What are the causes of low participation rates in preventive (WC2011-031)


Starting date: 20/06/2011

Depression is a highly prevalent condition, affecting about 150 million people worldwide at each moment in time. The disease burden of depression is high. Currently, depressive disorders are the fourth group of disorders worldwide in terms of disease burden, and will be the disorder with the highest disease burden in high-income countries in 2030 (Mathers and Loncar, 2006). Furthermore, depressive disorders are associated with huge losses in quality of life in patients and their relatives (De Graaf et al., 2002), with increased mortality rates (Cuijpers and Smit, 2002), with high levels of service use, and with enormous economic costs (Smit et al., 2006). In The Netherlands it was found that the costs of major depression are 132 million Euros per million inhabitants per year (Smit et al., 2006). Current treatments can reduce the disease burden of depression only to a limited extent. A recent study in Australia estimated that about 34% of the disease burden of major depression can be averted in the current health system (Andrews et al., 2004). This percentage can only be reached in optimal conditions.

Prevention of the incidence of new cases of major depression may be an alternative for treatment which may reduce part of the 66% of the disease burden which is not averted by current treatments (Smit 2006; Cuijpers 2003). Interventions aimed at prevention of depressive disorders have shown to be effective and are available to prevent the onset or delay of depressive disorders (Cuijpers et al., 2008). However, only few people who could benefit from the interventions actually participate in this (about 1% of the potential participants actually participate). For preventive interventions to be considered a serious alternative to treatment of major depression, participation rates have to be increased. This is especially true for indicated prevention aimed at people with subthreshold depressive symptoms (i.e. people who score above the cutoff scores on screeners but do not meet diagnostic criteria for a major depression). Epidemiological research has shown that about 7.5% of the population in the Netherlands (750.000 people between 18 and 65) suffer from subthreshold depression (Cuijpers et al., 2004). Data from the Netherlands Institute for Mental Health and Addiction (Trimbos Institute) have shown, however, that in 2007 only 8.273 people (about 1%) participated in a preventive intervention (Ruiter & de Jonge, 2008). The causes for these low participation rates have not been examined systematically yet. In an earlier paper, we distinguished between three categories of reasons (Cuijpers et al., 2009); (1) people with subthreshold depression are not willing to participate in preventive interventions (for example because they do not consider themselves to have a subthreshold depression; they are not willing because of the stigma associated with treatment for mental health problems; they think preventive interventions are not effective); (2) the organization of preventive interventions is not optimal (for example, these interventions are now organized by specialized mental health services, while they may be better positioned in primary care; and general practitioners and other health care professionals in primary care should refer better to these interventions); and (3) the information about the interventions does not reach the target group sufficiently. Which of these reasons the most important ones are, is currently unknown. Knowledge about this is very important for the development of measures to improve the participation rates in preventive interventions.

We have received a grant to conduct extensive research on the reasons for (non) participation in preventive interventions for depression. However, help-seeking behavior is an important topic in people who have already developed major depression as well. Many people with major depression do not receive the help that they need either. The current project offers the unique opportunity to examine help-seeking behavior in depressed patients with minimal additional resources needed. Therefore, we will extend our study to include people with a major depression as well. We expect that the same reasons and processes that play a role in (non) participation of participants with subthreshold depression in preventive interventions for depression play a role in help-seeking in depressed patients as well.