School programmes with 'at risk' children andadolescents

In the USA, Shure & Spivack (1982) describedimproved problem-solving skills with a programme targeted at over 200 young children withbehaviour problems who came from disadvantagedbackgrounds. Others describe small projects whichreduced neurotic traits in adolescents through theuse of rational emotive therapy. School programmes that educate children and adolescents inhow to cope with conflict and crises and improve

Table 1. Primary prevention strategics

Strategy

Reduce individual vulnerabilityImprove parent-child interactionsOffer event-centred interventions

Example

School programmes to improve coping skills in adolescentsSupporting mothers of children with behaviour disorderCounselling for individuals:

at risk of abnormal grieffacing severe trauma e.g. cancer surgerywith risk factors for depression e.g. divorce

Prevention of depression APT (1995), vol. 1, p. 97

life skills may benefit women more than men(Mrazek & Haggerty, 1994).School-based suicideprevention programmes are not deemed effective.

Event centred interventions

Most life events implicated in studies of depressionare inevitable consequences of the life cycle.However, the occurrence may signal a period ofincreased risk of onset of depression and preventiveinterventions may be feasible. This approach lieson the border between primary and secondaryprevention.

Support and counselling reduces depression andother psychiatric morbidity in those at high risk ofabnormal grief reactions (Raphael, 1977; Parkes,1981). Futhermore, research showed that treatedhigh-risk individuals were less symptomatic thannontreated controls up to 20 months post-intervention. Morbidity rates in the counselledgroup were reduced to the same levels as found inindividuals at low risk of an abnormal griefreaction.

In the USA, Bloom et al (1985) describe aprogramme of pre-divorce counselling targeted atadults demonstrating other risk factors fordepression. A four year follow-up study of 150individuals demonstrated fewer symptoms ofanxiety and depression and better vocationaloutcomes in the intervention group.

Maguire et al (1980)randomly assigned womenhaving surgery for breast cancer to counselling orto practical advice. The prevalence of anxiety anddepression was similar in both groups, but episodeswere of shorter duration in the counselled womenand they showed better social and psychologicaladjustment at post-operative follow-up after 18months. However, the reduced morbidity duringepisodes might have been a function of earlyrecognition and prompt referral (i.e. secondaryprevention), rather than representing primaryprevention.

Secondary Prevention

The secondary prevention of affective disordersencompasses early case detection and earlyinitiation of treatment (see Table2).Early detection

Early detection of affective disorders depends inpart on the attitude of the individual towards anysymptoms which develop, and the behaviour of theprofessional they present to. As few as 50%of thosedeveloping depressive disorders seek help (Scott& Paykel, 1994). Individuals with endogenoussymptoms, limitations in ability to work, impairedfunctioning and lower levels of social support aremore likely to consult. Between 25-50% ofindividuals with depressive disorder will remainundetected by their GP. Depression is morefrequently missed in young men, people presentingwith somatic symptoms, and those who mentionemotional disturbance late in the interview.

The use of self-report or simple observer-ratedquestionnaires such as the General Health Questionnaire, the Beck Depression Inventory, or theHospital Anxiety and Depression Scaleoffer a cost-effective method (a GHQ costs about two pence tocomplete) of helping primary care staff detectdepression. Importantly, research has shown thatnotifying a GP that a patient was a psychiatric caseproduced a better outcome than non-notification.

An alternative approach is to use educationalprogrammes to improve case recognition. InSweden, Rutz et al (1989)described a programmethat improved detection and management ofdepression and suicide risk. Evidence from England(Scott & Paykel, 1994) suggests that a packageaimed at improving the interviewing skills ofprimary care physicians produces similar results.At a national level, professional colleges (AmericanPsychiatric Association; Royal College of Psychiatrists) have initiated the 'DART' (DepressionAwareness, Recognition and Treatment) and the

Strategy

Improve early case detection

Offer early intervention

Example

Screening questionnaires e.g. Beck Depression InventoryEducation and interview skills training for GPsIncrease awareness of depression and enhance help-

seeking e.g. Defeat Depression campaignSupport and monitoring of at-risk mothers or pregnant

women e.g. NEWPINprojectImprove access to professional help e.g. self-referral,

liaison attachment to primary care

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Tertian/prevention

Strategy

Reduce relapse and recurrence

Provide vocational rehabilitationDevelop support programmes

Example

Psychotherapies alone or as an adjunct to pharmacotherapyCognitive therapyCouples therapy/IPTFamily therapy

Establish meaningful daytime activityPsycho-education programmesNetwork therapySocial skills trainingBefriending schemesAssertive outreachLifestyle counselling

'Defeat Depression' campaigns. These aim toimprove knowledge and treatment skills ofprofessionals, and to raise awareness, reduce stigmaand encourage help-seeking by sufferers.

