COMMENTARY

“Nudges” to Prevent Behavioral Risk Factors Associated With Major Depressive Disorder Major depressive disorder— colloquially called “depression”—is a primary global cause of disability. Current preventive interventions, such as problem-solving therapy, are effective but also expensive. “Nudges” are easy and cheap interventions for altering behavior. We have explored how nudging can reduce three behavioral risk factors of depression: low levels of physical activity, inappropriate coping mechanisms, and inadequate maintenance of social ties. These nudges use cognitive biases associated with these behavioral risks, such as valuing the present more than the future, following the herd or the norm, making different choices in light of equivalent conditions, and deciding on the basis of salience or attachment to status quo. (Am J Public Health. 2015;105:2318–2321. doi:10. 2105/AJPH.2015.302820)

Ashleigh Woodend, MSc, Vera Schölmerich, PhD, and Semiha Denktas¸, PhD

MAJOR DEPRESSIVE DISORDER (MDD) occurs following at least two major depressive episodes. Such an episode is diagnosed when a person shows at least five of the following seven symptoms for longer than two weeks without experiencing a previous traumatic life event: depressed mood, loss of interest or pleasure in nearly all activities, weight gain or loss without being on a diet, insomnia or hypersomnia, persistent sadness or irritability, fatigue, and recurrent suicidal thoughts.1 MDD imposes a significant burden on developing countries2 and is the second leading cause of disability among developed nations.3 According to the Global Burden of Disease Study, MDD will continue to hold this position in 2020.4 The disorder is highly prevalent, tends to be chronic or recurrent, emerges at an early age,5 and inflicts a burden on both the individual and the economy. On the individual level, patients with MDD exhibit problematic social relationships and lower performance at school and in the workplace.6---8 Those suffering from MDD also have higher rates of comorbidity, such as diabetes and cardiovascular disease.9 MDD comes at a significant cost to the economy through lower labor productivity and higher welfare costs. Depressive episodes among employees are associated with lower productivity, disability, absenteeism, and suicide.10 Furthermore, patients suffering from severe MDD tend to be disabled or unemployed11 and therefore make higher demands on social

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welfare. The impact of MDD on economic output and welfare costs is especially high because of the early onset of the disease (usually in the late twenties),12 which means that individuals suffering from the disorder tend to be impaired before, or during, their prime years of employment.12 Faced with budget constraints, current policies for MDD prioritize treatment in the acute phase (i.e., the six- to 12-week period following the onset of MDD), to the detriment of preventive strategies.13 Nevertheless, treatment shows limited effectiveness. Studies, assuming an (unrealistic) treatment coverage rate of 100%, estimate that current treatments avert only 30% to 36% of the global population’s years lived with disability stemming from MDD.14---16 Even when MDD is treated, residual symptoms remain, making relapse more likely.14 Taking into account the limited long-term effectiveness of treatments for MDD and Healthy People 2020’s emphasis on preventing as opposed to treating disease,17 we focused on preventive interventions targeting individuals before the onset of MDD.15 Recently, studies have shown that MDD prevention is feasible.13,16 Numerous clinical trials that looked at preventive interventions, such as cognitive behavioral therapy and interpersonal therapy, have shown that prevention groups show up to 21% lower levels of incidence than do control groups.16 Although effective, these approaches put high time demands on trained professionals and are

thus costly to implement and scale up. The relatively new scientific discipline called behavioral economics (BE) suggests new routes to intervention design that could be a cost-effective complementary strategy for MDD prevention. According to BE, people often exhibit cognitive biases when making choices. “Nudges,” defined as adaptations in the way choices are presented to individuals, explicitly use these biases to encourage people to make choices that are in their best interest. We introduce BE and nudges, and propose some nudges aimed at lowering behavioral risk factors for MDD. This overview of nudges is not exhaustive and can be expanded upon in the future.

FROM BEHAVIORAL ECONOMICS TO NUDGES BE combines economics and psychology. Traditional economic theory claims that when having to make a choice, people thoroughly search for all available information. By contrast, BE argues that people have bounded rationality. They are faced with cognitive limitations and as a result must sift through information using rules of thumb, or heuristics, to speed up an otherwise enormous task.17 BE suggests that rules of thumb lead people to exhibit systematic cognitive biases.18 Although at times efficient, these biases can have a negative influence on people’s choices. An example of this is the status quo bias, which describes people’s tendency to stick

