mental illness prevention
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Coming Together for a Shared Goal of Prevention: Bridging the Gap between Substance Abuse Prevention Experts and Mental Health Professionals. Michael T. Compton, M.D., M.P.H. The George Washington University School of Medicine & Health Sciences Department of Psychiatry & Behavioral Sciences - PowerPoint PPT PresentationTRANSCRIPT
Coming Together for a Shared Goal of Prevention: Bridging the Gap between Substance Abuse PreventionExperts and Mental Health Professionals
Michael T. Compton, M.D., M.P.H. The George Washington University School of Medicine & Health
SciencesDepartment of Psychiatry & Behavioral Sciences
Washington, D.C.
Center for the Application of Prevention TechnologiesRegional Technical Expert Panel (RTEP) Meeting
September 19, 2011 – Atlanta, Georgia
Mental Illness Prevention Prevention has mainly been in the domain of
public health; however, it is now being embraced by the general health sector and is becoming more widely accepted in the mental health field
Both general medicine and psychiatry are primarily involved in individual-level treatment
With the high prevalence of chronic medical and psychiatric illnesses, and an aging population, there has been increased recognition of the importance of prevention
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
Mental Health Promotion A subset of health promotion Strategies and interventions that
enable positive emotional adjustment and adaptive behavior
Whereas mental illness prevention aims to avert onset of illness, mental health promotion focuses on maintaining health
Primary Preventionreducing the incidenceof disease by risk factor
reduction well beforeonset of illness
Secondary Preventionreducing prevalence
via early identificationand treatment during
the latent stage
Tertiary Preventionreducing morbidity,
disability, andmortality by treatingestablished disease
UniversalInterventiontargeting the
generalpopulation
SelectiveInterventiontargeting a
select groupat higher risk
IndicatedInterventiontargeting a
group at veryhigh risk
Pre-Disease
► Level of Risk ►
Latent Disease Symptomatic Disease
Stage of Disease
Target Population
DOCTORS OFTEN ACT AS THOUGH THEIR PROFESSIONAL RESPONSIBILITY DOES NOT GO BEYOND THE SICK AND THE NEARLY SICK (THOSE AT IMMINENT
RISK), AND POLITICIANS, WHO INFLUENCE HEALTH MORE THAN THE DOCTORS, ARE RARELY TROUBLED BY
THOUGHTS FOR THE DISTANT FUTURE.
Rose’s Strategy of Preventive Medicine, 2008
Risk Factors… are dynamic across time and context rarely occur in isolation (they tend to
co-occur) and their meaning may change across the developmental continuum
are usually not linked to specific mental illnesses
accumulate, and a greater number of risk factors increases likelihood of negative outcomes
Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010
Risk Factors… exert different effects on
development depending on timing, context, and duratione.g., the impact of the death of a parent in
childhood may vary as a function of the age at which the loss occurred, the nature of the relationship with the deceased caregiver, the quality of the relationships with remaining caregivers, and the surrounding familial and cultural context in which the loss occurred
Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010
Risk Factors Accumulation of risk and
vulnerability factors increases the likelihood of maladaptation
Elimination or reduction of such factors will reduce the probability of negative outcomes
Identification of risk factors is critical to effective prevention; knowing what increases the likelihood of a negative outcome is the first step toward preventing that outcome
Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010
Risk Factors Some risk factors are causal (e.g.,
cigarette smoking linked to lung cancer)
Others are proxies (e.g., living in an area with a high prevalence of cigarette smoking)
And yet others are markers of the underlying process (e.g., having a smoker’s cough)
Protective Factors Some factors may be risk factors in one
setting, but protective factors in anothere.g., authoritarian, restrictive parenting is
protective in a high-risk setting, but is negatively related to competence in a low-risk sample
An emphasis on the processes by which risk and protective factors influence development of psychopathology is a large step forward from earlier correlational research that simply sought to detect associations among variables
Shaffer & Yates, Clinical Manual of Prevention in Mental Health, 2010
Eight Prevention Principles for Mental Health Providers
1. The application of prevention efforts in mental health is based on epidemiologic findings. With limited resources for prevention
programs, more highly prevalent psychiatric conditions (e.g., depressive, anxiety, and substance use disorders), may be particularly important targets of prevention efforts
Yet, relatively low-incidence disorders or events, such as suicide, also call for prevention resources given the large associated costs and public health impacts
Awareness of changing trends in incidence and prevalence allows for effective targeting of scarce prevention resources
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
2. Practicing prevention in the field of mental health requires an understanding of risk and protective factors. Some risk factors may be malleable through
preventive interventions (e.g., parenting skills deficits, availability of firearms, poverty or socioeconomic deprivation)
Although others may not be malleable (e.g., family history), they may be useful for targeting early detection and intervention
Protective factors protect against the adverse effects of stressors that occur or decrease the likelihood of developing a disorder
