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The Inside Story: The spotlight is on treating depression...

But what about preventing it in the first place?

Given the serious burden of depression on every aspect of life—including the workplace where it drives up absenteeism, presenteeism, and disability—there is now a large body of evidence about treatment. But why not also decrease its impact through prevention? Fortunately, the evidence is building regarding preventing depression, so finally some encouraging news on this topic…

Adding prevention to the mix

Thankfully, effective therapies are available for treating depression, but imagine if we could actually decrease its incidence. Of course, this would be ideal, but Canada’s approach to health care—or should we say “sick care”—is often anything but ideal. It typically focuses on reacting to sickness by diagnosing and treating illness, rather than preventing disease onset in the first place.

Historically this reactive approach made sense given that Canada’s health care system was designed in the post-Second World War era to address acute care needs. However, it no longer makes sense today with just over half of Canadian adults having one or more chronic disease.3 A focus on prevention has never been more important. So why not apply to depression a preventive approach like the ones identified for chronic conditions for decades?

Adding prevention to the mix may also be especially beneficial regarding depression because of its many variations and treatment challenges. As you may recall from the June 2016 and the January 2017 editions of The Inside Story, a range of issues have led to today’s trends, including prescribing antidepressants at subtherapeutic doses and overprescribing them. And we’re sure you will remember (since we keep talking about it) that medication adherence is a significant issue regarding antidepressants  where we see a lot of “dropouts”—those who  never start their prescription—and “one and done’rs”—those who don’t continue their prescription past the first fill.

Clearly, just like with chronic conditions, there is value in incorporating prevention to tackle the impact of depression. But how?

Identify key risk factors to depression

A main aspect of proactive care is to categorize individuals based on key risk factors. For example, research indicates that four risk factors—tobacco use, alcohol consumption, physical inactivity, and unhealthy eating—lead to 90% of chronic disease.4

And here’s the kicker... all four are modifiable, which means that proactive interventions have the potential to help people change their behaviour to reduce the risk factors and in turn, reduce their risk of developing a chronic condition.

So in theory, to help plan members from becoming depressed, all we have to do is figure out the risk factors of depression and then offer interventions to help them address risk. Easy peasy, right? Wrong—there is nothing simple about depression. Part of what makes depression difficult to diagnose is its myriad of risk factors. Compared to physical health conditions like cardiovascular disease, a lot less is known about the risk factors of depression, but fortunately evidence continues to emerge. And it’s showing that some of the main risk factors are modifiable.

Not just any risk factors… modifiable  risk factors

Most existing research surrounding prevention of depression focuses on specific age groups—like adolescents or seniors— and a lot of attention is placed on preventing relapse. However, an Australian study is especially insightful because it used participants ranging from 20 to 64 years old. The researchers developed profiles of the participants that included demographic and lifestyle characteristics, then followed up with the participants over four years to check their health status.

They discovered that participants who had developed full-blown major depressive disorder had initially reported some depression-type symptoms, possibly foreshadowing depression on the horizon. In addition, depression was significantly higher for those who were “younger, smoked, used alcohol at a harmful or hazardous level, used marijuana, did not participate in moderate physical activity, rated their health more poorly, had less education, were in less secure employment or under financial pressure, or had experienced more life events.”6

Findings like these highlight the role of modifiable factors driving the risk of depression. This provides hope that if plan members can modify lifestyle behaviours, they may be able to decrease risk factors, and possibly decrease the risk of developing depression. In addition, perhaps intervening early can help curb initial depression symptoms from further developing. Here are highlights of several studies contributing to the growing body of evidence around some main modifiable risk factors...

Physical inactivity

To examine the role of physical activity in preventing depression, researchers recently collected data from 49 studies to create a sample of more than 266,000 people on four continents. Those who followed the guideline of 150 minutes each week of moderate aerobic activity—like cycling or brisk walking—were less likely to develop depression during nearly eight years of follow-up compared with those who didn’t meet the guideline.

The researchers theorize that this may be the case because exercise can impact biological risk factors through brain chemistry and the endocrine/immune systems. In addition, exercise may impact environmental risk factors by, for example, providing opportunities for social interaction. Overall, the researchers conclude that exercise helps protect against depression regardless of age or location anywhere in the world—you can’t get much better than that. Or maybe you can; another recent, large study found that even small amounts of exercise at low intensity are beneficial.7 Sweet!