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to their current situation, even when change is likely to lead to a better outcome. The rule of thumb applied here is as follows: bearing in mind an uncertain alternative, stick with the current situation.19 Inspired by BE, policymakers have looked into ways to make use of humans’ systematic cognitive biases by designing interventions using nudges. Such interventions play into cognitive biases by adapting the choice architecture for humans—that is, by changing how choices are presented to individuals—so that people’s cognitive biases lead them to act in their best interest, that of society’s, or both. An example of a popular nudge that uses the status quo bias is having people automatically registered as organ donors with the possibility of opting out. This leads to a substantially higher donation rate than does a system in which donors must actively opt in.19 Nudges enact small tweaks in the choice architecture, and proponents therefore see them as providing low-cost, unobtrusive solutions to many challenges facing contemporary society.20 They alter people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives19(p6)

(i.e., do not constrain choice) and are often as effective as or even more effective than approaches grounded on traditional economic theory.20 Nudges appeal to systematic cognitive biases that—according to the theory—are universal behavioral traits,21 and therefore proponents expect them to potentially address a large number of people.

MITIGATING MDD RISK FACTORS USING NUDGES Some of the risk factors for developing MDD are behavioral. For example, people who

consistently make the choice not to engage in physical activity are at higher risk for developing MDD.22 Therefore, interventions using nudges to alter people’s choice architecture—and ultimately influence their behavior—could be useful in MDD prevention. We have outlined how nudges can help prevent MDD. We selected nudges on the basis of the MINDSPACE framework, which lists effective nudging approaches.23 These nudges reduce the following behavioral risk factors: low levels of physical activity, inappropriate coping mechanisms,24 and the maintenance of inadequate social ties. It should be noted that there are nonbehavioral risk factors for MDD, such as comorbid physical diseases and socioeconomic hardship13; BE cannot stand alone in preventing MDD but should be seen as complementing existing approaches.

Low Levels of Physical Activity A lack of physical activity increases the risk of developing MDD.22 Lindeman et al. found that a complete lack of exercise shows an odds ratio (OR) of 2.1 for the onset of a major depressive episode.22,25 Physical activity increases calcium production in the brain, which increases dopamine synthesis.26 Dopamine functions, most notably, in enhancing motivation, concentration, and pleasure. As physical exercise is seen as a virtue by society, people who exercise tend to have higher levels of self-esteem. Self-esteem plays a fundamental role in mental wellbeing27; individuals with higher self-esteem are substantially happier and less likely to exhibit depressive symptoms.28 We suggest three nudges to promote physical activity that use three biases: the

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present bias, the bandwagon effect, and framing. According to the present bias, people value the present more than the future29 and therefore prefer immediate satisfaction (e.g., avoiding exercise) to the detriment of long-term consequences (e.g., weight gain). This helps to explain why people tend to exercise less often than they would like to, despite their strong intentions.30 An intervention on the basis of BE could tackle this bias by combining exercising with more attractive activities such as listening to audiobooks or receiving goods such as healthy snacks. In another study, this “temptation bundling” has been shown to be effective.31 The bandwagon effect is the human tendency to follow the herd or the norm. Often people’s choices are influenced by the most salient attitudes and actions of others.19 An intervention could make use of this tendency and highlight the physical activity norm to people who are likely to be below it. This could be done, for example, by matching people with partners of high-perceived fitness in gyms32 or by using digital physical activity monitors for peer-to-peer comparison via social media. A third nudge for encouraging physical activity is framing. According to the framing effect, people make different choices from essentially equivalent—but slightly differently phrased— descriptions of the same thing.18 Within the domain of health, it has been found that positive, (gain)framed messages are more effective than are negative, (loss)framed messages in promoting prevention behaviors, such as physical activity.33 The opposite is true for illness-detection behaviors, such as conducting a mammography. To promote exercise, a message stating, “If you exercise,

you reduce your risk of heart disease” is likely to be more effective than is a message stating, “If you don’t exercise, your risk of heart disease will increase.”

Inappropriate Coping Mechanisms A person’s coping mechanisms and ability to use internal and external resources in a stressful event influence the likelihood of developing MDD.24 Within a month of a stressful life event, the ORs for the onset of MDD have been found to range from 2.32 for a personal crisis to 25.36 for a personal assault.34 Broadly speaking, there are two types of coping mechanisms: the more healthy, adaptive mechanism and the less healthy, maladaptive mechanism.35 People employing the adaptive mechanism identify the stressful situation, actively pursue support, reflect on possible solutions, and take action to minimize stress. By contrast, the maladaptive mechanism—which is most commonly employed by young adults—is characterized by avoidance in identifying the stressful situation and failure to actively seek support and solutions.35 Instead of minimizing stress, people employing the maladaptive mechanism show unhealthy behaviors, such as avoiding social interaction35 and self-medicating. To guide individuals to adaptive coping mechanisms, a nudge could appeal to the salience hypothesis, which says that people tend to choose the option that is most salient to them.18 A simple way to use this tendency is to expose individuals experiencing high stress to posters highlighting the large proportion of their peers who said yes to stress management training. Placing these posters where target groups often visit will increase the salience of this

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option. It could also help to remove some of the stigma associated with soliciting professional help by normalizing it, that is, using the bandwagon effect.

