"Brief interventions in primary care are effective in preventing depression"

"Yes, the prevalence and incidence studies on depression and anxiety are clear. In the context of the pandemic, if we talk about subjective feelings, my sense is that there is a lot of demand related to mental health, sometimes hidden and sometimes explicit. Some studies have already been published that provide objective data on the current situation, and there is no doubt that prevalence has increased."

This increase has an explanation related to the model that explains how anxiety or depression begins. It's a model called the cumulative risk model , meaning that as risks accumulate, the probability of developing depression increases.

Let's take an example. Imagine someone who has lost their job, which is already a significant risk factor. Add to that the death of a close relative from COVID-19; the fact that they haven't been able to say goodbye or grieve properly; and the fact that they can't leave their home, which reduces their social support. And so we continue adding and adding risks, which obviously increases the likelihood of developing a common mental health disorder. Given this likelihood, we need to consider the protective factors, since some people are able to cope with adversity, but many others are not.

Maite Peñarrubia María

Family and community medicine. ABS Bartomeu Fabrés Anglada

Institut Català de la Salut (ICS)

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" Now there are many people suffering from insomnia due to COVID-19, and it's because we have so many stimuli that activate our brains with worries. Naturally, if we're constantly hearing news about deaths, hospitalizations, and all the tragedies, it's a daily hammering that, when you go to bed and need to disconnect, you can't. If you don't disconnect and don't sleep, the brain doesn't recover. A biochemical storm occurs that affects specific neurons and, in the long run, triggers an affective disorder."

The link between insomnia and depression is scientifically proven. Several trials have studied people with sleep problems, all of whom did not have depression. One group received cognitive training to improve their sleep. Once they achieved this, the incidence of depression in that group was much lower than in the group that did not receive the training. This is causal proof that sleep deprivation leads to depression.

"It's a very complex issue because it doesn't have a single cause. On the one hand, there are people who have anxiety or depression and don't seek help. As a general rule, over the course of a year, approximately 30% of people with depression will not seek help. And when they do reach primary care, half of them are never fully diagnosed. But the reasons for not being diagnosed are also multiple; most people don't say they have emotional problems, but rather express other physical ailments, such as headaches or dizziness."

Furthermore, the population tends to associate the reason for entering the healthcare system with physical, not mental, issues. This is likely due to the stigma surrounding mental illness. People often prefer to suffer from osteoarthritis than from depression. This perception is reinforced by what they frequently encounter in consultations.

Some professionals, in the search for the origin of that headache, may consider the possibility that it is depression, while other professionals do not.

In other words, primary care professionals each have a professional profile: the biomedical one, who feels very comfortable with everything related to physical illnesses, and the biopsychosocial one, who also takes into account the psychological and social dimensions and perceives that he has the capacity to address these dimensions of the problems.

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Let's look at a possible scenario that serves as an example. Imagine a person visiting a doctor with a biomedical background for physical symptoms. At some point during the visit, this person mentions having recently lost their job and feeling unwell. The doctor might suspect there's an underlying issue causing this discomfort that they can't control, or they might feel they don't have time to discuss it. At that moment, the doctor stops looking at the patient, glances at their computer, and asks, "What did you say your headache was like?" In other words, they change the subject. The doctor ignores the verbal clue provided by the patient and focuses the consultation on a physical issue.

But if time goes by and the doctor continues with that attitude, the next time the person goes to the consultation they will no longer talk about their lack of motivation because they know they will not get an answer, they do not feel heard.

And that is one of the ways to "feed" the population, when they have emotional problems, to seek help for physical symptoms."

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"In prevention, we need to talk about scientific evidence; that is, we need to talk about what has been proven to prevent depression. Other things are theoretical causal approaches, because there are also genetic factors, learning factors, etc., but in practice, what people are interested in is: What works to prevent me from getting depressed?"

What we have evidence of is the effectiveness of psychological and psychoeducational programs , both more or less structured programs and very simple proposals, such as those carried out by teachers in schools.

There is also evidence for regular physical exercise at a moderate intensity. There is no evidence for other things at the moment.

Online calculators that predict if you will have depression

"In healthcare, there is a long tradition of using predictive models. For example, in the case of cardiovascular diseases, these models have been used since the 1970s, calculating the probability of having a heart attack."

In mental health, however, predictive models are a relatively recent development. Our research group pioneered this field, publishing the first article in 2008 on predicting depression. The good news is that the predictive models we validate are even slightly better than those used for other physical illnesses. All the scientific evidence supporting our risk calculators can be found on our website.

I like to say that the evolution of these predictive models is a bit like weather forecasting: when the famous meteorologist Mariano Medina gave his weather predictions in the 1960s, they were very bad. Now, however, we enjoy weather prediction models that, three days in advance, are excellent.

