Depression

Depression is an affective disorder

Depressive symptoms are widely spread throughout the population with almost everyone having experienced most of these symptoms at one time or another. Within the class of psychiatric disorders, major depression and dysthymia are two of the main diagnostic categories. They are also often referred to as affective or mood disorders. Dysthymia is generally defined as a mild (although persistent) form of depression. The category of affective disorders also includes other disorders such as bipolar disorder; however this EUphact is limited to major depressive disorder and dysthymia.

Depressed mood and loss of interest are the main symptoms of a depressive episode

The International Classification of Disease (ICD-10) is the most widely recognized system in Europe for describing and defining disorders. The ICD-criteria for a depressive episode are depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatigability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:

• reduced concentration and attention;
• reduced self-esteem and self-confidence;
• ideas of guilt and unworthiness (even in a mild type of episode);
• bleak and pessimistic views of the future;
• ideas or acts of self-harm or suicide;
• disturbed sleep;
• diminished appetite.

To meet the diagnostic criteria, the symptoms need to be present for at least two weeks. Symptoms typically do not vary from day to day, however there may be a variation in the symptoms during the course of a day. Depression can be described as mild, moderate or severe.

Dysthymia is a mild but persistent form of depression

Dysthymia is generally defined as a mild but persistent form of depression, which lasts at least two years. It mostly starts in young adolescence. The main symptoms of both dysthymia and depression are a persistent depressed mood and a loss of interest or pleasure in daily activities. It is not unusual for people with dysthymia to experience also major depressive episodes. In fact, more than 75% of people with dysthymia will meet the criteria for a major depressive episode at some point in their lives (Keller et al., 1995). Those that suffer from both a major depressive disorder and dysthymia are said to suffer from “double depression” (Klein et al., 2006).

Depression is a recurrent disorder

It is very common for depressive episodes to recur in individuals. Most people (75%-90%) who have experienced an episode of depression will experience at least one more episode in their life (Greden, 2001). There is a general consistency across Europe regarding the course of this illness (Paykel et al., 2005). When symptoms of a depressive episode do not fully subside, the potential for relapse is significantly increased (Judd, 2000). Lower recurrence rates are found in studies of out-patients than in studies of in-patients. Even lower rates of recurrence are found in surveys of the general population (Paykel et al., 2005). This suggests that the likelihood of recurrence is tied to the severity of the symptoms. Dysthymia is also a highly recurrent disorder, with results from a longitudinal study yielding a relapse rate of over 70% (Klein et al., 2006).

Depression often occurs together with other mental disorders

Depression often occurs in connection with other mental disorders. A series of general population surveys in six European countries found that 53.1% of individuals with depression suffered from more than one mental disorder (Alonso et al., 2004). 73.3% of individuals with dysthymia had more than one mental disorder. Depression was most commonly associated with dysthymia and was also linked to anxiety and alcohol disorders in all of the six countries surveyed. It is estimated that 30-40% of all persons suffering from a depressive disorder also suffer from an anxiety disorder and vice versa (Wittchen & Jacobi, 2005).

Depression often occurs together with physical disorders

Depression also often occurs alongside physical disorders. The lifetime prevalence of affective disorders in people suffering from a physical disease is almost double that of people not suffering from a physical disease. Arthritis, cancer, chronic lung disease, cardio-vascular disease and neurological disease are closely related to the prevalence of depression. With increased age, comorbid mental and physical disorders also increase (Wells et al., 1988). The exact nature of the interaction between mental and physical disorders is still under investigation. In some cases physical disease precedes depression (e.g. chronic pain is a risk factor for depression), while in other cases depression precedes physical morbidity. Depression and physical disease can also occur together by chance.

18.4 million Europeans suffer from depression

On the basis of meta-analytic techniques as well as on reanalyses of selected data sets from 17 studies including subjects from 12 European countries, it is estimated that 18.4 million Europeans aged 18 to 65 have suffered from depression in the last twelve months. The corresponding prevalence rates range between 3.1% and 10.1% (Wittchen & Jacobi, 2005). It has to be noted though that the studies assessed in these analyses applied quite different designs and methods, which hampers the comparability of their outcomes.