Inadequate Social Ties Research has shown that social ties (i.e., relationships with family, friends, and members of the community) promote psychological well-being.36 In a large community sample study, an OR of 2.95 was found for developing MDD owing to social isolation.37 Although scholars agree that higher levels of social isolation may push individuals from the onset of MDD into full MDD, it should be noted that there is little conclusive evidence regarding whether lack of social ties is antecedent to, or concomitant with, mental distress. Cohen and Wills assert that social ties lead to beneficial influences and positive affective states (e.g., recognition of self-worth and belonging).38 This can in turn encourage beneficial health behaviors, such as regular exercise and moderation of alcohol consumption. Social ties may also modulate the hormonal response to stress. A simple workplace intervention to promote social relationships in companies characterized by little social participation would be to place employees in an environment that encourages social interaction, such as an open office. Such an intervention, like the organ donor example, takes advantage of the status quo bias by implicitly making social participation the default option. In this way, it facilitates and encourages faceto-face interaction and social engagement between employees.

CHALLENGES IN APPLYING THESE NUDGES BE asserts that systematic cognitive biases are universal and

therefore nudges should work on the general population.21 Because of limited empirical evidence, it is unclear whether this assumption is true. There are at least two factors that could influence people’s decision-making processes and therefore lead them to react differently to the proposed nudges: poverty and cultural background. As Mani et al. argue, people living in poverty tend to have impaired cognitive abilities because of pressures imposed by financial scarcity.39 Limited research suggests that people with impaired cognition stemming from poverty might more easily respond to nudges. We need to better understand this mechanism because living in poverty is a primary risk factor for developing MDD.25 Besides poverty, people’s cultural background might also influence how they react to our proposed nudges. Selinger and White argue that there is “semantic variance” between cultures, meaning that different cultures embody varying values, attributions, histories, and symbols of meaning.40 In turn, these differences might mean that people have different perceptions and so exhibit varying cognitive biases. It is unclear how our proposed nudges would influence people of varying cultural backgrounds. Considering these potential challenges, more research on the applicability of nudging strategies to the general population is required, and nudges may need to be tailored to specific sociocultural groups. The questionable application of nudges to the general population is also a case in point for nudges used for the treatment of those already suffering from MDD. This disorder is associated with dysfunctions in cognitive domains

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such as attributions, memory, and information processing and interpretation. Those experiencing MDD may respond in unexpected (and potentially unwanted) ways to nudges. Looking specifically at the nudges we suggest, a challenge with the open office intervention is ensuring that this default option does not become a source of social pressure. Although open offices have been found to increase face-to-face interaction,41 they have also been found to decrease motivation and job satisfaction and distract individuals from job-related tasks.42 A very plausible reality could be that whereas social interaction is enhanced, individuals feel lower levels of satisfaction and self-esteem owing to lower work productivity. Therefore, the effect of this nudge may rely heavily on individual characteristics.

CONCLUSIONS MDD is a major cause of disability in both developed and developing countries,2 and places a significant burden on individuals and the economy. Despite evidence showing MDD to be preventable, current therapeutic approaches focus predominantly on treatment during the acute phase of MDD. These preventive approaches are effective but relatively expensive. We have proposed the use of nudges as a complementary and more costeffective strategy to the current preventive approaches, and we have shown how nudges can be used to tackle three behavioral risk factors for MDD: low physical activity, the use of inappropriate coping mechanisms, and the maintenance of inadequate social ties. These nudges use the present bias, the bandwagon

effect, framing, the salience hypothesis, and the status quo bias, and they present strategies to promote healthier behaviors among individuals at high risk of developing MDD—a worthy pursuit in light of rising health care costs and budgetary constraints. j

About the Authors Ashleigh Woodend, Vera Schölmerich, and Semiha Denktas¸ are with the Social and Behavioral Sciences Department, Erasmus University College, Rotterdam, the Netherlands. Correspondence should be sent to Ashleigh Woodend, Nieuwemarkt 1A, 3011 HP Rotterdam, the Netherlands (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 21, 2015.

Contributors A. Woodend wrote the first and subsequent drafts of the article. A. Woodend and V. Schölmerich conceptualized the commentary. V. Schölmerich and S. Denktas¸ reviewed and critiqued drafts of the article.

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"Nudges" to Prevent Behavioral Risk Factors Associated With Major Depressive Disorder.

Major depressive disorder-colloquially called "depression"-is a primary global cause of disability. Current preventive interventions, such as problem-...
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