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Department of Epidemiology & Public Health
Lunchtime seminar, 18th Feb 2014

Self-management strategies for mild to
moderate depression
The internet-based iFightDepression tool
Dr Celine Larkin
National Suicide Research Foundation
Prof Ella Arensman, Prof Ulrich Hegerl, and PREDI-NU Consortium
Outline
• What is depression?
– Characteristics
– Prevalence
– Depression and suicidality

• European Alliance against Depression and PREDI-NU
project
• The iFightDepression self-management tool
– Development
– Implementation
– Evaluation

• iFightDepression awareness website
What is depression?
• Depression is a serious condition
• Depression is not stress or merely feeling unwell
• Depression involves biological processes
• Depression is a systemic illness

• Depression is a common disorder
• Depression can affect anyone
• Depression might be recurrent or chronic
Background
Public health significance of depression
– Lifetime prevalence of any mood disorder approximately 12%
(Kessler et al., 2009 – Data based on WHO World Mental Health Surveys)

– 12-month prevalence approximately 6% (Kessler et al., 2009 – Data based on WHO
World Mental Health Surveys)

– Unipolar depressive disorders represent 6% of all diseases in
disability adjusted life-years in Europe (WHO 2004, Update 2008)
Causes of depression
PSYCHOSOCIAL ASPECTS

Vulnerability

e.g. negative life
experience,
personality

Triggers

e.g. acute psychosocial burden, stress

Therapy

Psychotherapy

BIOLOGICAL ASPECTS

e.g. genetic factors

e.g. hyperactivity of the
axis of stress hormones

Pharmacotherapy
How does depression affect cognition?
“I can never do
anything right”

Self

“Life is lousy- I
don’t seem to enjoy
anything anymore”

World

Negative
thoughts

“Things aren’t
going to get
better”

Future
Diagnosing depression (ICD-10)

Feelings of guilt
and
worthlessness

Sleep
disturbances

Suicidal
thoughts/suicidal
behaviour
Decrease in
energy

Lower selfesteem and selfconfidence

Lowering of
mood

Change in
appetite

Loss of interest
Reduced
concentration

Change in
psychomotor
activity
Depression and suicide
– 1 million suicides worldwide and 58,000 suicides per year
in the European Union
(www.who.int/mental_health)

– Rate of attempted suicides 10-20 times higher (WHO, 2003)

– Depressive disorders are among the major risk factors for
suicide (Yoshimasu et al., 2008; Borges et al., 2010)
– Those with major depression are up to 20 times more likely
to die by suicide than non-depressed individuals (Lonnqvist , 2009; Harris
& Barraclough, 1998)

– Improving depression treatment of depressed patients is
an effective suicide prevention method (Mann et al., 2005; Gusmao et al., 2013)
Suicide, self-harm and
depression in Ireland
Suicide
ca. 550.
Self harm
presentations
(ca. 12,000 p.a)

“Hidden” cases of
Deliberate self harm
ca. 60,000 p.a.

Psychiatric
admissions for
depressive disorders
(ca. 5,800 p.a.)

12-month
prevalence of
depression
~7%
European Alliance against Depression
OSPI-Europe
2008-2012

Nuremberg,
Germany
2000-2002
Development
community-based
4-level approach
and
implementation
Results:
-24% suicidal acts
 to be spread
across Europe

EAAD
2004-2008
Implementation of
4-level approach in
model
regions in 17
countries in Europe

Optimizing suicide
prevention
programs and their
implemen-tation in
Europe

EAAD society
2008-present
Sustainability

Dissemniation of
results

PREDI-NU
2011-2014
Preventing
Depression and
Improving Awareness through Networking in the EU
Four-level approach
to suicide prevention

Co-operation
with general
practitioners
in primary
care

Support for
patients and
their relatives

Public awareness
initiatives:
education of the
broad public
Our Aim:
Early detection of
depression and suicidal
behaviour and
optimisation of the care of
depressed and suicidal
patients

Cooperation with
professional health
care and community
workers, e.g.
counsellors, police,
priests, teachers,
media
The PREDI-NU project
Aim
To contribute to the
promotion of mental
health and the
prevention of
depression and
suicidality through
information and
communication
technologies (ICT)
Expected Outcomes
Increased uptake of support options by young people and
adults with mild to moderate depression

Increased uptake of support options by men who otherwise
may not receive support

Increased awareness of depression among health
professionals which will contribute to early identification of
depression and the prevention of suicidal behavior

