10 October 2012 is World Mental Health Day, an annual event sponsored by the World Health Organisation (WHO), and designed to raise public awareness about mental health issues. This year will focus on depression, which is quickly becoming one of the greatest threats to public health. 350 million people worldwide suffer from depression with 10% of the UK population suffering from depression or anxiety at any one point in time. WHO predicts that depression will become the second-highest disease in terms of disease burden amongst all general health problems by 2020.
Beyond the individual distress and suffering they cause, mood disorders have severe consequences including impaired social and occupational functioning, ill health, increased mortality and suicide. There are enormous associated economic costs through the expenses of public services and output lost from time off sick and non-employment. In the UK, depression and anxiety are estimated to cost the economy £17 billion in lost output and direct health care costs annually, with a £9 billion impact on the Exchequer through benefit payments and lost tax receipts. Therefore, research that increases our understanding of mood disorders and leads to more effective and accessible interventions is a priority for improving human health.
The Mood Disorders Centre (MDC) at the University of Exeter works to advance such understanding and treatment of mood disorders through experimental research and clinical trial research. The MDC provides integrated research across the translational spectrum from experiment through to treatment development and evaluation all the way through to dissemination and health services organisation. In parallel with the MDC, our Clinical Education Development and Research group (CEDAR) has led the way in developing and providing high-quality training programmes for clinical practitioners, with a focus on disseminating evidence-based psychological treatments.
A key component within the development of better approaches to mood disorders is a focus on the development and dissemination of effective psychological treatments. Whilst antidepressant medication is a moderately effective intervention for depression, and very commonly used, it has its limitations. Many patients want an alternative to taking medication and want to feel that they are contributing to their own wellbeing. Furthermore, rates of adherence to medication are low, with a substantial proportion of patients stopping their medication within 6 weeks, often because of unwanted side effects. Moreover, antidepressant medications are only effective as long as they continue to be taken – once they are discontinued, their benefits rapidly fade. For all these reasons, good alternative interventions to medications are required to provide patients with a choice between effective treatment options.
In addition, psychological approaches to depression play a critical role in addressing depression because of their potential to increase resilience and prevent subsequent depression. Critically, depression is a chronic and recurrent condition: 50% of people who have had one episode of depression will go on to have further episodes of depression. The only way medication can prevent future episodes is for it to be continued indefinitely, which is both expensive and at odds with what most patients want. In contrast, there is evidence that some psychological treatments, such as cognitive-behavioural therapy (CBT), can continue to reduce risk for future episodes after a relatively brief treatment period (16-20 sessions) has finished. For example, clinical trials in the MDC have found that training people with a history of depression in mindfulness meditation coupled with CBT can significantly reduce their risk for future episodes of depression. It appears that psychological treatments such as CBT may help to protect individuals from future depression by teaching them coping skills to manage stressful situations better and by helping them to find ways to resolve difficulties in their lives. This ability of psychological interventions to improve coping skills and resilience makes them an integral part of any comprehensive and long-term treatment approach to depression.
The ability of psychological treatments to increase resilience is particularly pertinent when we consider the extremely high prevalence rates of depression. Its high frequency means that focusing on treating the acute symptoms of depression alone is never going to significantly reduce the overall rates of depression. Just as one person is successfully treated, there will be new onsets of depression and recurrences in those with a history of depression. Therefore, in order to significantly reduce the global burden of depression, treatment for people with depression needs to be combined with preventive interventions that stop vulnerable individuals from developing depression. An ounce of prevention will definitely be better than a pound of treatment because of the chronic and relapsing nature of depression. Prevention requires the identification of individuals at risk for later depression and then providing them with better coping skills and enhanced resilience. A psychological approach is extremely well-placed to do this in a way that pharmacotherapy is not. Research in the MDC has already identified patterns of thinking and behaviour, such as the habit of repeatedly dwelling on and worrying about difficulties or a tendency towards avoidance, that predict increased risk for depression and anxiety. Our research has begun to look at ways to then effectively target these risk factors through psychological treatments. Moreover, there is a growing evidence-base that psychological interventions can be effective at preventing the onset of depression in high-risk groups, such as the children of parents with depression or adolescents with elevated symptoms of depression. The development and evaluation of psychological interventions to prevent the onset and relapse into depression is a major priority of work within the MDC, including the use of internet-based interventions that can be widely accessible to large numbers of people.
Another important issue is whether individuals with depression are able to easily access effective psychological treatments. Because of the scale of the problem, there is insufficient evidence-based psychological therapy available, leaving many people unsupported and lacking access to recommended treatments. In response to this treatment gap, in 2008, the NHS began the Improving Access to Psychological Therapies (IAPT) programme, dedicated to spending over £700 million on psychological therapies between 2008 and 2014. At the heart of this programme was the implementation of a new evidence-based approach to treatment alongside training a new workforce to deliver these treatments. By 2013/14, IAPT will deliver 6000 newly trained therapists nationally and increase access to treatment for 2 million more people.
The research conducted by the Mood Disorders Centre has influenced the provision, nature and content of therapy training and provision. CEDAR has had lead roles in the design, delivery and quality assurance of the training for the IAPT national programme. In 2008 we were awarded a contract from the South West Strategic Health Authority to begin training the new IAPT workforce. Since then we have trained over 300 practitioners. In recognition of our psychological treatment expertise, CEDAR is now the sole commissioned provider of IAPT training in the South West. CEDAR has just been awarded a contract to provide Child IAPT, which aims at early treatment and prevention of mood disorders and will be working alongside Young Devon to promote mental health at an early age.
By conducting research addressing how to improve psychological treatments, how to develop better interventions to prevent the initial onset and recurrence of depression, and how to make treatment more available to more people, and by training the next generation of therapists and clinical leaders, the MDC’s vision is to make significant inroads into reducing the global burden of depression.