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”.