Diffusion of effects throughout Europe through awareness
website, which will be made available in nine languages
The iFightDepression Tool
A guided internet-based self-management tool for mild to moderate
depression
Developed based on:
• CBT theory and practice
• Literature review
• Best practice examples
• Consensus process involving:
– Scientific advisory board and additional international experts
– Representatives from patients organisations
– Representatives from family organisations
What is self-management?
‘…involves engaging in activities that protect and promote health…
…monitoring and managing the symptoms and signs of illness…

…managing the impact of illness on
functioning, emotions and interpersonal

relationships…

…and adhering to
treatment
regimes.’
(Centre for Advancement of Health, 1996)
Cognitive-Behavioural Therapy (CBT)
• A type of psychotherapy
• Focuses on “here and now”

Computerised CBT is …
•

effective in reducing depressive symptoms &
improving diagnostic status

•

equally effective to therapist-led CBT

•

more effective than treatment as usual and
bibliotherapy

•

more effective in guided interventions than
non-guided cCBT interventions

•

more effective for people with mild to
moderate depression than for those with
major/severe depression
Maxwell et al. (in preparation)
Cognitive-Behavioural Therapy (CBT)
The iFightDepression Tool
Phase 1 implementation
 Currently improving tool,
training & procedures
 Carried out focus groups
evaluations of the pilot tool
 Implemented the tool in ten centres and
practices in Cork
 Delivered three-hour training sessions to 19 GPs
and MHPs in Cork

 Completed a pilot version of the iFightDepression selfmanagement tool for mild to moderate depression

Tool implemented in five regions, inc Cork
Phase 1 evaluation
• Focussed on acceptability and feasibility

• Three focus groups conducted in each IR
– 1 x healthy internet users, 1 x professionals guiding the tool and 1x
patients using the tool

• Quantitative data
– Professionals’ satisfaction with training
– Outcome measures: pre- and post professionals’ checklist, including CGI
(pre- and post-) from professionals
– Outcome and process: pre- and post patient- evaluation questionnaire
– Intervention intensity indicators
• e.g. information materials distributed, trainings, professionals trained, patients offered tool
Phase 1 evaluation
Training outcomes (%)
Phase 1 evaluation
Professionals’ reports of patients’ present treatment
• At baseline:
•
•
•
•
•

92% had a mild or moderate depression
6% had severe depression
48% received pharmacological treatment as well as the tool
48% received psychotherapy as well as the tool
21% only use the tool

• Received treatment differed between countries:
• In Germany and Hungary patients received more often psychotherapy
• In Spain and Ireland patients received more often pharmacological treatment
• In Estonia both treatment options were in balance

• Older patients much more often received pharmacological
treatment
22
Phase 1 evaluation
– Patients estimated their depression as more severe
than professionals did
Depression severity

Percentage

No depression

8

Minimal depression

9

Mild depression

26

Moderate depression

23

Moderately severe depression

20

Severe depression

13

• Half of the patients had mild to moderate depression
• But 33% self-reported moderately severe or severe
depression
23
Phase 1 evaluation
Focus group feedback in Ireland
• Importance of guidance and support
• Suggestions for changes to tool format and wording
• On-going training and support for professionals
• Tool interface needs to be more visual and interactive
• Tool seen to be useful in the context of greater waiting lists
• May be applicable to relapse prevention in more severe depression
Phase 1 evaluation
Health care professional: “There was less pressure on him,
Client: “Those trackers and stuff – that’s something new and
Client: “I’d been looking for a way to track these things
because he could do it […] he could have a cup of tea while he
Client: I really you can efficient”
something“I wouldbenefitted fromsee why you are thesceptical
[sleep/mood] andfind very kinda that and I’m a very way you
was doing it”
person – I’m not into psychotherapy and it... but this really
are… that for me is on my…the strength of stuffyou can do this
kinda stuff” all my thoughts you know. So if you get a chance to
challenged
do it person to person then I totally recommended it. But if
they don’t have the resources this is the next best thing almost.
It is worthwhile”
Implementation & evaluation
Phase 2
• Intervention regions:
– Continued involvement of Estonia, Hungary, Spain, Germany, & Ireland
– Plus Austria, Belgium, & Bulgaria

• Optimised tool, procedures & trainings
• Train-the-Trainer programme for multipliers

• Optimised evaluation
• Symposium in European Parliament 1st April 2014
• Randomised controlled trial by colleagues in Spain
iFightDepression website
• European depression awareness website (April 2014)
Thank you!

