Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research

Embarking on a journey into the wilderness of prevention research for mental disorders is not such a solitary, limiting venture as it was 10 years ago. Pioneers in prevention research now have a credible resource book, Reducing Risks for Mental Disorders. The book, written by the Institute of Medicine's Committee on Prevention of Mental Illness, comprises the contributions of highly respected research professionals who have made significant contributions to the treatment of major mental illnesses. This collaborative work by an interdisciplinary committee has resulted in a book that is well organized, highly informative, and easy to read. After focusing for decades on treatment research for mental illness, a science of preventive interventions has come of age. Initiation of a science of prevention research in psychiatry depends on the provision of funds and setting of priorities by the National Institute of Mental Health, National Institute on Drug Abuse, National Institute on Alcohol and Alcohol Abuse, and other granting agencies. Such funds and priorities will be needed to develop an infrastructure for identifying, developing, analyzing, and evaluating prevention models and programs in the next decade that might reduce the incidence and prevalence of mental illness.

Public awareness of the need for mental illness prevention research was raised by John F. Kennedy's message to Congress in 1963. However, prevention research was only an intangible vision in 1963. Psychiatric epidemiology, diagnostic specificity, and biobehavioral treatments had not advanced sufficiently to provide a framework or foundation for prevention. Prevention was an ambiguous and nonspecific bon mot in search of a technology.

Thirty-four years later, the vision has taken form and prevention researchers are ready to embark on the next frontier in mental health research. Mental illness is not limited to the 20% of adults in the United States who suffer from active mental illness each year. It is estimated that 12% of the nation's 63,000,000 children and adolescents also suffer from mental disorders. These statistics are based on reported cases only. The social, financial, and emotional consequences of mental illness on individuals, families, and society are staggering. Moreover, state and community mental health agencies have lost a significant proportion of the financial resources they were using to provide treatment and support for the mentally ill. Thus, prevention of disorders takes on new and urgent significance.

Research has primarily been focused on treatment of already existing disorders and not on preventing them. In the 1960s, there were a few research studies aimed at prevention, but it has not been until this decade that the inertia of mental health is propelling research dollars and talents to investigate prevention strategies.

In Reducing Risks for Mental Disorders, a risk and protective factors model is proposed for the onset of five mental disorders: Alzheimer's disease, schizophrenia, alcohol abuse and dependence, depressive disorders, and conduct disorder. The authors clarify that risk and protective factors may be common to most, if not all, mental disorders. Whereas treatment research has focused on treating the symptoms of specific disorders, prevention research aims to focus intervention on “malleable” risk and protective factors. One example of preventive interventions that have already been documented as effective is the work of Richard Price and his colleagues at the University of Michigan, who have created a model for the prevention of depression. They identified an at-risk population of individuals laid off from their jobs and randomly assigned them to an intervention program (i.e., job search training) or to a control group. Those receiving training in job- finding skills not only had better employment outcomes but also showed significantly less depression at various follow-up points.

Some risk and protective factors will be deemed more “malleable” than others. Although much progress is being made in molecular genetics, focusing prevention efforts at this level is not likely to be feasible for some time in psychiatry. However, interventions with the school system (i.e., improving the capacity of teachers and administrators in their efforts to help students who are at risk for behavioral or psychological problems), with the family (i.e., improving family solidarity, child- management skills, communication, and problem-solving capacity), and with the social competence of individuals (as in social skills training) have already surfaced in research on preventive interventions for conduct disorders.

Even schizophrenia—the most severe of the mental disorders—holds promise for preventive interventions. Studies have now identified vulnerability or risk factors that appear to be neurodevelopmental markers for this disorder. Eye-tracking abnormalities and defects in early visual processing of information (e.g., detecting degraded numbers or an array of letters flashed on a computer screen for milliseconds) are abnormal during both periods of remission and periods of relapse in schizophrenia; furthermore, these abnormalities are found in a substantial minority of first-degree relatives of individuals with schizophrenia—suggesting that they may serve as genetic markers for individuals who have the predisposition to the disorder but who never develop it. In a similar manner, schizotypal personality traits also have been identified as possible risk factors for schizophrenia. By selecting individuals with these abnormalities and randomly assigning them to groups that receive training and family psychoeducation in identifying the early prodromal signs and symptoms of the illness, to groups that receive low-dose antipsychotic medication, or to control groups, it may be possible to see progress made in this most devastating of mental disorders.

Reducing Risks for Mental Disorders presents concepts clearly and parsimoniously; thus, it can serve as an excellent primer and overview for both professional and lay readers. Since the book also provides a well-organized and systematic framework for methodology in prevention research, it has value for specialists in the field of preventive interventions as well. The book illustrates concepts effectively by providing timelines, illustrative tables, and resource information for workshops and conferences. It is the type of book that will be useful throughout the next decade as prevention research gathers steam. It should not collect dust on the bookshelf.

The roads of prevention research will be charted in the next decade. Unlike the moth that flies directly to the light, prevention research will make scientific progress by inching along a winding scientific causeway. There will be no magic here, just hard scientific inquiry. Reducing Risks for Mental Disorders is a valuable resource book to guide this exciting expedition. The journey has begun.