Definition of Depression

‘Depressive disorders are characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration’ (WHO 2017 (pdf)). Depression is a clinical term describing a medical condition that affects the way mood is controlled by the brain. ‘The common feature of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function’) (WHO 2017 (pdf))(Joint Action on Mental Health and Well-being 2015) (WHO 2016 (pdf))(DSM-5 2013).

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), depressive disorders can be categorised in major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/ medication – induced depressive disorder, depressive disorder due to another medical condition and other specified and unspecified depressive disorders.

Major depressive disorder appears as the most common in adults and for its diagnosis:

A. Five (or more) of the following symptoms should have been present during the same 2-week period; at least one of the symptoms should be depressed mood or loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
2. Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day
3. Significant weight loss when not dieting, or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying) recurrent suicidal ideation without specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C. The episode is not attributable to the physiological effects of a substance or to another medical condition (DSM-5 2013).

Prevalence of depression in the EU

Depression is amongst the most common mental disorders in the EU. In 2014 6.9 % of people aged 15-64 years in the EU have reported suffering from depression (Table 1). It is estimated that globally over 300 million people suffer from depression, which is equivalent to 4.4% of the world’s population (WHO 2017 (pdf)).

Table 1: Percentage of individuals aged 15 and over reporting chronic depression in the past 12 months by age in 2014 

Factors associated with the risk of depression in adults

Mental health is often defined as ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO 2004 (pdf)). This definition highlights that mental well-being is influenced not only by the individual’s attributes and behaviours such as the ability to manage thoughts, emotions and interactions with others, but also by social, economic, cultural and environmental factors such as living standards, working conditions and social protection (WHO 2013).

Depression rarely has one single cause. The onset or maintenance of depression can be attributed to biological, psychological or social factors and their interactions. Biological and physiological factors include genetic predisposition, changes in hormone levels and certain medical conditions (WHO 2007 (pdf)).

There is a link between depression and highly prevalent chronic diseases. Depression is often present along with other conditions such as diabetes, cancer, heart disease and Parkinson’s diseases. It is associated with worse outcomes for these diseases and vice versa. Additionally, it can be that medication for such illnesses could contribute to the development of depressive symptoms (WHO 2018 (pdf)).

Psychological and social factors include difficulty coping with stress, grief and other difficult life circumstances. Many of the causes of mental disorders and poor mental wellbeing lie in the social, economic and political spheres of people's daily lives (WHO 2014).

Adverse conditions in early life such as negative family conditions, and quality of parenting are associated with higher risk of mental disorders and depression in adulthood. Socioeconomic factors have the strongest association with depression in both genders in most European countries. High-risk groups for depression and suicide include those with severe somatic and other psychiatric illnesses, the socially disadvantaged, those suffering from recent loss, and vulnerable groups like the unemployed, LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queers), indigenous and immigrant groups (Joint Action on Mental Health and Well-being 2015 (pdf)).

Table 2 summarises the factors related to depression risk, mainly focusing on conditions and parameters that could be prevented or modified with appropriate public health interventions.

Table 2: Factors associated with depression as described by health-related organisations 

Disease burden and economic burden related to depression

Disease burden related to depression

The Global Burden of Disease 2019 Study (GDB 2019) estimates that globally in 2019 more than 37 million Disability Adjusted Life Years (DALYs – sum of years lost due to premature death and years lived with disability) have been attributed to major depressive disorder. In the EU major depressive disorder resulted in more than 3 million DALYs in 2019.

Table 3 presents the rate of DALYs per 100.000 population attributed to major depressive disorder in the EU Member States in 2019 for all ages.

Table 3: Disability Adjusted Life Years/ 100 000 population attributed to Major Depressive Disorder in European Union Member States in 2019 

The maps below present the rate of DALYs per 100 000 population attributed to major depressive disorder in the EU Member States in 2019 for adults (men and women) over 20 years of age.

View visualisation - DALYS map and data table - men >20 years old

View visualisation - DALYs map and data table - women >20 years old 

Economic burden related to depression

There are significant societal costs of depression due to its profound impact on all aspects of a person's life, and the often recurrent and chronic course of the disorder. The economic cost of depression is attributed to direct spending on health care, cost of social security programmes and indirect costs driven by lower employment rates and reduced productivity.

People reporting depression, have much lower employment rates than the rest of the population. In the EU, only about half of the population aged 25-64 years that report having chronic depression are in employment, compared with over three-quarters among those who do not report having depression (OECD/ EU 2018). Lost income due to the lower employment rate of people with depression is estimated at EUR 176 billion per year across EU countries (OECD/ EU 2018).

Depression is a leading cause of low workplace productivity (OECD/ EU 2018). Individuals with major depression report almost two times more lost workdays than people having heart disease or diabetes. The cost of depression corresponds to 1% of the total European Gross Domestic Product (GDP). The biggest part of this cost is due to indirect cost due to productivity loss, increased morbidity, sickness absence, early retirement and increased mortality (EU 2016 (pdf)).

Policy recommendations on depression prevention

Despite the fact that a lot of effort has been put into making treatments of depression available, there are relatively limited actions to prevent the influx of new cases of depression. Depression prevention aims at raising awareness, detecting groups at risk, developing coping strategies, and building resilience. ‘Resilience refers to a person’s capacity to cope with changes and challenges and bounce back during difficult times or in the face of adversity’ (EC 2016 (pdf)).

Three categories of mental health primary prevention strategies have been identified:

• Universal prevention, targeting the general public or a whole population group;
• Selective prevention, targeting individuals or subgroups of the population whose risk of developing mental health disorders is significantly higher than the rest of the population;
• Indicated prevention, targeting persons at high risk for mental disorders.

Promoting resilience differs from universal, selective and indicated prevention as it focuses on contributing to improving overall well-being rather than prevention of illness and disorder.

Preventive interventions in the field of mental health are particularly important for people who exhibit depressive symptoms which are sub-threshold to warrant a formal diagnosis, or people with high risk of developing depression, for instance after the exposure to transitions, or stressful life events (EC 2016 (pdf)).

The European Commission together with Member States prioritised mental health and depression prevention in the Public Health agenda. The aim is to develop mental health promotion and prevention programmes, such programmes and initiatives are included in the Best practices portal.

Table 4 presents examples of policy recommendations as well as good practices for the prevention of depression, early detection of depressive symptoms and building of resilience.

Table 4: Policy recommendations related to the prevention of depression 

Implemented policies

According to the World Health Organization Mental Health Policy and Service Guidance Package (WHO 2003), many areas of action and strategies should be taken into consideration in the development of an effective mental health policy: financing, legislation and human rights, organisation of services, human resources and training, promotion, prevention, treatment, rehabilitation, advocacy, quality improvement, information systems, research and evaluation.

Table 5 presents examples of implemented policies for the prevention of depression and mental health promotion.

Table 5: Examples of implemented policies related to depression prevention and mental health promotion 

References

Overview of the references to this brief