Prevention Psychiatry What is it?

1. Prevention PsychiatryWhat is it? Group for the Advancement of Psychiatry Committee on Prevention, 2006-2007 David Pruitt, M.D., Michael T. Compton, M.D., M.P.H., Carol Koplan, M.D., Rebecca Powers, M.D., M.P.H., Larry Wissow, M.D., M.P.H., Anthony Charuvastra, M.D.*, Christopher Oleskey, M.D., M.P.H.* * Ginsberg GAP Fellows The Committee gratefully acknowledges the work of formermembers, including Daniel Z. Lieberman, M.D. and James MacIntyre, M.D. December 2007

2. Definition Prevention psychiatry is the reduction of mental disorders and behavioral problems by A) Identifying risk and protective factors, and B) Applying evidence-based interventions.

3. Prevention Examples • Reduction of specific disorders • Substance abuse, depression, PTSD • Reduction of risky behaviors • Substance use, unsafe sex • Reduction of negative outcomes • Suicide, teen pregnancy, school dropout, delinquency • Promotion of mental health and wellness

4. Positive Prevention Outcomes • Decrease incidence and prevalence • Delay onset • Minimize adverse impact on family, peers, and society • Demonstrate cost-effectiveness

5. Public Health Classifications • Primary prevention: Reduction of the incidence of a disorder. • Secondary prevention: Reduction of the prevalence of a disorder. • Tertiary prevention: Reduction of the disability associated with a disorder.

6. Institute of Medicine Classifications • Universal preventive intervention: An intervention targeted to an entire population. • Selective preventive intervention: An intervention targeted to members of a population with higher than average risk factors. • Indicated preventive intervention: An intervention targeted to members of a population with subsyndromal symptoms of a disorder.

7. The Mental Health Intervention Spectrum for Mental Disorders Source: Mrazek and Haggerty (1994) Reducing Risks for Mental Disorders

8. Types of Prevention – A Synthesis Primary - Universal interventions - Selected interventions - Indicated interventions Secondary - Screening - Early intervention/treatment Tertiary - Relapse prevention - Prevention of morbidity/disability

9. Risk Factors • Risk factors predate the associated disorder. • They are highly associated with the disorder. • Some risk factors are malleable, or subject to change via a preventive intervention.

10. Examples of Risk Factors • Biological • Expression of genetic vulnerability, adverse prenatal event (traumatic, toxic, infectious) • Psychological/Psychosocial • Family discord, parenting skill deficits • Social/Environmental • Availability of drugs and firearms, extreme economic and social deprivation

11. Risk Factors by Domain Source: Hawkins and Catalano. (1992) Communities That Care.

12. Protective Factors • Protective factors predate the associated disorder. • They reduce the risk of developing a disorder or adverse outcome. • Some are malleable, or subject to enhancement via a preventive intervention (i.e., promoting resiliency).

13. Examples of Protective Factors • Support from caring adults • Parents, relatives, mentors • Good school performance • Conflict resolution skills • Positive role models and positive peers • Clear and consistent discipline in the family

14. What Constitutes “Evidence-Based?” • Determination of effectiveness and/or efficacy is based on scientific studies. • Downplays intuition and unsystematic clinical experience as sufficient grounds for decision-making. • Interventions are tested in systematic, empirical, and rigorous ways.

15. Illustration: Universal Intervention • Prevention of marital distress and divorce • Target population: Married couples and couples planning to marry • Intervention: Group sessions for couples to build skills to handle disagreements

16. Illustration: Universal Intervention • Prevention of poor school and family bonds, violence, substance abuse, risky sexual behavior • Target population: Elementary school-aged children • Intervention: Modified teacher practices and parent training in child behavioral techniques

17. Illustration: Universal Intervention • Prevention of behavioral and health problems in children later in life • Target population: New mothers • Intervention: Counseling sessions aimed at enhancing self worth of the new mother, fostering gentle interactions with the baby

18. Illustration: Selective Intervention • Prevention of alcohol abuse among college students • Target population: Students with high-risk drinking behavior • Intervention: Motivational interviewing and skill-based training to help students “mature out” of high-risk drinking

19. Illustration: Selective Intervention • Prevention of protracted bereavement, depression, and social withdrawal • Target population: New widows • Intervention: Widows are paired with a widow contact who provides emotional support and practical assistance

20. Illustration: Selective Intervention • Prevention of behavioral and attitude problems • Target population: Children with parents who have affective disorders • Intervention: Parent, child, and family sessions performed with semi-structured interviews

21. Illustration: Indicated Intervention • Delaying or preventing the onset of schizophrenia • Target population: Patients with sub-threshold (prodromal) symptoms • Intervention: Low dose atypical anti-psychotic and cognitive-behavioral therapy (or other psychosocial interventions)

22. General Principles for Effective Prevention Programs • Address factors that play causal roles. • Reverse or reduce risk factors. • Enhance protective factors to increase competency in multiple domains. • Age-specific, developmentally appropriate, and culturally sensitive.