The PREDI-Nu consortium at its 5th meeting in Innsbruck (2013)
Contact details
Celine Larkin
National Suicide Research Foundation
4.28 Western Gateway Building,
Western Road
Cork
Ireland
T: 021 4205547
E-mail: c.larkin@ucc.ie

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Self-management strategies for mild to moderate depression The internet-based iFightDepression toolSelf-management strategies for mild to moderate depression: The internet-based iFightDepression tool

  • 1. Department of Epidemiology & Public Health Lunchtime seminar, 18th Feb 2014 Self-management strategies for mild to moderate depression The internet-based iFightDepression tool Dr Celine Larkin National Suicide Research Foundation Prof Ella Arensman, Prof Ulrich Hegerl, and PREDI-NU Consortium
  • 2. Outline • What is depression? – Characteristics – Prevalence – Depression and suicidality • European Alliance against Depression and PREDI-NU project • The iFightDepression self-management tool – Development – Implementation – Evaluation • iFightDepression awareness website
  • 3. What is depression? • Depression is a serious condition • Depression is not stress or merely feeling unwell • Depression involves biological processes • Depression is a systemic illness • Depression is a common disorder • Depression can affect anyone • Depression might be recurrent or chronic
  • 4. Background Public health significance of depression – Lifetime prevalence of any mood disorder approximately 12% (Kessler et al., 2009 – Data based on WHO World Mental Health Surveys) – 12-month prevalence approximately 6% (Kessler et al., 2009 – Data based on WHO World Mental Health Surveys) – Unipolar depressive disorders represent 6% of all diseases in disability adjusted life-years in Europe (WHO 2004, Update 2008)
  • 5. Causes of depression PSYCHOSOCIAL ASPECTS Vulnerability e.g. negative life experience, personality Triggers e.g. acute psychosocial burden, stress Therapy Psychotherapy BIOLOGICAL ASPECTS e.g. genetic factors e.g. hyperactivity of the axis of stress hormones Pharmacotherapy
  • 6. How does depression affect cognition? “I can never do anything right” Self “Life is lousy- I don’t seem to enjoy anything anymore” World Negative thoughts “Things aren’t going to get better” Future
  • 7. Diagnosing depression (ICD-10) Feelings of guilt and worthlessness Sleep disturbances Suicidal thoughts/suicidal behaviour Decrease in energy Lower selfesteem and selfconfidence Lowering of mood Change in appetite Loss of interest Reduced concentration Change in psychomotor activity
  • 8. Depression and suicide – 1 million suicides worldwide and 58,000 suicides per year in the European Union (www.who.int/mental_health) – Rate of attempted suicides 10-20 times higher (WHO, 2003) – Depressive disorders are among the major risk factors for suicide (Yoshimasu et al., 2008; Borges et al., 2010) – Those with major depression are up to 20 times more likely to die by suicide than non-depressed individuals (Lonnqvist , 2009; Harris & Barraclough, 1998) – Improving depression treatment of depressed patients is an effective suicide prevention method (Mann et al., 2005; Gusmao et al., 2013)
  • 9. Suicide, self-harm and depression in Ireland Suicide ca. 550. Self harm presentations (ca. 12,000 p.a) “Hidden” cases of Deliberate self harm ca. 60,000 p.a. Psychiatric admissions for depressive disorders (ca. 5,800 p.a.) 12-month prevalence of depression ~7%
  • 10. European Alliance against Depression OSPI-Europe 2008-2012 Nuremberg, Germany 2000-2002 Development community-based 4-level approach and implementation Results: -24% suicidal acts  to be spread across Europe EAAD 2004-2008 Implementation of 4-level approach in model regions in 17 countries in Europe Optimizing suicide prevention programs and their implemen-tation in Europe EAAD society 2008-present Sustainability Dissemniation of results PREDI-NU 2011-2014 Preventing Depression and Improving Awareness through Networking in the EU
  • 11. Four-level approach to suicide prevention Co-operation with general practitioners in primary care Support for patients and their relatives Public awareness initiatives: education of the broad public Our Aim: Early detection of depression and suicidal behaviour and optimisation of the care of depressed and suicidal patients Cooperation with professional health care and community workers, e.g. counsellors, police, priests, teachers, media
  • 12. The PREDI-NU project Aim To contribute to the promotion of mental health and the prevention of depression and suicidality through information and communication technologies (ICT)
  • 13. Expected Outcomes Increased uptake of support options by young people and adults with mild to moderate depression Increased uptake of support options by men who otherwise may not receive support Increased awareness of depression among health professionals which will contribute to early identification of depression and the prevention of suicidal behavior Diffusion of effects throughout Europe through awareness website, which will be made available in nine languages
