Opinion
EDITORIAL
Increasing the Impact of Prevention of Depression—New Opportunities
Pim Cuijpers, PhD; Charles F. Reynolds III, MD
Depressive disorders are highly prevalent and are associated
with a substantial loss of quality of life for patients and their
relatives, with increased levels of morbidity and mortality and
with enormous economic
costs. Although effective
Related article pharmacologic and psycho-
logical treatments are avail-
able, the effects are modest, relapse rates are high, and many
patients do not respond to treatments at all. Current treat-
ments can reduce only an estimated one-third of the disease
burden of depression at the population level and only under
optimal conditions, assuming that all people with major de-
pression receive an evidence-based treatment.1 Depressive dis-
orders can therefore be seen as one of the major public health
challenges of the coming decades.
Prevention of the onset of depressive disorders is one of
the most important possibilities for a further reduction of the
disease burden of depression. Selective prevention (aimed at
target groups with an increased risk of developing depressive
disorder) and indicated prevention (aimed at people with sub-
clinical depressive symptoms who do not meet the criteria for
major depression) are effective in the reduction of the inci-
dence of major depression and can reduce the incidence of ma-
jor depressive disorders by approximately 20%.2 However, the
uptake of these interventions is low. A previous study3 esti-
mated that only 1% of those with subthreshold depression par-
ticipate in indicated prevention, even when the interven-
tions are offered for no or only minimal costs. Reasons for the
low uptake include the expectation that problems are only tem-
porary, the assumption that they can be solved without pro-
fessional help, and the stigma associated with mental health
problems. Because the uptake of these interventions is so low,
the effect on the disease burden of depression is only mini-
mal. If prevention is to reduce a sizeable portion of the dis-
ease burden of depression, other approaches to prevention are
clearly needed.
An Innovative Way to Reduce the Incidence
of Major Depression
The article by Irwin and colleagues4 in this issue of JAMA
Psychiatry reports a completely new and innovative way of in-
creasing the effect of preventive interventions on the disease
burden of depression. Their study was aimed to reduce the in-
cidence of major depression not only in older adults with in-
somnia but also in those with no current depressive disorder.
Insomnia has been associated with an increased risk of devel-
oping major depression, but participating in an intervention
for insomnia is less stigmatizing than participating in an in-
tervention for depression. This study indicates that an inter-
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vention aimed at insomnia can effectively reduce the inci-
dence of major depression in those without a depressive
disorder at the start of the intervention, meaning that depres-
sion can be prevented effectively without even using the word
depression and thus avoid the associated stigma. The study by
Irwin and colleagues4 found that this innovative preventive
strategy is effective in older adults, which is important be-
cause insomnia and depression are highly prevalent in this
population and the uptake of both preventive and treatment
services is low. Older adults can therefore benefit consider-
ably from this new approach.
The prevention of depression through insomnia treat-
ment may be especially beneficial in older adults. Increasing
evidence indicates that insomnia and depression are impor-
tant risk indicators for suicide,5 as well as for cognitive de-
cline and dementia.6,7 If interventions are successful in both
reducing sleep problems and preventing depression, new op-
portunities to prevent suicide and dementia may become avail-
able. Future research is needed to examine these possibili-
ties, but these subjects are certainly exciting new directions
for research.
Insomnia is, however, not only a problem in older adults.
Approximately one-third of the general adult population ex-
periences symptoms of insomnia, and approximately 10% meet
the criteria for a sleep disorder. Insomnia is also an important
public health challenge in the adult population because it is
associated with considerably reduced productivity, in-
creased health care use, increased risks of unintentional in-
jury, excess mortality and morbidity, and huge economic costs.
Effective interventions for insomnia are therefore highly rel-
evant from a public health perspective. If such interventions
can also reduce the incidence of major depression in adults not
(yet) meeting the criteria for depressive disorders, the public
health importance of these interventions would be consider-
ably further increased. The study by Irwin and colleagues4
found that 25.9% of the participants in the control group de-
veloped a depressive disorder, whereas only 12.2% in the in-
tervention group did. If these numbers could be generalized
to the total population with insomnia, the incidence of major
depression could be reduced considerably. Future research
should therefore examine the uptake of such interventions and
how much they can contribute to the reduction of the disease
burden of insomnia and depression.
Indirect Interventions
This indirect approach to the prevention of depressive disor-
ders also offers several new opportunities for the develop-
ment of innovative interventions. The uptake of treatments for
depression is low, with no more than half of those meeting
(Reprinted) JAMA Psychiatry Published online November 24, 2021 E1
 Opinion Editorial

criteria for depressive disorders receiving treatment, even in
high-income countries. This proportion is much lower in spe-
cific target groups, such as older adults, adolescents, and eth-
nic minority groups. The stigma associated with major depres-
sion as a mental disorder is one of the main reasons for not
seeking treatment. If people with insomnia and depression are
willing to participate in an intervention for insomnia, this in-
tervention may also indirectly treat the depressive disorder.8
This willingness to undergo intervention may offer new op-
portunities to increase treatment uptake not only in the gen-
eral population but also in difficult-to-reach groups.
If prevention of major depression can be realized by fo-
cusing on insomnia, would it be possible to prevent depres-
sive disorder by focusing on other problems that are associ-
ated with depression? Can we prevent depression through
interventions aimed at procrastination in college students, in-
terventions aimed at perfectionism in perinatal women, stress
management training for employees, social skills training in
adolescents? This approach offers all kinds of new opportu-
nities to develop and test indirect interventions for problems
that are less stigmatizing but are significantly associated with
the onset of depression.
Conclusions
The seminal study by Irwin and colleagues4 in this issue found
that treatment of insomnia may be effective in the preven-
tion of depressive disorders. This major finding offers excit-
ing new opportunities for the prevention field and opens a new
field of research into indirect preventive interventions for
avoiding the stigma of mental disorders.

ARTICLE INFORMATION
Author Affiliations: Department of Clinical, Neuro,
and Developmental Psychology, Amsterdam Public
Health Research Institute, Vrije Universiteit
Amsterdam, Amsterdam, the Netherlands
(Cuijpers); Department of Psychiatry, University of
Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania (Reynolds).
Corresponding Author: Pim Cuijpers, PhD,
Department of Clinical, Neuro, and Developmental
Psychology, Amsterdam Public Health Research
Institute, Vrije Universiteit Amsterdam, Van der
Boechorststraat 7-9, 1081 BT Amsterdam, the
Netherlands (p.cuijpers@vu.nl).
Published Online: November 24, 2021.
doi:10.1001/jamapsychiatry.2021.3153
Conflict of Interest Disclosures: Dr Reynolds
reported being coinventor of the Pittsburgh Sleep
Quality Index for which he receives royalties.
No other disclosures were reported.
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