Depression prevalence rates vary across surveys and countries

The most recent coordinated survey of European countries, the European Survey of the Epidemiology of Mental Disorders (ESEMeD), investigated representative national samples in six European countries. The study revealed notable cross-national differences regarding affective disorders. The percentage of population with mood disorder one time in their life and in the previous 12 month shows that the lowest 12-month prevalence rate was found in Germany (3.3%) and the highest in France (6.5%) (EPREMeD). The reasons for these differences are not fully understood.

Psychological distress is a different dimension of mental health to psychiatric disorders

Depression is not a simple consequence of psychological distress but depression always has psychological distress as a symptom and consequence. It is possible to separate depressed mood as a normal human reaction to difficult life circumstances from a severe depressive disorder. The latter is characterised by deep anhedonia, the inability to perceive normal feelings, complete hopelessness and even hypochondriacal delusions or delusions of poverty and guilt.

Major depressive episode is the most important risk factor for lifetime suicide attempts

The ESEMeD 2000 study found that major depressive episode is the most important risk factor for lifetime suicide attempts among examined respondents from 6 EU-countries, with a population attributable risk proportion of roughly 28%, which implies that the lifetime prevalence of suicide attempts could be cut by almost one-third by preventing major depression (Bernal et al., 2007).

For more details see Factors associated with suicidal ideation and attempts in 6 EU-countries and Relative Risk for lifetime suicide attempts

High rate of suicide ideas does not always correlate with high completed suicide rates

Depression and dysthymia are also associated with an increased premature mortality due to suicide. A high rate of suicide ideas does not always correlate with high completed suicide rates. For example, a higher frequency of completed suicide was found among men compared to women (see suicide), while suicide ideation and suicide attempts are more prevalent in women (see suicide ideation). There was a correlation between the high suicide ideas and the high completed suicide rates found in Belgium and France. Also, Italy and Spain ranked last in suicidality ideas as well as in completed suicide rates. The Netherlands, however, had relatively low rate of completed suicide and intermediate rates in suicidal ideation and attempts (Alonso et al., 2008). For 15-34 years old people suicide is one of the top two leading causes of death in Europe (Murray & Lopez, 1996).

Highest suicide rates found in Eastern Europe

Suicide rates vary considerably across Europe. Generally speaking, the countries with the highest suicide rates are found in Eastern Europe (including the Baltic states), and the lowest rates are found in southern Europe. In all countries, higher rates of completed suicides are found in males than in females. The differences in suicide rates between countries cannot be explained by differences in risk factors for suicidality (Värnik et al., 2008, Bernal et al., 2007). Suicide rates depend on a complex combination of factors, such as availability of suicide means, the prevalence of mental disorders, and societal processes (Levi et al., 2003).

Lifestyle factors and chronic illness related to early mortality

Early mortality in depressed persons can also be due to other causes, besides suicide. Associations between depression and smoking, depression and substance abuse and depression and chronic physical illness are all thought to contribute to earlier deaths for depressed persons (Wulsin et al., 1999). Associations have also been found between depression and poor outcomes in breast cancer, malignant melanoma, and cardiovascular disease (Greden, 2001). Prospective epidemiological studies reveal that depression increases the risk for cardio-vascular disease later in life with the factor 2 – 2.5 (Glassman & Shapiro, 1998). In fact, depression affects about 40% of all cardio-vascular patients and worsens prognosis after myocardial infarction (Frasure-Smith et al., 1993). In addition, increased premature mortality in depression and dysthymia is related to a higher rate of accidents (Wulsin et al., 1999; Joukamaa et al., 2001).

Large contribution of depression to total burden of disease

The Global Burden of Diseases Study of WHO calculated that depression is the leading cause of disability among all major illnesses. Their results indicated that depression is the fourth leading contributor to the total world burden of disease in 2000, accounting for 4.4% of disability-adjusted life years (DALYs). In Europe, depression is the third leading contributor to the total burden of disease, measured in DALYs. The large contribution of depression to the burden of disease is a result of a combination of a high prevalence, high impact on functioning and early age of onset (Üstün et al., 2004). Future projections for global DALYs in the year 2020 show a significant increase in the impact of non-communicable diseases worldwide. As a consequence, depression is expected to reach the second place on the WHO DALYs ranking list in 2020 (Murray & Lopez, 1996).

