What is needed to eradicate the depression epidemic, and why

Despite substantial investments in the treatment of major depressive disorder (hereafter ‘depression’), especially antidepressant medications and cognitive behavioral therapy, epidemiological data do not indicate that depression burden, as measured by the period prevalence, has decreased in recent decades. Although improving the delivery and quality of treatment will undoubtedly reduce episode duration and recurrence risk, and thereby reduce depression burden, the effect is probably limited because treatment does not always improve long-term outcomes. To further reduce the burden, prevention of depression episodes is crucial. Unfortunately, so far preventive efforts have not succeeded in reducing depression burden either. This, we argue, arises from a lack of socially-embedded structural prevention efforts and the difficulty of reducing the impact of major determinants. First we summarize the evidence on period prevalence and treatment trends and the limitations of current prevention strategies that have hampered both their effectiveness and large-scale implementation. Then we analyze the modifiability of major determinants of depression and identify the prerequisites for effective prevention to reduce depression burden and explain their importance. Prerequisites include embedment in major social institutions, structural funding, legal consolidation, starting early in life, simultaneous targeting of major personal and environmental determinants and their interactions. This includes addressing both poor parenting and children's maladaptive personality traits and insufficient life skills, and combining universal, selective, and indicated prevention strategies with an emphasis on universal prevention. Although it is necessary to determine the feasibility and cost-effectiveness of the proposed prevention strategy, we think that without it, the depression epidemic will not subside.