Mental Illness Prevention

1. Coming Together for a Shared Goal of Prevention: Bridging the Gap between Substance Abuse PreventionExperts and Mental Health Professionals Michael T. Compton, M.D., M.P.H.The George Washington University School of Medicine & Health Sciences Department of Psychiatry & Behavioral Sciences Washington, D.C. Center for the Application of Prevention Technologies Regional Technical Expert Panel (RTEP) Meeting September 19, 2011 – Atlanta, Georgia

2. Mental Illness Prevention • Prevention has mainly been in the domain of public health; however, it is now being embraced by the general health sector and is becoming more widely accepted in the mental health field • Both general medicine and psychiatry are primarily involved in individual-level treatment • With the high prevalence of chronic medical and psychiatric illnesses, and an aging population, there has been increased recognition of the importance of prevention Compton et al., Clinical Manual of Prevention in Mental Health, 2010

4. Mental Health Promotion • A subset of health promotion • Strategies and interventions that enable positive emotional adjustment and adaptive behavior • Whereas mental illness prevention aims to avert onset of illness, mental health promotion focuses on maintaining health

6. Stage of Disease Pre-Disease Latent Disease Symptomatic Disease Primary Prevention reducing the incidence of disease by risk factor reduction well before onset of illness Secondary Prevention reducing prevalence via early identification and treatment during the latent stage Tertiary Prevention reducing morbidity, disability, and mortality by treating established disease Universal Intervention targeting the general population Selective Intervention targeting a select group at higher risk Indicated Intervention targeting a group at very high risk Target Population ► Level of Risk ►

8. Doctors often act as though their professional responsibility does not go beyond the sick and the nearly sick (those at imminent risk), and politicians, who influence health more than the doctors, are rarely troubled by thoughts for the distant future. Rose’s Strategy of Preventive Medicine, 2008

9. Risk Factors… • are dynamic across time and context • rarely occur in isolation (they tend to co-occur) and their meaning may change across the developmental continuum • are usually not linked to specific mental illnesses • accumulate, and a greater number of risk factors increases likelihood of negative outcomes Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010

10. Risk Factors… • exert different effects on development depending on timing, context, and duration • e.g., the impact of the death of a parent in childhood may vary as a function of the age at which the loss occurred, the nature of the relationship with the deceased caregiver, the quality of the relationships with remaining caregivers, and the surrounding familial and cultural context in which the loss occurred Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010

11. Risk Factors • Accumulation of risk and vulnerability factors increases the likelihood of maladaptation • Elimination or reduction of such factors will reduce the probability of negative outcomes • Identification of risk factors is critical to effective prevention; knowing what increases the likelihood of a negative outcome is the first step toward preventing that outcome Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010

12. Risk Factors • Some risk factors are causal (e.g., cigarette smoking linked to lung cancer) • Others are proxies (e.g., living in an area with a high prevalence of cigarette smoking) • And yet others are markers of the underlying process (e.g., having a smoker’s cough)

13. Protective Factors • Some factors may be risk factors in one setting, but protective factors in another • e.g., authoritarian, restrictive parenting is protective in a high-risk setting, but is negatively related to competence in a low-risk sample • An emphasis on the processes by which risk and protective factors influence development of psychopathology is a large step forward from earlier correlational research that simply sought to detect associations among variables Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010

14. Eight Prevention Principles for Mental Health Providers

15. 1. The application of prevention efforts in mental health is based on epidemiologic findings. • With limited resources for prevention programs, more highly prevalent psychiatric conditions (e.g., depressive, anxiety, and substance use disorders), may be particularly important targets of prevention efforts • Yet, relatively low-incidence disorders or events, such as suicide, also call for prevention resources given the large associated costs and public health impacts • Awareness of changing trends in incidence and prevalence allows for effective targeting of scarce prevention resources Compton et al., Clinical Manual of Prevention in Mental Health, 2010

16. 2. Practicing prevention in the field of mental health requires an understanding of risk and protective factors. • Some risk factors may be malleable through preventive interventions (e.g., parenting skills deficits, availability of firearms, poverty or socioeconomic deprivation) • Although others may not be malleable (e.g., family history), they may be useful for targeting early detection and intervention • Protective factors protect against the adverse effects of stressors that occur or decrease the likelihood of developing a disorder Compton et al., Clinical Manual of Prevention in Mental Health, 2010