Depression restricts daily functioning, especially if there is comorbidity

Depressed individuals commonly report poor functioning at work as well as relationship difficulties. The more severe the symptoms of depression are, the more the psychosocial problems worsen. Similarly, when the depression subsides, the affected person’s psychosocial functioning, work performance and relationships return to normal levels (Judd, 2000).

Depression is frequently associated with other psychiatric conditions. Disability increases and quality of life decreases with such comorbidity; the more mental disorders a person has, the more likely he will be disabled by these conditions and experience a low quality of life. People suffering from depression in combination with an anxiety disorder experience a very high rate of functional disability. This has been shown to lead to a substantial demand on healthcare resources (Tylee, 2000).

Economic consequences mainly due to sickness absence

Depression has major economic consequences similar to that of physical illnesses (Smit et al., 2006). Patients with depressive disorder make more use of health care services than patients without this disorder (Bijl & Ravelli, 2000b, Koopmans et al., 2005), and they also often take sickness leave from work. For example, almost 10% of the days of sickness absence taken in Germany in 2004 were recorded as being due to a mental disorder diagnosis, mostly depression (IGES, 2005). The number of sickness days taken for depression in Germany increased by 40 % from the year 2000 to 2004, while decreasing days of sickness was the general trend. This increase affected particularly men and women below the age of 30. Similar trends are reported from some other European countries, although no cross-country comparable data are available (Hensing et al., 2006; Savikko et al., 2001). The high level of sickness absence in depressed people generates high costs in the employment sector. The ESEMeD study demonstrated a strong impact of mental disorder on absenteeism from work in the general population (Alonso et al., 2004). Generally, production losses are estimated to account for 85% of the total costs of mental disorders, with an average of 2,725 euro per person per year in the Netherlands. Of the distinct mental disorders, dysthymia generates the highest costs (Smit et al., 2006).

See also Average length of stay, Mood disorder.

There is no known single cause of depression; rather depression is generally attributed to a combination of psychological, social and biological factors. Numerous factors affect a person’s likelihood of developing depression, including: stressful life events, their age, sex, socioeconomic and marital status, hereditary factors, childhood adversities as well as mental and physical comorbidity.

Prevalence highest in adulthood

Depression rarely occurs before puberty; prevalence rates start rising from about age 12. Prevalence rates increase continuously until the age 60 when they start declining (Ernst & Angst, 1995). There are very few epidemiological surveys assessing depression morbidity in the very old. Whether depression prevalence decreases or only depression expression changes continues to be debated (Ernst & Angst, 1995; Henderson et al., 1998); (Stordal et al., 2003; Roberts et al., 1997). In old and very old age there is a shift in the presentation of depressive syndromes away from the classic picture of major depression towards a more sub-clinical and somatic manifestation (Ernst & Angst, 1995, Bramesfeld et al., 2007a).

Depression more common in women than in men

Depression is more common in women than in men. Consistently epidemiologic surveys have found prevalence rates of depression to be twice as high in females. The reasons for that are not understood. Hormonal and genetic factors as well as gender differences in living circumstances (such as poverty, single parenthood, dependent life style) and coping styles (internalisation, a stronger interpersonal orientation) are discussed in this context. Whereas attempted suicide rates are higher for females in most countries the opposite is true for completed suicides (Värnik et al., 2009).

Social factors: marital status and socioeconomic status

Widowed and divorced persons have a higher risk of developing depression (Klose & Jacobi, 2004). This is also true for parents who are single or unemployed and have dependent children (Helbig et al., 2006). There is a clear socioeconomic gradient in depression risk. The higher the educational degree and the higher the social status (as a construct made of education, work status and income), the lower the depression risk is. Unemployment is associated with a doubled risk for depression (Fryers et al., 2005). All these studies, however, do not allow to draw strong conclusions about causality because especially recurrent or chronic depression often causes socioeconomic decline, divorce and unemployment.

Also see Predictors of mental disorders

Childhood adversities are associated with depression

Adversity is a major negative event in childhood or adolescence challenging seriously one's ability to cope. Such adversities are sexual abuse (rape and sexual molestation), physical abuse and serious neglect before the age of 18. Childhood adversities are associated with depression and its prognosis in adulthood, as well as with increased somatic morbidity and mortality in both childhood and adulthood. Childhood adversities are strongly associated with vulnerability and several background factors (such as personality and genotype) moderate the outcome of the adversity (MINDFUL, 2008).

