Public Health Shifts Focus To Preventing Chronic Illness
American public health, long focused on control of infectious disease, is undergoing a fundamental change in outlook as it turns its attention to chronic disease, including mental illness.
So said psychiatrist Neil Cohen, M.D., New York City's former commissioner of health, during a lecture on public health challenges in psychiatry at the APA institute on Psychiatric Services in New York in October.
Cohen said the success of American public health measures over the last 100 years in controlling infectious disease, combined with the increase in prevalence of chronic conditions, is forcing a change in the priorities of public health departments across the country. And with this change has come a recognition of the pervasiveness of mental illness.
Meanwhile, psychiatric epidemiology research has advanced to the point that risk factors can be identified. “Psychiatric epidemiology is not just about counting anymore,” Cohen said. “We are at the dawn of an era when we can now look at risk-factor epidemiology, examining the causes that contribute to—and the protective factors that decrease risks for—mental illness in communities.
“The knowledge to be gained from modern-day psychiatric epidemiology is as much about psychopathology and understanding the roots of mental illness as it is about epidemiology,” he said. “The advances that derive from this approach allow us to look at subthreshold syndromes, at the number of factors at play that put an individual at risk for advancing pathology.”
Cohen was the city's health commissioner from 1998 to 2002. In that post, he oversaw the public health responses to several crises: the outbreak of West Nile virus, the attacks on the World Trade Center, and anthrax-laced letters sent to media outlets in the city. He also served as commissioner of the New York Department of Mental Health, Mental Retardation, and Alcoholism Services, and he oversaw the merger of the health and mental health departments into a unified public health agency. He is currently clinical director and vice chair of the department of Psychiatry at mt. Sinai Medical Center and director of its Division of Community Medicine.
Infectious-Disease Focus Has a Price
Cohen noted that the significant extension of life expectancy for Americans during the 20th century was due not so much to medical advances as to the success of core public health activities such as improvements in nutrition and hygiene and the monitoring and control of infectious diseases.
“But the preoccupation with infectious disease came with a cost,” Cohen said. “it slowed the development of measures to deal with stroke, heart disease, and diabetes. And it limited the amount of attention that was paid to curtailing high-risk behaviors that contribute to prevalence of chronic conditions.”
The focus began to shift in the early 1990s, with the emergence of several lines of research demonstrating the profound effect of behavior on human health.
“Despite the need for public health interventions to address behavior, only 5 percent of each health care dollar is devoted to behavior modification,” Cohen stated.
Related to this have been the historic neglect of mental health and illness and the segregation of public mental health activities from the rest of public health and medicine. These too have begun to change in the wake of studies in the early 1990s by the World Bank and Harvard School of Public Health showing the enormous burden of disease related to mental illness.
That research found that major depression trailed behind only ischemic heart disease in terms of lost years of productivity due to death or disability and that depressive disorders, taken together, are the leading cause of disability worldwide.
Satcher Reports Changed Thinking
Even more powerful were the reports on mental health and illness by former Surgeon General David Satcher, M.D. Along with President Bush's New Freedom Commission on Mental Health and the enormous strides made in biomedical research on mental illness, the result has been a slow but certain realignment of priorities.
Cohen said the threat of terrorism and bioterrorism has also galvanized the integration of mental health and public health. Drawing on his experience helping to coordinate the response to the terrorist attacks on September 11, 2001, Cohen said there has been an effort to “bring mental health issues to bear on the larger public health response” to the threat of terrorism and bioterrorism.
And those threats have raised the profile of public health departments.“ In this post-9/11 world, the decades-long neglect of the public health system has been changing,” Cohen said. “Increasingly, the public and government are aware that a robust public health infrastructure is critical to the capacity to respond to a whole host of emerging threats.”
Cohen believes that a principal public health challenge facing psychiatry today is to draw on the new power of psychiatric epidemiology to develop models that focus on maintenance of positive mental health and prevention of mental illness rather than merely the treatment of disease when it appears. And he cited satcher in pointing out that “successful performance really rests on a foundation of successful mental health.”
“What I've been talking about is an alignment with the larger public health system and a greater focus on community well-being than has heretofore been our focus,” Cohen said. “The relationship between physical and mental disorders is profoundly influential with respect to morbidity and mortality and could very well be the core of a new model of public mental health...[that will] really take up the challenge of improving quality of life not only for individuals but entire communities.” ▪
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Published online: 1 December 2006
Published in print: December 1, 2006
Notes
A new era in psychiatric epidemiology is dawning in which risk factors contributing to mental illness in communities can be identified, as can protective factors that mitigate against it.
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