Enligt OECD lider 350 miljoner människor av depression, vilket också är den vanligaste orsaken till självmord. I Forum för Health Policys tidigare publicerade policy brief presenteras rekommendationer för att möta samhällets stora utmaning med en ökande psykisk ohälsa. Rekommendationerna baseras på Forums workshop i mars 2019. I dagens blogg skriver Professor Ricardo F. Muñoz, University of California, särskilt för Forums läsare, om möjligheterna att förhindra individers utveckling av depressioner samt potentialen i digital behandling av psykisk ohälsa, bl.a. genom sk MOII, massive open online interventions, evidensbaserad terapi, i stor skala. Professor Munoz gör även ett inspel på Forums workshop den 8 oktober om framtidens hälso- och sjukvård. En längre version av artikeln med fullständiga referenser finns här.
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Toward a world without (preventable) depression
Ricardo F. Muñoz, Ph.D.
- Expand mental health services beyond treatment into prevention of depression and promotion of mental health and
- Scale up depression prevention and treatment interventions beyond face-to-face interventions into automated Internet and other digital interventions
According to the World Health Organization, 350 million people suffer from depression, which is the leading cause of disability worldwide. Depression is one of the major global causes of suicide, which takes 800,000 lives a year. Yet, there are well-researched methods to treat depression such as cognitive therapy and behavioral activation, which teach patients to alter patterns of thoughts and behaviors that maintain or worsen depressive mood.
Beyond treatment: We must begin preventing depression
Why wait until people are suffering from depression to teach them the mood management skills that have been found helpful in the treatment of depression? Meta-analyses of randomized controlled depression prevention trials show that, on the average, we can prevent approximately 21% of new major depressive episodes.
In the last 25 years, the United States National Academies of Science, Engineering, and Medicine have released three major consensus reports focused on the prevention of mental disorders and the promotion of healthy mental, emotional, and behavioral development.
The first report, released in 1994, titled “Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research) set up a clear line of demarcation between prevention and treatment: prevention interventions occur before the onset of a clinical episode. The second report, released in 2009, titled “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” concluded that enough progress had taken place in the intervening 15 years so we could now prevent the onset of certain specific mental disorders, such as depression.
The most recent report, titled “Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda” moves further into the realm of promotion. It focuses on scientific advances showing how the environment can affect gene expression and produce changes in the brain that influence healthy or unhealthy development. Among other things, the report calls for
- the implementation of evidence-based preventive and promotion interventions,
- the utilization of methods to scale up interventions focused on the individual, such as digital interventions, and
- moving beyond individual interventions to preventive and promotion interventions that involve the family, the community, and social policies.
The report highlights the need to take advantage of the full range of research findings in the area of prevention and promotion. Many of these findings will require the involvement of community systems beyond the mental health care system, involving general health care, the educational system, urban planning, the business community, and so on. The cost of mental, emotional, and behavioral disorders affects all these systems. And all are needed to collaborate if we are going to reduce the burden of mental disorders in our communities.
The advantage of the cognitive and behavioral approaches to prevent or treat depression is that they can be administered using digital tools. Meta-analyses of online interventions for depression have shown that they are effective.
Based on our experiences with online smoking cessation interventions, we have advocated for the creation of “Massive Open Online Interventions” (MOOIs), inspired by the better-known Massive Open Online Courses, or MOOCs. These would be automated self-help prevention and treatment interventions open to anyone in the world who wants to use them. Self-help automated interventions provide great scalability at very low cost. The bulk of the cost derives from the process of development and testing. This approach has great potential in reducing health disparities worldwide, at little or no cost to the user or to the country’s health care system.
Massive Open Online Interventions (MOOIs) could be housed in “Digital Apothecaries”, that is, online portals that would make available evidence-based interventions to prevent or treat many mental, emotional, and behavioral conditions. Ideally, these digital interventions would be available in many languages and accessible worldwide.
Developing, evaluating, and disseminating Internet and other digital interventions would contribute to reducing health disparities. It will be important to monitor the impact of future digital interventions to make sure that, in addition to equity in access, we also achieve equity in outcomes across socioeconomic levels.
Although the average randomized controlled depression prevention trial yields a 21% reduction in new cases, about a third of these trials have yielded reductions in new cases of 50% or more. I have argued, then, that reducing new episodes by 50% is within our reach. Evidence from the United Kingdom suggests that psychological treatment interventions used routinely (not in research studies, but in actual practice) yield recovery rates between 44% and 58%. From these findings, I surmise that our current interventions are able to successfully prevent or treat approximately half of major depressive episodes.The field of prevention and the field of digital interventions are both still in early phases of development. Yet both have much potential that should be exploited. Both focus on modifying human behavior to achieve greater health. A large portion of the global burden of disease is modifiable via human behavior. Changing health behavior could help us eradicate multiple sources of unnecessary human suffering, such as depression. Focusing on depression is an example of “thinking globally, acting locally.” Digital tools now allow us to, in addition, “share globally.” They can potentially reach all corners of the world. The potential benefit of implementing prevention and treatment interventions via Massive Open Online Interventions could indeed be massive, with much more modest funding than that necessary for eradicating malaria, for example. Let’s begin taking the first steps on the road to a world without preventable depression.
Distinguished Professor of Clinical Psychology, Palo Alto University
Professor of Psychology, Emeritus, University of California, San Francisco.