Unhealthy diet

Turns out comfort food may not be that comforting and in fact, may be doing more harm than good for preventing depression. Researchers analyzed data of more than 5,500 adults, looking at the association between depression and five previously identified factors associated with depression: demographics, lifestyle, diet, biomarkers, and somatic symptoms (bodily sensations that a depressed person may perceive as unpleasant or worrisome, like changes in sleep, appetite, or digestion, as well as fatigue and pain). Not only did results indicate that unhealthy eating heightens the risk of depression, but also that diet had the highest association with developing depression. The researchers think this finding will be key in raising awareness of the association between depression and diet, which is in sync with the growing body of evidence around how gut health affects brain health and behaviour.9

Although it is well documented that what happens in your brain can affect your gut, researchers are discovering that the reverse may also be the case. In fact, the gut is now being referred to as a “second brain” or technically, as the enteric nervous system (ENS). The ENS appears to communicate back and forth with the central nervous system and our other brain (the one in the head). And research is building that shows irritation in the ENS may result in signals to the brain that trigger mood changes like depression and anxiety.10

Poor sleep

Evidence is building that things really do look brighter in the morning, in that a good night’s sleep can help improve mood. Various studies show an association between poor sleep—like sleep disturbances and short sleep duratio —and an elevated risk of depression in a range of populations known for sleep issues, such as university students, new mothers, and physician trainees (or think of yourself during the Stanley Cup playoffs).11 In addition, a number of longitudinal studies—where participants are observed and data collected over a period of time, anywhere from several months to several years—support that insomnia is a risk factor for developing both first-onset and recurrent depression.

For example, a study followed 1,244 middle-aged adults for 12 years where a third of women and quarter of men had insomnia. At follow-up, three-quarters of participants still reported insomnia. However, the women who initially reported insomnia were significantly more likely to report feeling depressed. This was not the case with men (interestingly, this jibes with the sidebar about the causes of depression: just being a woman is a risk factor).12

Although sleep problems are common in people with a range of mental health issues including depression, the reverse may also be the case—lack of sleep may contribute to mental health issues. In fact, researchers believe that sleep and mood are so closely linked that clinically it is often difficult to tell which came first—the poor sleep or the low mood.

Sustained or chronic stress

When relaxed, the body’s chemicals and hormones regulate processes like sleep, hunger, and energy, as well as moods and emotions. Enter stress—particularly stress that lasts a long time or becomes chronic—and you can say goodbye to normal regulation of body processes. Hormone  like cortisol rise while others like serotonin and dopamine decrease. When this stress response doesn’t shut off, it can lead to depression. In fact, research indicates that stressful life events have been consistently associated with an increase in depressive symptoms in adults and adolescents.13 And not surprisingly, the more stressful life events a person experiences, the more likely it is they will develop depression.14 

Although the scientific research continues to show an association between chronic stress and depression, it also provides hope regarding prevention. For example, a recent scientific review examined existing studies of brain areas impacted by chronic stress, anxiety, and fear in humans and animals. The review warns that people need to reduce chronic stress and anxiety, or they may be at increased risk for developing stress-induced damage to the brain that could contribute to depression and even dementia. However, the researchers also provide hope suggesting that stress-induced brain damage may not be completely irreversible. They feel that interventions—like exercise, mindfulness, and cognitive behavioural therapy—warrant further investigation.15

Let’s put all the prevention pieces together… … eat healthy… exercise (even a little)… sleep well… de-stress

Seem familiar? The modifiable risk factors for depression are in many cases the same as those for various chronic conditions. In turn, many of the preventive measures are also similar. And just like with chronic conditions, there is no magic bullet; it’s the combination of lifestyle changes that will make the difference in terms of preventing depression. Accordingly, by encouraging plan members to adopt healthier lifestyles, you help them decrease their risk of not just depression, but other health issues.

… And of course, a big part of developing a healthy lifestyle is figuring out how to keep stress at bay in the workplace. As you may recall from the November 2017 edition of The Inside Story, the benefits of psychotherapy—like mindfulness and cognitive behavioural therapy— are growing as a way to not just treat depression by de stressing, but also to prevent it. However, more research is needed, especially on the role of psychotherapy in preventing the initial onset of depression, not just relapse, and on how to implement psychotherapy techniques specifically in the workplace setting. We’re on it! To be continued—the results of our new depression prevention pilot project are coming later in 2018 and 2019.

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