The mathematical application that is able to pass on risk factors and calculate a probability is like a black box that the population doesn't necessarily have to understand, but they are mathematical models and they work reasonably well."

"Prediction is good as long as you can prevent it. It would be absurd to give a risk prediction and not have any tools to reduce that risk. Naturally, we provide guidelines for healthcare professionals and for the general public."

The key is that there are a whole range of risk factors that can be addressed and modified. It has been shown that these brief interventions in primary care are effective.

Our study shows that patients who completed our "predictD" prevention program were able to avoid the onset of depressive episodes by 21% and anxiety episodes by the same proportion, compared to those who continued their usual care at the health center.

The study was carried out in 70 health centers in Malaga, Granada, Jaen, Barcelona, Zaragoza, Bilbao and Valladolid, with the participation of 140 family doctors and 3,326 primary care patients.

After completing a brief questionnaire, patients in the intervention group were informed, during a 10-minute consultation, of their risk level for developing depression in the coming year and their modifiable risk factors. The intervention consisted of discussing each patient's specific risk factors with them and exploring ways to modify them. We call this creating personalized prevention plans.

In other words, we informed people who had a high probability of developing depression, but explained that at that moment they didn't have depression precisely because they were already doing things to prevent it. They told us what they were doing, and it was all very reasonable: playing sports, going out into nature, seeing family. The doctor reinforced these protective habits and also warned about habits that posed a risk, such as alcohol consumption, if applicable. Every six months we followed up and recalculated that risk.

"Studies would have to be done, and we know that there are already professionals working on them for psychosis and schizophrenia. It's important to keep in mind that these are very complex studies, because they require very large samples of healthy people, and the follow-up can last for many years, until the illness appears. They are very expensive studies, but once they are done, validated, and proven, we will have confidence that the model predicts well."

Transferring prevention strategies to key areas

"We know for a fact that the effectiveness of prevention programs has a small effect, between 20 and 30% reduction in incidence. But of course, if the entire population participated in prevention programs, we would be talking about quite significant figures."

In Spain, nearly 800,000 new episodes of depression occur each year. A reduction of just 20% would prevent 160,000 cases, so the impact on health, quality of life, employment, and costs would be truly spectacular.

The key lies in how to scale up these programs. In any case, every prevention program, whether global, national, or regional, should consider these four scaling strategies to truly have an impact:

1. In the school setting
   Virtually everyone is in school, and preventative programs, even those run by teachers, have proven effective. Imagine what could be achieved if a course on mental health prevention (emotional management, conflict resolution, etc.) were included in the teachers' curriculum. It could be quite feasible.
2. In the workplace
   Implementing workplace prevention programs on a large scale would be possible because, fortunately, many people are still employed. Furthermore, it's important to consider that the prevalence and incidence of depression is significantly higher among working-age individuals. There is already a growing interest among companies in occupational risk prevention and legal changes. Depression is a leading cause of sick leave and carries a very high economic cost. I believe we can work towards requiring companies to implement psychosocial risk prevention programs, perhaps even by law.
3. In primary care .
   Over 90% of the population will visit a primary care physician at least once within the next five years. Even if the visit is for other reasons (a cold, follow-up care for a chronic illness, etc.), many people will have risk factors for depression, and some may even be at high risk (patients with chronic pain, poor physical quality of life, loneliness, etc.). Therefore, there are numerous opportunities to identify this risk and implement effective and simple preventative programs to reduce it.
4. In the use of Information and Communication Technologies (ICT).
   Many trials have already been conducted with apps, and they have proven effective in preventing depression. The advantage of using a prevention app is that practically everyone has a mobile device, although we know there is a group of people, over 65 or 70 years old, who would not be reached due to a lack of digital literacy.

"The issue of digitalization is a reality, and it's true that the pandemic has accelerated it considerably. It can be used for good, for example, to provide access to mental health services for people living in isolated areas or to reduce waiting lists. In fact, there have been various initiatives for years. The important thing is to distinguish which proposals and programs have scientific evidence of their effectiveness because behind the hundreds of applications we can find, there's also a lot of business."

To give an example, in Spanish there is the program “Smiling is fun” , which is an online intervention for the treatment of emotional disorders developed by Researchers from the Universitat Jaume I de Castellón (UJI), the Universitat Politècnica de València (UPV) and the Universitat de València (UV).

In English, I would highlight those developed by the British National Health Service (NHS), which has incorporated these ICT developments into its service portfolio, or in Australia, where the health system and the University of Sydney developed MoodGym, designed to serve the thousands of people who live at great distances in the country.