Early intervention

Early intervention offers possibilities both ofinterrupting distress before it reaches the level ofclinical depression (at the border of primary/secondary prevention) and of markedly shorteningclinical depressive episodes.

Newton (1988) describes befriending projectswhere at-risk parents are supported in thecommunity in an attempt to enhance childdevelopment and improved parental functioning.The Newpin project in London relates most closelyto those at risk of depression. Mothers who werevulnerable to depression according to the Brownand Harris model, formed a contract with avolunteer supporter from a similar social background who offered input over an extended period.Self-evaluation by the women suggested that self-esteem, self-confidence and interpersonal relationships had improved and that the mothers relatedbetter to their children (Newton, 1988).

In New South Wales Barnett & Parker (1985)undertook a project with primiparous women whohad been shown to be at greater risk of neuroticand depressive disorders. The women wereassigned postnatally to either professional support,lay support or a control group with no additionalhelp offered. Overall, those who received professionalhelp showed a significantreduction in postnatal anxiety levels compared to the other groups;those receiving lay support showed a nonsignificant improvement.

Access to services

Increasing direct access to mental health services(e.g. offering self-referral or providing liaisonsessions in primary care) is another way ofincreasing detection and early intervention. Moreinformation is needed about the accessibility oracceptability of the services to certain high riskgroups. For example, young Asian women havehigher suicide rates than young Asian men, butattend GPs less often than any other subgroup inthe general population.

Tertiary prevention

Although the measures described in this sectionlie more in the realm of treatment they havepreventive implications since the interventionsreduce prevalence rates of symptomatic disorder.Recent studies confirm that at least 50% of thosewith first depressive episodes have a furtherepisode, while the median prevalence of chronicityis 12%(Scott, 1992).About 15%of deaths are dueto suicide, and mortality rates from other causesare also increased in people with affectivedisorders.

Prevention of recurrence and relapse

The role of pharmacotherapy in preventing furtherepisodes has been well studied and clear guidelinesexist. Psychosocial approaches are less clearlyevaluated, but the literature is expanding rapidly(see Table3).

Interpersonal psychotherapy was of significantvalue in reducing recurrence in one study, but didnot reduce early relapse in a controlled study of

Prevention of depression APT (1995), vol. 1, p. 99

continuation medication (Scott & Paykel, 1994).There is accumulating evidence that cognitive

therapy may reduce relapse rates in mild tomoderately severe unipolar depressions (USDepartment of Health and Human Services, 1993).Evans et al (1992) demonstrated that the relapserate with cognitive therapy was no different fromthat of patients receiving continuous drugtreatment and was only half that of the patientswho stopped their drug treatment immediatelyafter their depression remitted. If cognitive therapyalone reduces risk of relapse this will be the firsttime any form of antidepressant treatment has beenshown to have an effect beyond the point oftermination of the intervention. Whether thecombined use of cognitive therapy and pharmaco-therapy bestows any additional benefit over eithertreatment alone is inconclusive. However, acognitive approach may significantly enhancecoping skills, lithium compliance and outcome inbipolar and unipolar cases (Scott, 1992).

The research on EE demonstrated that (incontrast to schizophrenia) depressives with highEE relatives were not protected by drug treatmentor by reduced contact. However, Jacobson et al(1993) reported that marital therapy alone or incombination with individual cognitive therapyoffers effective treatment of the acute depressiveepisode and may prevent relapse.

Rehabilitation

There has been a failure to investigate the residualdisabilities of individuals with affective disorders(Scott, 1992). Vocational rehabilitation of thesepatients focuses less on the role of work performance and more on its potential for restoringconfidence, improving self-esteem and enhancingfeelings of mastery. Only broad guidelines areavailable, but meaningful daytime activity seemsimportant. Re-employment may reduce depressionin socially isolated men who have been maderedundant, and women working outside of the homeshow less impairment following depression thanhousewives.