  • 14. The iFightDepression Tool A guided internet-based self-management tool for mild to moderate depression Developed based on: • CBT theory and practice • Literature review • Best practice examples • Consensus process involving: – Scientific advisory board and additional international experts – Representatives from patients organisations – Representatives from family organisations
  • 15. What is self-management? ‘…involves engaging in activities that protect and promote health… …monitoring and managing the symptoms and signs of illness… …managing the impact of illness on functioning, emotions and interpersonal relationships… …and adhering to treatment regimes.’ (Centre for Advancement of Health, 1996)
  • 16. Cognitive-Behavioural Therapy (CBT) • A type of psychotherapy • Focuses on “here and now” Computerised CBT is … • effective in reducing depressive symptoms & improving diagnostic status • equally effective to therapist-led CBT • more effective than treatment as usual and bibliotherapy • more effective in guided interventions than non-guided cCBT interventions • more effective for people with mild to moderate depression than for those with major/severe depression Maxwell et al. (in preparation)
  • 19. Phase 1 implementation  Currently improving tool, training & procedures  Carried out focus groups evaluations of the pilot tool  Implemented the tool in ten centres and practices in Cork  Delivered three-hour training sessions to 19 GPs and MHPs in Cork  Completed a pilot version of the iFightDepression selfmanagement tool for mild to moderate depression Tool implemented in five regions, inc Cork
  • 20. Phase 1 evaluation • Focussed on acceptability and feasibility • Three focus groups conducted in each IR – 1 x healthy internet users, 1 x professionals guiding the tool and 1x patients using the tool • Quantitative data – Professionals’ satisfaction with training – Outcome measures: pre- and post professionals’ checklist, including CGI (pre- and post-) from professionals – Outcome and process: pre- and post patient- evaluation questionnaire – Intervention intensity indicators • e.g. information materials distributed, trainings, professionals trained, patients offered tool
  • 22. Phase 1 evaluation Professionals’ reports of patients’ present treatment • At baseline: • • • • • 92% had a mild or moderate depression 6% had severe depression 48% received pharmacological treatment as well as the tool 48% received psychotherapy as well as the tool 21% only use the tool • Received treatment differed between countries: • In Germany and Hungary patients received more often psychotherapy • In Spain and Ireland patients received more often pharmacological treatment • In Estonia both treatment options were in balance • Older patients much more often received pharmacological treatment 22
  • 23. Phase 1 evaluation – Patients estimated their depression as more severe than professionals did Depression severity Percentage No depression 8 Minimal depression 9 Mild depression 26 Moderate depression 23 Moderately severe depression 20 Severe depression 13 • Half of the patients had mild to moderate depression • But 33% self-reported moderately severe or severe depression 23
  • 24. Phase 1 evaluation Focus group feedback in Ireland • Importance of guidance and support • Suggestions for changes to tool format and wording • On-going training and support for professionals • Tool interface needs to be more visual and interactive • Tool seen to be useful in the context of greater waiting lists • May be applicable to relapse prevention in more severe depression
  • 25. Phase 1 evaluation Health care professional: “There was less pressure on him, Client: “Those trackers and stuff – that’s something new and Client: “I’d been looking for a way to track these things because he could do it […] he could have a cup of tea while he Client: I really you can efficient” something“I wouldbenefitted fromsee why you are thesceptical [sleep/mood] andfind very kinda that and I’m a very way you was doing it” person – I’m not into psychotherapy and it... but this really are… that for me is on my…the strength of stuffyou can do this kinda stuff” all my thoughts you know. So if you get a chance to challenged do it person to person then I totally recommended it. But if they don’t have the resources this is the next best thing almost. It is worthwhile”
  • 26. Implementation & evaluation Phase 2 • Intervention regions: – Continued involvement of Estonia, Hungary, Spain, Germany, & Ireland – Plus Austria, Belgium, & Bulgaria • Optimised tool, procedures & trainings • Train-the-Trainer programme for multipliers • Optimised evaluation • Symposium in European Parliament 1st April 2014 • Randomised controlled trial by colleagues in Spain
  • 27. iFightDepression website • European depression awareness website (April 2014)
  • 28. Thank you! The PREDI-Nu consortium at its 5th meeting in Innsbruck (2013)
  • 29. Contact details Celine Larkin National Suicide Research Foundation 4.28 Western Gateway Building, Western Road Cork Ireland T: 021 4205547 E-mail: c.larkin@ucc.ie