THE PREVENTION OF

1
ANXIETY AND DEPRESSION:
INTRODUCTION
DAVID J. A. DOZOIS AND KEITH S. DOBSON

Anxiety and depression are frequently referred to as the common colds

of mental disorders. Although this statement is accurate in terms of the prev-
alence of these debilitating conditions, it tends to minimize their personal
and social consequences. Among such consequences are the psychological,
social, and emotional suffering of the individual as well as the interpersonal
and economic costs to society (Barlow, 2002; Gotlib & Hammen, 2002).
Given these serious and widespread implications of anxiety and depression,
the development of models for their understanding and treatment is of para-
mount importance.
The empirical knowledge base has increased dramatically in recent
years. Psychologists and psychiatrists now have well-developed and vali-
dated models of anxiety disorders and depression from a range of theoretical
perspectives. These models have significantly enhanced the development
of effective treatments. For example, biological models, new-generation
anxiolytics, and selective serotonin reuptake inhibitors and related antide-
pressants have generated unprecedented excitement for the psychobiological
approach to these mental illnesses. At the same time, from a psychological

1
perspective, the development of the cognitive-behavioral therapies in par-
ticular has generated a wide range of highly effective treatment methods tied
to specific anxiety disorders and depression (Chambless & Ollendick, 2001;
DeRubeis & Crits-Christoph, 1998).
As both participants in, and observers of, the strides made in treat-
ing the anxiety disorders and depression, we have been struck by the fact
that whereas treatment for the acute phase of anxiety and depression has
advanced significantly, our understanding of risk and vulnerability factors is
relatively less developed. Consequently, the amount of empirical attention
and research that has been devoted to preventing these disorders has been
commensurately less. Our belief, which is echoed throughout this book, is
that the time is right to adopt existing treatment models, our knowledge of
risk and protective factors, and evolving conceptualizations of vulnerability
and apply them to preventative efforts. This book evolved from discussions
we have had over the years about anxiety and depression and was specifi-
cally crystallized at a conference we attended in Granada, Spain, that was
devoted to cognitive-behavioral therapies. At that conference, we pondered
the current state of the treatment literature and noted in particular the need
for more sustained efforts at developing prevention models and testing them
with current scientific methods. Although this is not a novel idea, it was and
remains our conviction that the literature has developed to the point that
prevention efforts are likely to be more fruitful than they have previously
been.
On the basis of our discussions of the need for a book that would distill
the work that has been accomplished to date, and also to provide directions
for the future, we began to read and think more in the area of prevention. It
quickly became clear that alternative ways of viewing prevention itself exist
in the literature. The earliest well-accepted frameworkperhaps what can
now be called a classic modelentails a distinction between three levels
of prevention (Commission on Chronic Illness, 1957): primary prevention,
or intervention efforts at the broadest population level (Klein & Goldston,
1977); secondary prevention, or prevention focused on identifying groups at
risk or those showing early symptoms of specific disorders; and tertiary preven-
tion, or the use of maintenance strategies and the prevention of relapse to
treat individuals with a disorder, shorten the length of a given episode, and
minimize its long-term consequences (National Institute of Mental Health,
1993).
More recently, the Institute of Medicine (IOM, 1994) has recom-
mended a spectrum of intervention efforts focused on prevention, treatment,
and maintenance (see Table 1.1). Subsumed under prevention efforts are
strategies that have been labeled universal (aimed at the general public with-
out any predetermination of risk or vulnerability status), selected (intended
for groups with a higher risk of developing a disorder than the population
at large has), and indicated (targeted toward individuals who are developing

2 DOZOIS AND DOBSON

 TABLE 1.1
Alternative Models and Stages of Prevention

Classic model
(Commission on Institute of Medicine (1994)
Chronic Illness,
1957) Intervention spectrum Type of intervention
Primary Prevention Universal
Secondary Prevention Selective
Secondary Prevention Indicated
Case identification Treatment Case identification
Treatment Treatment Standard treatment
Tertiary Maintenance Compliance with long-term treatment
Tertiary Maintenance Aftercare

early signs and symptoms of a disorder). Prevention of relapse is categorized

within the maintenance component of this paradigm.
These alternative models of prevention have their relative strengths
and weaknesses. The classic model, for example, does not make the increas-
ingly important distinction, captured in the IOM model, between selective
and indicated prevention. It was, however, the chronic nature of anxiety
and depression that ultimately most influenced the model adopted for this
book. In our discussions of anxiety and depression as well as in our initial
reviews of the literature, it became clear that because these disorders are
often characterized by a chronic course and are known to have high rates
of relapse and recurrence, neither of the existing models optimally captures
the required focus on the prevention of relapse. In fact, to the extent that
we considered the IOM framework, we discussed the idea that not only were
certain indicated methods necessary, but "reindicated" strategies aimed at
preventing the relapse and recurrence of anxiety and depression were also
equally, if not more, important. Unfortunately, this type of prevention effort
was not identified within the IOM framework, whose definition of preven-
tion includes only the prevention of the first episode of a given condition.
As a consequence of the aforementioned deliberations, the primary-second-
ary-tertiary framework, which explicitly identifies the need for maintenance
strategies and the prevention of relapse in the tertiary level of prevention,
became a more compelling framework around which to organize the book.
Given our decision to use the primary-secondary-tertiary distinction
in this volume, we also had to decide the level of specificity with which to
address the constructs of anxiety and depression. We were well aware of the
ongoing debate about whether it is more appropriate to discuss anxiety and
depression as continuous or dichotomous phenomena. We were also cog-
nizant that notions of prevention can be applied equally well at either the