17. 3. Evidence-based preventive interventions can be applied in the clinical setting. • Practice guidelines incorporating prevention principles are available (e.g., recommendations on the monitoring of metabolic indices in patients prescribed antipsychotics) • Well-validated screening tools (secondary prevention) are widely accessible • Risk and protective factors should be assessed in daily clinical practice Compton et al., Clinical Manual of Prevention in Mental Health, 2010

18. 4. For patients with established psychiatric illnesses, important goals include the prevention of relapse, substance abuse, suicide, and adverse behaviors that lead to physical illnesses. • Relapse prevention in the clinical setting through psychoeducation and psychosocial methods of promoting medication adherence • Every patient should be screened (and periodically re-screened) for comorbid substance use disorders; likewise, those in treatment for substance use disorders should be screened for comorbid psychiatric conditions • Ongoing screening for suicidality • Addressing poor diet, physical inactivity, and other adverse health behaviors Compton et al., Clinical Manual of Prevention in Mental Health, 2010

19. 5. Clinic-based prevention efforts should focus on family members of individuals with psychiatric illnesses in addition to patients themselves. • Relatives of psychiatric patients may be at elevated risk • When working with adult psychiatric patients with children, it is critical to be aware of potentially evolving symptoms in the children that may warrant a referral to family therapy or a child/adolescent psychiatrist • Assess parenting skills • Evaluate family dynamics Compton et al., Clinical Manual of Prevention in Mental Health, 2010

20. 6. Primary and secondary prevention often takes place in schools, the workplace, and community settings. • Many prevention goals (e.g., anti-bullying, teen pregnancy prevention, suicide screening, substance abuse prevention) are best addressed during childhood and adolescence, in school settings • Employee assistance programs address substance abuse, stress/depression, and aggression/violence in workplaces • Many prevention activities take place at the level of the entire population (e.g., legislative/policy actions such as enforcing restrictions on selling alcohol to minors) Compton et al., Clinical Manual of Prevention in Mental Health, 2010

21. 7. Mental health professionals have a role in broad prevention goals (beyond the prevention of mental illnesses), such as the prevention of delinquency, bullying, and behavioral problems; the prevention of teenage pregnancy and unwanted pregnancy; and the prevention of intentional and unintentional injuries. • Prevention activities, such as those taking place in schools, target diverse outcomes, not necessarily mental illnesses per se, and mental health professionals can have a role in these broader goals Compton et al., Clinical Manual of Prevention in Mental Health, 2010

22. 8. Mental health professionals can play a role in mental health promotion, overall health, and wellness. • Help to build the capabilities of organizations, communities, and individuals in ways that change social, economic, and physical environments so that they improve health • Encourage proper sleep hygiene • Promote routine exercise • Attend to stress reduction Compton et al., Clinical Manual of Prevention in Mental Health, 2010

23. Bridging the Gap between Substance Abuse PreventionExperts & Mental Health Professionals

24. Bridging the Gap • First, we must recognize that we are serving the same people, though perhaps at different stages. • Second, we must realize that we speak the same language (of prevention), and so it makes sense that we should talk together more often. • Third, we can benefit from our differences (prevention leaders and mental health clinicians) as well as our shared values.

25. A Unified Approach to Prevention • The (clinical) high-risk strategy: efforts are focused on those individuals who are judged most likely to develop disease (which avoids the “wastefulness” of the mass approach, with its need to interfere with people most of whom neither ask for help nor will benefit from it) • The (public health) population strategy: is necessary wherever risk is widely diffused through the whole population Rose’s Strategy of Preventive Medicine, 2008

26. A Unified Approach “…the conclusion will be that preventive medicine must embrace both, but, of the two, power resides with the population strategy.” Rose’s Strategy of Preventive Medicine, 2008

27. Syndemic: two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population (e.g., inextricable and mutually reinforcing connections between substance abuse, violence, and AIDS among urban women in the U.S.) Thus, we must focus on connections among health-related problems and consider those connections when developing health policies

28. Bridging the Gap • We have the same goal • We serve the same people • We speak the same language • We can benefit from our differences • Mental health professionals are more familiar with the (clinical) high-risk approach • Preventionists are more familiar with the (public health) population-based approach • We are both dealing with syndemics • Social determinants of health are at play for us both