Do
“prevention” and “psychiatry” even belong in the same sentence?
Clearly, there is no immunization against mental illnesses. However,
appropriate health promotion, elimination of high-risk factors, and
well-tailored interventions can lead to substantial reductions in mental
health disability. In fact, mounting evidence suggests that prevention
in psychiatry is both practical and cost-effective.
Better
sanitation, vaccines, improved perinatal care, and other medical
advances introduced during the last century have dramatically improved
the quality of life and eradicated many devastating medical diseases.
Today similar long-term and intersectoral preventive measures are needed
in the arena of mental health. Mental illnesses are still imposing an
enormous psychological, social, and economic burden on society and are
associated with increased morbidity and mortality. Even a cursory look
at the statistics is eye opening: 1 in 4 Americans will develop a
psychiatric disorder during his or her lifespan. Further efforts to
expand the spectrum of prevention in psychiatry would be highly
beneficial for patients, communities, and societies.
Psychiatrists
have been alleviating the symptoms of depression, schizophrenia, and
other diseases and trying to minimize the risk of complications, such as
disability, physical illness, and suicide. However, the question is
whether we can prevent mental illnesses from developing in the first
place, or at least prevent their clinical manifestations so they remain
dormant throughout life. Admittedly, this would be an ambitious
undertaking, as most psychiatric disorders are multi-determined. For
instance, depression might have causal pathways ranging from genetic
predisposition to social factors to the use of certain depressogenic
drugs. Some of these causes are currently preventable, others are not.
Yet protecting individuals from developing a clinical illness, even in
the presence of the underlying risk factor, is not a futuristic fantasy.
An excellent example is a debilitating intellectual disability and
seizure disorder associated with phenylketonuria (PKU). Patients who are
diagnosed early and maintain a strict special diet for PKU can have a
normal lifespan with normal mental development.
In
2009, the Institute of Medicine issued a remarkable report titled
“Preventing Mental, Emotional, and Behavioral Disorders Among Young
People: Progress and Possibilities.” It showed how behavioral health
could learn from public health in endorsing a population health
perspective. It gave examples of evidence-based kernels and “behavioral
vaccines” that have been found to reduce mental, emotional, and
behavioral problems at the community level. Thus, simple strategies such
as positive notes from home, group public feedback with group rewards,
reduction in TV viewing and video game use at home, and cooperative
games on the playground have been shown to reduce aggression at school,
even among very high-risk children or adolescents.
In 2011, Carl Bell and I published a volume on prevention in psychiatry from a lifespan perspective (Prevention in Mental Health: Lifespan Perspective,
W.B. Saunders Co.). Our goal was to discuss how prevention is not
restricted to children and youth, but also can be practiced in
adulthood, including old age. Depression has been studied most
extensively from this viewpoint, and several types of preventive
interventions have been shown to be effective. Thus, the likelihood of
adolescent depression can be reduced in the offspring of parents with a
history of the disease through measures such as individually targeted
psychotherapy, strategies for improving self-esteem, and encouraging
quality relationships with caring adults. Similarly, early screening for
depression and intensive support and counseling can reduce the risk of
postpartum depression in mothers.
Finally,
there is a growing body of research on preventing development of
depression that commonly follows myocardial infarction, cardiac bypass
surgery, and strokes. Other malleable risk factors for depression
include physical disability, sleep problems, social isolation, and a
lack of stimulating environment or activities. Interventions aimed at
altering such factors or their consequences can be successful in
preventing the onset of depression across the lifespan.
Another
line of research suggests that posttraumatic stress disorder (PTSD)
presents an opportunity for preventive measures. Counseling victims of
natural disasters, wars, or other tragic events can prove beneficial in
substantially lowering the risk of developing PTSD throughout the
lifespan.
Fostering positive
psychosocial traits, such as optimism, resilience, self-efficacy, and
spirituality, has been shown to be effective in promoting mental health
and preventing psychopathology.
People
who are optimistic about the future, who are resilient after stressful
events, and who are confident in their abilities to manage day-to-day
affairs tend to experience better cognitive and emotional health
following negative life events, even in older age. In addition, the
burgeoning fields of genetics and genomics hold a promise that, in the
near future, prevention in psychiatry will be even more effective. With
better understanding of psychiatric genetics, we might be able to
identify genetic risk factors for a number of mental illnesses. We could
then improve screenings and develop biological and
psychosocial/behavioral treatments that would positively impact the
expression of relevant genes.
While
more research on various aspects of psychiatric prevention is obviously
needed, applying current knowledge in clinical practice can contribute
to reducing a number of the psychiatric disabilities. Well-designed and
implemented preventive strategies should lead to significant reduction
in the burden of many psychiatric diseases. Preventive psychiatry is not
an oxymoron!http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1356729