Substantial evidence supports the heritability of lifetime major depression

People who have relatives who have had clinical depression have a greater chance of developing it themselves. The heritability of lifetime major depression as assessed at personal interviews in over 15,000 complete pairs of twins from the national Swedish Twin Registry, was estimated to be 38% (Kendler et al., 2006). Similar result of 37% heritability of major depression was obtained from a meta-analysis of other twin studies (Sullivan et al., 2000). There was a difference with regards to gender; the heritability of major depression was estimated at 42% in women and 29% in men (Kendler et al., 2006). There is no single major gene responsible for depression. However, a larger set of genetic variants showing complex interactions among themselves as well as with environmental factors are supposed to influence the risk of a certain person to become depressed.

European Commission green paper focuses on effective interventions

On the European public health level, there have been numerous activities aimed at preventing depression, promoting mental health and encouraging treatment for depression. In its 2005 Green Paper Improving the mental health of the population: towards a strategy on mental health, the European Commission confirmed its commitment to the mental health of its citizens.

European Pact for Mental Health and Well-being

On June 2008 the participants in the EU conference "Together for Mental Health and Wellbeing", acknowledged the importance and relevance of mental health and well-being for the EU, its member states, stakeholders and citizens.

Mental health was recognised as a human right and as a key resource for the success of the EU as a knowledge-based society and economy. Complementary action and a combined effort at EU-level can help member states promoting good mental health and well-being in the population, strengthening preventive action and self-help, and providing support to people who experience mental health problems and their families.

Policy makers and stakeholders were invited to take action on five priority areas:

• Prevention of depression and suicide
• Mental health in youth and education
• Mental health in workplace settings
• Mental health of older people
• Combating stigma and social exclusion

Prevention and health promotion are effective

Currently there is some evidence that prevention can be effective in reducing the incidence of depression (Jané-Llopis et al., 2003; Cuijpers et al., 2005). Promising interventions mostly consist of cognitive behavioural group interventions (Kuehner, 2003b; Munoz et al., 1995).

Preventive interventions can be targeted at:

• parts of the general population, such as school classes, without considering individual risks (universal prevention);
• persons carrying an increased risk for developing depression, such as children of depressed parents, people suffering chronic physical disease, the unemployed, (selective prevention);
• persons suffering increased symptoms of depression, but not severe enough to be classified as clinically depressed (indicated prevention).

Intervention strategies that target social and structural conditions might be effective in promoting mental health but strict evaluation of such interventions is difficult to obtain (Douglas et al., 2001; Cole et al., 2002; Stansfeld et al., 1999).

Primary care setting is relevant for preventing depression and improving treatment

Since most of the cases of depression are treated in outpatient settings, primary care is considered a key setting for effectively tackling depressive disease (WHO/ OMS; Thornicroft & Tansella, 2004; Paykel et al., 2005), for the following reasons:

• Patients prefer to be treated by their primary care physician rather than in the specialised mental health system.
• Primary care is often the first entry into the system because of its widespread availability, community proximity and accessibility. It is widely used by the population: the majority of the population report at least one primary care visit per year. Relationships between primary care physicians and patients can be typically characterized as stable, continuous and long-lasting. These are important conditions for detecting and effectively treating a disease that is not only widely spread but also often reoccurring and chronic (Wittchen et al., 2001a).
• The increased availability and accessibility of effective pharmacologic interventions for depression have shifted the focus of treatment from the mental health sector to primary care (Wittchen et al., 2001a).

However, to diagnose and treat depression requires often special knowledge, especially for patients with comorbidity, multimedications, delusional depression or suicidality. In these cases referral to specialists has to be recommended.

Focusing on depression screening or solely training primary care physicians in treating depression has been revealed as being ineffective in improving care (Gilbody et al., 2005; Gilbody et al., 2003).

