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Prevention Psychiatry

What 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

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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.

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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

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Positive Prevention Outcomes

Decrease incidence and prevalence

Delay onset

Minimize adverse impact on family,

peers, and society

Demonstrate cost-effectiveness

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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.

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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.

Institute of Medicine Classifications

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Source: Mrazek and Haggerty (1994) Reducing Risks for Mental Disorders

The Mental Health Intervention Spectrum

for Mental Disorders

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Types of Prevention – A Synthesis

Primary - Universal interventions

- Selected interventions

- Indicated interventions

Secondary - Screening

- Early intervention/treatment

Tertiary - Relapse prevention

- Prevention of morbidity/disability

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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.

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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

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Risk Factors by Domain

Source: Hawkins and Catalano. (1992) Communities That Care.

Substa

nce

Abuse

Delin

qu

ency

Teen

Pre

gna

ncy

Vio

lence

Community

Availablity of Drugs and Firearms

Extreme Economic Deprivation

Family

Family Conflict

Parental Attitudes and Involvement

Individual/Peer

Alienation and Rebelliousness

Friends Who Engage in a Behavior

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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).

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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

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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.

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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

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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

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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

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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

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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

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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

Illustration: Selective Intervention

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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)

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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.

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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)]

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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.

Roles for Mental Health Professionals

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.

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 Pediatr1996;129:136-139.

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.

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.