THE PREVENTION OF ANXIETY AND DEPRESSION 3

symptom or the syndrome level. Because of the broad applicability of the
concept of prevention, we decided not to constrain our contributors to look
only at one or the other of these levels, or to be too prescriptive in terms of
which specific anxiety disorder or subtype of depression was being discussed.
That said, we encouraged those chapter authors writing in the area of sec-
ondary prevention to differentiate, as much as the literature permitted, pre-
vention models organized around risk factors (more consistent with selective
prevention) from those based on early signs or symptoms of disorder (more
consistent with indicated prevention).
A third consideration related to the theoretical models to be addressed
in the book. Our instructions to chapter authors encouraged them to broadly
consider alternative theoretical models of anxiety and depression and to in-
tegrate these models into their contributions to the volume, to the extent
that doing so was supported by the empirical literature.
The resulting volume comprises three distinct parts. The first consists
of three chapters that highlight the nature of anxiety and depression and fo-
cus on the myriad conceptual and methodological issues related to the study
and practice of prevention. Dozois and Westra (chap. 2) present information
about the variety of disorders that exist within the broad domain of anxiety
and depression, their epidemiology, and their comorbidity. They also exam-
ine the implications of these phenomena for models of risk and prevention.
In chapter 3, Bieling, McCabe, and Antony focus on measurement issues in
anxiety and depression. These contributors discuss the conceptual distinc-
tion between qualitative and quantitative (including dimensional) measures
related to the diagnosis of anxiety and depression. Specific measures are de-
scribed, and the reader is pointed toward other sources for obtaining them.
Chapter 4 (Clark) focuses on conceptual and methodological issuesin
particular, research methods that have a longitudinal emphasis, as preven-
tion studies must.
Part II of the book (chaps. 5-11) was designed to address the complete
matrix of primary, secondary, and tertiary prevention strategies for each of
the constructs of anxiety and depression. In six chapters, the risk and vulner-
ability factors, as well as the prevention efforts that have been evaluated to
date, are reviewed. These chapters also provide directions for the evolution
of models and techniques for dealing with anxiety and depression. As the
reader will observe, the amount of information available and research per-
formed varies dramatically among these chapters. For example, while there
is some limited information about primary prevention of anxiety (and what
is available focuses mainly on prevention in children), there is a veritable
dearth of controlled research in depression. In the domain of secondary pre-
vention, by contrast, the available database regarding depression is stronger
than that having to do with anxiety. In part, this phenomenon may be due
to the fact that primary prevention of anxiety seems to focus more around
general themes of anxiety sensitivity, whereas secondary (and tertiary)

4 DOZOIS AND DOBSON

prevention of anxiety is organized around the range of specific anxiety dis-
orders that have been identified. Thus, while the chapter authors have been
able to elaborate risk factors for these different disorders, specific tests of the
prevention strategies that follow from them are less in evidence. The last
chapter in this section focuses on the co-occurrence of anxiety and depres-
sion and discusses the implications of this comorbidity for prevention theory,
research, and practice.
Finally, in chapter 12, we summarized the 21 identifiable themes that
emerged in the previous chapters. These themes are clustered in four broad
areas: (a) theoretical issues, (b) population issues, (c) measurement issues,
and (d) treatment issues. The final chapter also offers general recommenda-
tions for furthering the prevention of anxiety and depression. As the reader
will note, the field is left with many unanswered questions and challenges,
which can be the source of a major body of theory and research.
Our conviction is that, while efforts to understand and ameliorate the
acute phase of anxiety and depression continue to be critical (cf. Antony
& Swinson, 2000; Beutler, Clarkin, & Bongar, 2000; Weissman, 2001), a
considerable increase is needed in our preventative intervention efforts to
enhance our ability to help individuals who suffer from these devastating
conditions. It is our hope that this book not only will provide readers with
the most up-to-date review of prevention in anxiety and depression but also
will encourage further research, theorization, and practical techniques. The
focus on prevention is relatively new, especially in the mental health arena.
Accordingly, this volume also represents a call for research. We are optimis-
tic that a subsequent edition of the book will represent a response to this
call and that the future will yield significant advances in our understanding
of how to best prevent the onset, relapse, and recurrence of anxiety and
depression.

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THE PREVENTION OF ANXIETY AND DEPRESSION 5

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DOZOIS AND DOBSON