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
3. Evidence-based preventive interventions can be applied in the clinical setting.
Practice guidelines incorporating prevention principles are available (e.g., recommendations on the monitoring of metabolic indices in patients prescribed antipsychotics)
Well-validated screening tools (secondary prevention) are widely accessible
Risk and protective factors should be assessed in daily clinical practice
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
4. For patients with established psychiatric illnesses, important goals include the prevention of relapse, substance abuse, suicide, and adverse behaviors that lead to physical illnesses.
Relapse prevention in the clinical setting through psychoeducation and psychosocial methods of promoting medication adherence
Every patient should be screened (and periodically re-screened) for comorbid substance use disorders; likewise, those in treatment for substance use disorders should be screened for comorbid psychiatric conditions
Ongoing screening for suicidality Addressing poor diet, physical inactivity, and
other adverse health behaviorsCompton et al., Clinical Manual of Prevention in Mental Health, 2010
5. Clinic-based prevention efforts should focus on family members of individuals with psychiatric illnesses in addition to patients themselves.
Relatives of psychiatric patients may be at elevated risk
When working with adult psychiatric patients with children, it is critical to be aware of potentially evolving symptoms in the children that may warrant a referral to family therapy or a child/adolescent psychiatrist
Assess parenting skills Evaluate family dynamics
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
6. Primary and secondary prevention often takes place in schools, the workplace, and community settings. Many prevention goals (e.g., anti-bullying,
teen pregnancy prevention, suicide screening, substance abuse prevention) are best addressed during childhood and adolescence, in school settings
Employee assistance programs address substance abuse, stress/depression, and aggression/violence in workplaces
Many prevention activities take place at the level of the entire population (e.g., legislative/policy actions such as enforcing restrictions on selling alcohol to minors)
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
7. Mental health professionals have a role in broad prevention goals (beyond the prevention of mental illnesses), such as the prevention of delinquency, bullying, and behavioral problems; the prevention of teenage pregnancy and unwanted pregnancy; and the prevention of intentional and unintentional injuries.
Prevention activities, such as those taking place in schools, target diverse outcomes, not necessarily mental illnesses per se, and mental health professionals can have a role in these broader goals
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
8. Mental health professionals can play a role in mental health promotion, overall health, and wellness.
Help to build the capabilities of organizations, communities, and individuals in ways that change social, economic, and physical environments so that they improve health
Encourage proper sleep hygiene Promote routine exercise Attend to stress reduction
Compton et al., Clinical Manual of Prevention in Mental Health, 2010
Bridging the Gap between Substance Abuse PreventionExperts & Mental Health Professionals
Bridging the Gap First, we must recognize that we are
serving the same people, though perhaps at different stages.
Second, we must realize that we speak the same language (of prevention), and so it makes sense that we should talk together more often.
Third, we can benefit from our differences (prevention leaders and mental health clinicians) as well as our shared values.
A Unified Approach to Prevention
The (clinical) high-risk strategy: efforts are focused on those individuals who are judged most likely to develop disease (which avoids the “wastefulness” of the mass approach, with its need to interfere with people most of whom neither ask for help nor will benefit from it)
The (public health) population strategy: is necessary wherever risk is widely diffused through the whole population
Rose’s Strategy of Preventive Medicine, 2008
A Unified Approach
“…the conclusion will be that preventive medicine must embrace both, but, of the two, power resides with the population
strategy.”
Rose’s Strategy of Preventive Medicine, 2008
Syndemic: two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population (e.g., inextricable and mutually reinforcing connections between substance abuse, violence, and AIDS among urban women in the U.S.)
Thus, we must focus on connections among health-related problems and consider those connections when developing health policies
Bridging the GapWe have the same goalWe serve the same peopleWe speak the same languageWe can benefit from our differencesMental health professionals are more familiar with the (clinical) high-risk approachPreventionists are more familiar with the (public health) population-based approachWe are both dealing with syndemicsSocial determinants of health are at play for us both