23. Prevention-minded Treatment Intervention for a whole family in which an individual with a mental disorder receives treatment and other family members (parents, children, spouse, etc.) receive preventive interventions. [NYS-OMH, Koilpillai (2000)]

24. Roles for Mental Health Professionals • Incorporate knowledge of risk and protective factors into clinical practice. • Promote awareness of the benefits of prevention. • Consult with schools and community agencies. • Collaborate with prevention groups to work together at reducing common risk factors and promoting protective factors.

25. References • World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options. Summary Report: http://whqlibdoc.who.int/publications/2004/924159215X.pdf. • World Health Organization. Promoting Mental Health: Concepts, Emerging Evidence, Practice. Summary Report: http://whqlibdoc.who.int/publications/2004/9241591595.pdf. • Hosman C, Jane Llopis E, Saxena S, Eds. Prevention of Mental Disorders: Effective Interventions and Policy Options. Oxford University Press, 2005. • Mrazek PJ, Haggerty RJ, Eds. Reducing the Risk for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press, 1994. • Kellermann AL, Rivara FP. Suicide in the home in relation to gun ownership. N Engl J Med 1992;327:467-472. • Hawkins JD, Catalano RF, Miller JY. Communities that Care: Risk-focused Prevention Using Social Development Strategies, Development Research and Programs, Inc. Psycholog Bull 1993;112:1-23. • Durlak JA. Common risk and protective factors in successful prevention programs. Am J Orthopsychiatry 1998;68:512-520.

26. References • Felitti VJ, Anda RF, Nordenberg D, et al. Relationshipof childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245-258. • Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (2007). Promotion and Prevention in Mental Health: Strengthening Parenting and Enhancing Child Resilience, DHHS Publication No. CMHS-SVP-0175. Rockville, MD. • Markman HJ, Renick MJ, Floyd FJ, et al. Preventing marital distress through communication and conflict management training: A 4- and 5-year follow-up. J Consult Clin Psychol 1993;61:70-77. • Olweus D. Bullying at school: Basic facts and effects of a school based intervention program. J Child Psychol Psychiatry 1994;35:1171-1190. • Dolan LJ, Kellam SG, et al. The short-term impact of two classroom-based preventive interventions on aggressive and shy behaviors and poor achievement. J Applied Devel Psychol 1993;14:317-345. • Hawkins JD, Catalano RF, Kosterman R, et al. Preventing adolescent health-risk behaviors by strengthening protection during childhood. Arch Pediatr Adolesc Med 1999;153:226-234. • Cullen KJ, Cullen AM. Long-term follow-up of the Busselton six-year controlled trial of prevention of children’s behavior disorders. J Pediatr 1996;129:136-139.

27. References • Baer JS, Kivlahan DR, Blume AW, et al. Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. Am J Public Health 2001;91:1310-16. • Vachon ML, Lyall WA, Rogers J, et al. A controlled study of self-help intervention for widows. Am J Psychiatry 1980;137:1380-1384. • Beardslee WR. Out of the Darkened Room: When a Parent is Depressed: Protecting the Children and Strengthening the Family. Boston, MA: Little, Brown, and Company, 2002. • McGorry PD, Yung AR, Phillips LJ, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry 2002;59:921-928. • Compton MT, McGlashan MD, McGorry PH. Toward prevention approaches for schizophrenia: An overview of prodromal states, the duration of untreated psychosis, and early intervention paradigms. Psychiatr Ann 2007;37:340-348. • Addington J, Francey S, Morrison AP (Eds.) Working with People at High Risk of Developing Psychosis: A Treatment Handbook. Wiley, 2007. • Group for the Advancement of Psychiatry (GAP) website: http://www.groupadpsych.org.

28. Group for the Advancement of Psychiatry • The Group for the Advancement of Psychiatry (GAP) was founded in 1946 by a group of physicians under the dynamic leadership of the late Dr. William C. Menninger. Their wartime experiences had brought them to realize the urgency of greater public awareness of the need for new programs in mental health for the people of the United States. • Over the ensuing years, GAP has had a tremendous influence in shaping psychiatric thinking, public programs, and clinical practice in mental health. It continues today to pioneer the exploration of issues and ideas on the frontiers of psychiatry and in applying psychiatric insights into the general medical, social, and interpersonal problems of our times. • GAP analyzes significant data in psychiatry and human relations, reevaluates old concepts, develops new ones, and applies this knowledge for the advancement of mental health.