Educational and support programmes

Psycho-educational programmes for hospital-treated depressives and their families may beassociated with better resolution of the indexdepressive episode and better global outcome(Click et al, 1994). Also, individuals with chronicneurotic disorders and their families benefit morefrom home-based support of a community psychiatric nurse rather than intermittent symptom-orientated out-patient appointments.

Improving individual coping repertoires,

network therapy (where each member of thesufferer's primary group takes responsibility forinitiating specific social changes), befriendingprojects and social skills training have beenadvocated but not fully evaluated. Lastly, in someindividuals, reducing stress can only be achievedthrough significant changes in lifestyle (e.g. takinga less demanding job). However, care is required.Change should not be made until the individual'smental state is stable, and it must not condemn theindividual to an unfulfilling existence.

Box 3. Controversial issuesNo model of depression onset is robust

enough to allow mental health servicesto introduce cost-effective primarypreventive programmes.

Many unrecognised cases of depression aremild and self-limiting. To be perceivedas clinically relevant preventive strategiesmust ensure that either.(a) early detection of mild cases is matchedby early detection of severe cases, or(b) the long-term outcome of the mildcases detected is significantly improved.

Few bipolar patients receive psychosocialinterventions in day-to-day clinicalpractice, yet the limited research dataavailable shows that outcome is improvedif such approaches are provided. Theeffect may be due to the indirect improvement in treatment compliance, but evenso, shouldn't we employ such approachesmore often?

Conclusions

Analysis of epidemiological data identifies high-risk groups and potentially allows the developmentof primary, secondary and tertiary preventivestrategies across the lifespan. Evidence of theprevention of first episodes of depression is notavailable.

Promising lines of primary prevention researchrelate to trying to improve coping skills, andenhancing 'protective' factors during times ofincreased vulnerability to depression onset.Individuals with a wide range of coping strategiesand resources available to them are less likely toreach the pathological end-state of depression inresponse to stress (Scott, 1992).

Event-centred interventions, which fall on the

APT (1995), vol. 1, p. 100

boundary between primary and secondary prevention, are the most relevant approaches forclinical psychiatrists. There is a possibility thatmajor affective disorders may be prevented byinterventions at the subclinical level. Psychosocialinput to individuals at high risk for depression whohave experienced, or are about to experience, asignificant life event seems to reduce morbidityrates to the same level as low-risk individuals.

Prospects for secondary prevention vary.Accessibility of services can be modified. Primarycare professionals can be encouraged to improvedetection rates of affective disorders and help-seeking behaviour may be promoted throughpublic education. However, improving caserecognition must be linked to training thatimproves the management of depression. Only 30%of recognised cases of depression in primary carecurrently receive adequate treatment.

While the mechanisms of action of putative riskfactors in the onset of depression are unresolved,the role of psychosocial variables in the presentationand maintenance of the disorder is less contentious.Clinically, the prompt introduction of multimodaltreatment during the acute depressive phase andrigorous attention to aftercare of the individual andtheir family are the most effective preventivestrategies currently available. As such, there is nosubstitute for following 'good practice' guidelinesin an attempt to reduce the morbidity and mortalityassociated with depressive disorders.

Acknowledgements

The author wishes to acknowledge the input of Professor E SPaykel. Many of the ideas expressed in this paper draw on ourprevious joint writings on this topic.

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Prevention of depression APT (1995), vol. 1, p. 101

Multiple Choice Questions

1 Epidemiological studies of depressive disordersdemonstrate that :a about 3% of GP attenders suffer from a

depressive disorderb the median age of onset is 35 yearsc never married individuals are at greater risk

than currently married individualsd early loss of a parent specifically predisposes

to adult depressione the lifetime risk of developing major

depressive disorder in those with a minordepression is 50%interview skills training has a demonstrableeffect on recognition ratesspecific rehabilitation programmes fordepressive disorder are well developedcognitive therapy and maintenance drugtherapy significantly reduce relapse ratesfollowing a major depressive episodepsycho-educational programmes mayimprove the outcome of hospital-treateddepressives

MCQanswers1abcdeFFFFF.2abcdeFTFTF3abcdeTTTTT

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