People with mood disorders often do not seek help (Friemel et al., 2005), not diagnosed as such by their general practitioner and do not receive or accept the right treatment. See also Underdiagnosis and undertreatment of depression and the probability of visiting a health care professional during the first year after the onset of major depression in 6 EU countries

Antidepressants and psychotherapy effective treatments

Antidepressants and psychotherapy have been shown to be effective in treating more severe forms of depression in multiple studies. Evidence has also recently been provided for their efficacy in milder forms of depression (Hegerl et al., 2009). For adults, both type of interventions are recommended treatment options in primary care (WHO/ OMS). For subgroups of depressed patients the combination of specific pharmaco- and psychotherapy has to be recommended (Hegerl et al., 2004). Antidepressants are less effective and more controversial in children and adolescents (Hazell et al., 2004; Whittington et al., 2004; Gunnell & Ashby, 2005). In practice, the type of treatment patients usually receive is more based on what is available than what is recommended in evidence based guidelines (Bramesfeld et al., 2007b). In the ESEMeD study less than one third of the adults interviewed with a 12-month prevalence of major depressive episodes had been taking antidepressants. In this study seeking help for emotional problems was a more important predictor of the use of antidepressants than a formal (DSM-IV) psychiatric diagnosis, suggesting that usage of antidepressants is not always according to the licensed DSM-IV (Demyttenaere et al., 2008).

The comparison of the consumption of antidepressants in 14 EU countries was done on the basis of three approaches (i.e., euros spending per inhabitant, number of prescriptions per inhabitant and defined daily dose (DDD) per 1,000 inhabitants). Sweden, Belgium and UK are higher antidepressant use countries, compared with Germany, Italy, Ireland, Austria and the Netherlands. France and Spain have no correlation between the suggested indicators. The approximation by DDD puts France in the highest category when France is at the middle with other indicators. The same applies for Spain, but in the reverse direction. Trends show a large increased consumption in antidepressant between 2000 and 2002 in Portugal, the UK and Italy (the state of the mental health in EU).

The care of depressed patients can be improved and suicidality can be prevented by community based four-level interventions

Intervention programmes with simultaneous activities on the level of 1) primary care providers, 2) general public, 3) community facilitators (e.g. clergy, teachers, pharmacist) and 4) patients and their relatives have provided strong evidence for their effectiveness (Hegerl et al., 2006). The number of suicidal acts (completed + attempted suicides) decreased during the 2-year intervention in the intervention region (Nuremberg, 500.000 inhabitants) by 24% with a further decrease during the follow-up year (- 32 %). Based on the experiences, concepts and materials of the model project in Nuremberg, the European Alliance Against Depression (EAAD) has further refined the intervention concept and implemented 4-level intervention programmes in many European countries. (Hegerl et al., 2008). EAAD has been cited as a best practive model in the European Commission´s Green Paper “Improving the mental health of the population: towards a strategy on mental health”.

European Study of the Epidemiology of Mental Disorders (ESEMeD)

ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries: Belgium, France, Germany, the Netherlands, Spain and the United Kingdom. The 90-minute interviews were based on the Composite International Diagnostic Interview (CIDI), the Medical Outcomes Study 36-Item Short From Health Survey and the EuroQuol 5D sections of the World Health Organisation Disablement Assessment Schedule II. The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the Diagnostic and Statistical Manual of Mental Disorders- Fourth Addition. A revised version, CIDI 3.0 is being used by the World Mental Health Surveys.

The ESEMeD 2000 study provided data on the prevalence of suicidality in 6 EU countries in the respondents’ lifetime and during the 12 months previous to the interview. The study also provided data on the factors associated with suicidality. The respondents were asked if they had seriously thought about committing suicide, and whether they had attempted suicide. Lifetime prevalence of suicidal ideas in ESEMeD was 7.8% and of suicidal attempts 1.8%.

The lowest risk for suicide ideas was found in Italy and Spain

Germany and France had the highest rate ratios of suicidal ideation and Belgium and France of suicidal attempts, while the lowest risk of ideas was found in Italy and Spain, societies that are generally more traditional and conservative.

The highest rate of onset of suicidal ideas and attempts is during teenage years and young adulthood

Suicidal ideas and attempts may appear for the first time at any age, with suicidal ideas having the highest rate of first presentation during teenage years and young adulthood. The number of years from the first suicidal idea to first suicide attempt also had a high variability, but for most individuals it happened within one or few years.

Women and young people are among the groups with higher risk for suicide ideation and attempts

Lifetime suicide ideation and suicide attempts are more prevalent among:

• Women
• Younger individuals
• People living in large urban areas. A relationship between social isolation and suicide has been demonstrated (Middleton et al., 2004), and living in a large city population may be related to higher frequency of social isolation.
• Respondents that had been previously married (separated, divorced, widowed)
• Individuals with lifetime major depression, dysthymia, Generalized Anxiety Disorder (GAD) and alcohol dependence.

