Evidence for Prevention Efficacy Said to Be Strong and Growing

A report in the March Psychiatric Services summarizes the evolution of evidence for the prevention of psychiatric disorders.

In the article, William Beardslee, M.D., Peter Chien, M.D., and Carl Bell, M.D., offer recommendations for implementing measures to prevent mental illness and urge systemic changes geared toward prioritizing prevention efforts and encouraging further research on preventive practices.

According to Chien, "the good news is that the evidence [for the effectiveness of prevention strategies] is stronger than most people believe and that it is mounting. The opportunities are there."

This state of preventive mental health programs did not always warrant such an optimistic outlook. In September 1989, the then General Accounting Office (GAO) issued a report in response to a congressional request for information on the status of implementing preventive mental health initiatives under the Public Health Service Act and subsequent 1980 and 1983 amendments detailing prevention-program requirements.

The GAO report, "Mental Health: Prevention of Mental Disorders and Research on Stress-Related Disorders," found that the prevention-related requirements had not been met and recommended programs had not been established. This report prompted a national conference on prevention research, leading to the Institute of Medicine (IOM) releasing its first report on prevention in 1994, "Reducing Risks for Mental Disorders: Frontiers for Prevention Research." The report recommended increases in both research on and implementation of preventive mental health programs.

Since the 1994 report, there has been an explosion in randomized, controlled studies in prevention, leading Bell to comment to Psychiatric News that "these studies have led to the increasing view that it is unethical to not do prevention in some areas." The evidence from these studies prompted the IOM to produce another report on the issue in 2009, titled "Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities." Beardslee, Chien, and Bell believe this report shows that prevention in psychiatry is possible, and it prompted them to marshal the evidence and offer recommendations in their article.

Preventive mental health programs serve two purposes. From a health care perspective, these programs address risk factors to individuals, providing for better long-term prognoses. In addition, the authors contended that preventive mental health programs accrue economic benefits. They marshalled statistics to illustrate that prevention is often less expensive than the economic and societal costs once an illness has manifested.

Prevention requires a paradigm shift, however. Mental, emotional, and behavioral disorders are predominantly developmental, and thus for maximum impact prevention must focus on the young. The authors noted that "half of lifetime cases of mental, emotional, and behavioral disorders start by age 14, and three-fourths of disorders start by age 24." The shift needs to occur in considering the needs of children. Chien pointed out that "when you see [adult] patients in the office, it is hard to do primary prevention because they already have a diagnosable disorder, but you can do primary prevention for their children. Think about their family." Beardslee agreed, noting that the same clinician can do both treatment and prevention.

In an interview with Psychiatric News, Beardslee said an interdisciplinary approach is needed and gave the example of the threat of homelessness for an increasing number of people in these economic times. The potential psychiatric problems from homelessness are many for the adults, families, and children. "Housing insecurity is a risk factor, while housing stability accrues numerous long-term benefits. It's a protective factor."

The interdisciplinary approach to prevention leads to the aforementioned economic benefits. The authors noted that the 2009 IOM report estimated that the costs associated with mental and behavioral disorders in young people totaled $247 billion in 2007. This took into account treatment, crime, and lost productivity. Prevention programs cost considerably less. They pointed to the Strengthening Families Program, which "realized reduced drug use, reduced delinquency, and increased academic performance" and highlighted that its interdisciplinary and preventive nature realized an estimated savings of $8 for every $1 invested.

The Strengthening Families Program has been implemented all around the country. It was created through a NIDA research grant in the early 1980s. The Web site is <www.strengtheningfamiliesprogram.org>.

All three authors are optimistic about the current direction of preventive mental health care. Bell said that originally it was not clear that the 2009 IOM report was getting any traction, but now he believes that the government, and the Substance Abuse and Mental Health Services Administration in particular, is moving in the right direction. The surgeon general is heading a prevention task force. Several provisions of the Patient Protection and Affordable Care Act—the Obama health care reform law—look back to the 2009 study, providing $3 billion for home visitation and $15 billion for a Prevention Intervention Council.

"Prevention is all coming together. Everyone is on the same page," said Bell.