It was also found that older individuals tended to show a lower prevalence of suicidality, though this was not statistically significant (Alonso et al., 2008, Bernal et al., 2007).

See Relative Risk for lifetime suicide attempts.

There is low use of service among ESEMeD countries

Although mental disorders are frequent in the ESEMeD countries, the rate of people who consult a medical professional for their mental health problems is considerably low. Among those with a 12 – month mood disorder, only between 36% (in Italy) and 56% (in the Netherlands) reported having consulted a general medical professional due to problems with emotions or mental health.

Among users of services, general medical professionals were the most frequently consulted in all countries (66 % on average), while the use of a mental health specialist ranged from 39.4% in France to 52.2% in Spain (EPREMeD).

See also the probability of visiting a health care professional during the first year after the onset of major depression in 6 EU countries

Recognition of depression in primary care is low

Although the primary care setting is considered important for depression prevention and treatment of depression, it has shown little recognition of depression and has not always offered adequate treatment (Ormel et al., 1991; Wittchen et al., 2001b; Van Os et al., 2006). There may be several reasons for this:

• The presentation of depression may be more difficult in primary care because of a high proportion of mild depressive episodes. Wittchen et al however, found in 2002 that the vast majority of depression seen by primary care physicians is of a moderate or severe nature according to the criteria of the ICD-10.
• There is a lack of diagnostic and treatment skills among general practitioners.
• In primary care, physicians typically have little time per patient (Wittchen & Pittrow, 2002).
• Patients in primary care might be more reluctant to accept the diagnosis of a mental disorder.

Physicians are more likely to identify depression when:

• The disease is more severe.
• The patient experiences less somatic comorbidity and somatic symptoms (Tiemens et al., 1996).

The under- and inadequate treatment of depression in primary care is the reason that many community-based depression and suicide intervention programs target primary care physicians.

Undertreatment of depression throughout Europe

The ESEMeD Study revealed that only 45% of depressed persons in need appear to be treated adequately. Adequate treatment was defined in this context as over the period of two months:

• Either receiving antidepressant medication plus minimum four visits to a physician
• Or at least eight sessions with a psychologist or psychiatrist of at least 30 minutes duration.

The likelihood of depressed persons receiving adequate treatment was substantially higher in specialised care (57%) than in primary care (23%). In northern countries (Belgium, France, Germany, and the Netherlands) treatment adequacy was higher in the specialised sector, whereas no difference was found in southern countries. Reasons for these variances between countries might be related to:

• Different health care systems. Spain and Italy have a national health service financed by taxation, whereas the other systems are financed by compulsory social health insurance (Fernández et al., 2007).
• In countries such as Spain and Italy there is a need for referral to specialised mental health care (Fernández et al., 2007).
• The availability of treatment guidelines in France, Germany and the Netherlands (Fernández et al., 2007).
• Another explanation could be the availability of psychiatrists and psychologists. The Netherlands, France and Germany have more psychiatrists and psychologists per 100,000 people (resp. 37, 27 and 62) in comparison to Italy and Spain (resp. 13 and 6) (WHO, 2007).

European Alliance Against Depression takes a multi-level community based approach

An example of an intervention program focussing on more awareness for depression is the European Alliance Against Depression (EAAD), which is co-funded by the European Commission. This program takes a multi-level, community based approach on improving depression care, thereby contributing to the prevention of suicide. The EAAD program approaches depression care and suicide prevention at three levels (Hegerl et al. 2006):

• Training general practitioners and community facilitators to recognise and treat people with depression.
• Informing the public on depression.
• Providing self-help measures to people at risk.

In a pilot study, implemented in the city of Nuremberg, this intervention resulted in a considerable decrease of non-fatal suicide acts compared to a control region. Today 17 EU countries are working towards implementing the community based EAAD intervention on a regional basis.

Suicide

Smoking

Drug use

Breast cancer

Ischaemic heart disease

Alcohol use

Social support

Mental Health in the EU

European Commission: The State of Mental Health in the European Union

EPREMeD: European Policy Information Research for Mental Disorders

MCD report

WHO: World Health Organization

EC: European Commission

European Pact for Mental Health and Well-being

Green Paper

EAAD: European Alliance Against Depression

Share: Survey of Health, Ageing and Retirement in Europe

Mental Health Europe

IMHPA: European Network for Mental Health Promotion and Mental Disorder Prevention

Mindful: Mental Health Information and Determinants for the European Level

Percentage of population with mood disorder one time in their life and in the previous 12 month

Relative risk for having any mood disorder in the last 12 months

Relative Risk for lifetime suicide attempts

Predictors of mental disorders

Probability of visiting a health care professional during the first year after the onset of major depression

Consumption of antidepressants

Increased consumption in antidepressants between 2000 and 2002

The figure above shows the percentage of population with mood disorder one time in their life and in the 12 month prior to the interview in 6 EU countries. Data were retrieved from EPREMeD report based on the ESEMeD/MHEDEA project.

ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries. The interviews were based on the Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the DMS-IV.

The figure above shows the relative risk of having had any mood disorder in the 12 months prior to the interview compared to Italy. Italy was used as the reference for comparison because the rates for mental health conditions were lower in Italy. Data were retrieved from The State of Mental Health in the European Union report presenting data from the ESEMeD/MHEDEA project.

ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries. The interviews were based on the Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the DSM-IV .

Data show that compared to Italy, there is a significantly increased risk of any mood disorder in Belgium, France and the Netherlands.

The figures above show the relative risk for lifetime suicide attempts by:

• Country
• Mental disorders
• Age
• Gender
• Marital status
• Geographical area

Data were retrieved from the European Commission’s Major and Chronic Diseases Report 2007 based on the ESEMeD/MHEDEA project. ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries. The interviews were based on the Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the DMS-IV

The table above shows the gender, age group, income circumstances and marital status in which mental disorders were more frequent during 12 months prior to the interview in 6 EU countries. It shows also the most common mental disorder occurring one time in life and in the 12 months prior to the interview. The numbers in parenthesis are the percentages of the corresponding disorders in the general population. Data were retrieved from EPREMeD report based on the ESEMeD/MHEDEA project.

ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries. The interviews were based on the Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the DMS-IV.

The figure above shows the probability of visiting a health care professional during the first year after the onset of major depression in 6 EU countries. Health care professional can be either a general practitioner or a mental health specialist. Data were retrieved from EPREMeD report based on the ESEMeD/MHEDEA project.

ESEMeD is a cross-sectional study in which 21,425 non-institutionalised adults were interviewed across six European countries. The interviews were based on the Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive, fully standardized interview that can be used to assess mental disorders according to the definitions and criteria of ICD-10 and the DSM-IV .

Data were retrieved from the state of mental health in EU report (EC, 2004).

The figures above show

• Amount of euros spending per inhabitant on antidepressants in 2002
• Number of prescriptions of antidepressants per inhabitant prescribed by physicians in 2002
• Defined daily dose (DDD) per 1,000 inhabitants in 2000.

Pharmaceutical companies provide data on the spending in euros per country and per inhabitants. However, this indicator reflects diverse prices so it does not reflect differences in consumption in countries. In the case of the number of prescriptions of antidepressants per inhabitant prescribed by physicians, the data are based on prescription analysis and one prescription could cover either a short or a long period of care, so they may correspond to rather different number of units. Furthermore, hospital consumption has not been taken into account. The DDD/1000 inhabitants system is supposed to be the standard as it uses total mg of product sold in a country by the standard dosage for a day‘s treatment and reports it per 1,000 inhabitants. Unfortunately the DDD data are not available for all countries. Also, a standard dose for antidepressants is not easy to define since this may be different for individual antidepressants.

A large increased consumption in antidepressants between 2000 and 2002 was observed in Portugal, the UK and Italy.

The figure above shows increase in consumption in antidepressants between the years 2000 and 2002.

Data were retrieved from the state of mental health in EU report (EC, 2004).

Also see consumption of antidepressants in EU countries.

Authors: Lisa Wittenburg, Anke Bramesfeld, Ulrich Hegerl (Universität Leipzig, Leipzig, Germany)

Editors: Susan Meijer, Hagit Eliyahu, Marieke Verschuuren (RIVM, Bilthoven, the Netherlands)