Transcript Prevention Psychiatry What is it?

Prevention Psychiatry
What is it?
Group for the Advancement of Psychiatry
Committee on Prevention, 2006-2007
David Pruitt, M.D., Michael T. Compton, M.D., M.P.H.,
Carol Koplan, M.D., Rebecca Powers, M.D., M.P.H.,
Larry Wissow, M.D., M.P.H.,
Anthony Charuvastra, M.D.*, Christopher Oleskey, M.D., M.P.H.*
* Ginsberg GAP Fellows
The Committee gratefully acknowledges the work of former
members, including Daniel Z. Lieberman, M.D. and James MacIntyre, M.D.
December 2007
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Definition
Prevention psychiatry is the reduction of
mental disorders and behavioral problems by
A) Identifying risk and protective
factors, and
B) Applying evidence-based
interventions.
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Prevention Examples

Reduction of specific disorders
– Substance abuse, depression, PTSD
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Reduction of risky behaviors
– Substance use, unsafe sex
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Reduction of negative outcomes
– Suicide, teen pregnancy, school dropout,
delinquency
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Promotion of mental health and wellness
Positive Prevention Outcomes
 Decrease
incidence and prevalence
 Delay onset
 Minimize adverse impact on family,
peers, and society
 Demonstrate cost-effectiveness
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Public Health Classifications

Primary prevention: Reduction of the
incidence of a disorder.

Secondary prevention: Reduction of the
prevalence of a disorder.
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Tertiary prevention: Reduction of the
disability associated with a disorder.
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Institute of Medicine Classifications

Universal preventive intervention: An intervention
targeted to an entire population.
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Selective preventive intervention: An intervention
targeted to members of a population with higher
than average risk factors.

Indicated preventive intervention: An intervention
targeted to members of a population with
subsyndromal symptoms of a disorder.
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The Mental Health Intervention Spectrum
for Mental Disorders
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Source: Mrazek and Haggerty (1994) Reducing Risks for Mental Disorders
Types of Prevention – A Synthesis
Primary
- Universal interventions
- Selected interventions
- Indicated interventions
Secondary
- Screening
- Early intervention/treatment
Tertiary
- Relapse prevention
- Prevention of morbidity/disability
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Risk Factors
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Risk factors predate the associated
disorder.
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They are highly associated with the
disorder.
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Some risk factors are malleable, or
subject to change via a preventive
intervention.
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Examples of Risk Factors

Biological
– Expression of genetic vulnerability, adverse
prenatal event (traumatic, toxic, infectious)

Psychological/Psychosocial
– Family discord, parenting skill deficits

Social/Environmental
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– Availability of drugs and firearms, extreme
economic and social deprivation
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Violence
Delinquency
Teen
Pregnancy
Community
Availablity of Drugs and Firearms
Extreme Economic Deprivation
Family
Family Conflict
Parental Attitudes and Involvement
Individual/Peer
Alienation and Rebelliousness
Friends Who Engage in a Behavior
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Substance
Abuse
Risk Factors by Domain
Source: Hawkins and Catalano. (1992) Communities That Care.
Protective Factors
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Protective factors predate the associated
disorder.

They reduce the risk of developing a disorder or
adverse outcome.

Some are malleable, or subject to enhancement
via a preventive intervention (i.e., promoting
resiliency).
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Examples of Protective Factors

Support from caring adults
– Parents, relatives, mentors

Good school performance
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Conflict resolution skills
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Positive role models and positive peers
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Clear and consistent discipline in the family
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What Constitutes “Evidence-Based?”
Determination of effectiveness and/or
efficacy is based on scientific studies.
 Downplays intuition and unsystematic
clinical experience as sufficient grounds for
decision-making.
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Interventions are tested in systematic,
empirical, and rigorous ways.
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Illustration: Universal Intervention
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Prevention of marital distress and divorce
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Target population: Married couples and
couples planning to marry

Intervention: Group sessions for couples to
build skills to handle disagreements
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Illustration: Universal Intervention

Prevention of poor school and family bonds,
violence, substance abuse, risky sexual
behavior
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Target population: Elementary school-aged
children
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Intervention: Modified teacher practices and
parent training in child behavioral techniques
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Illustration: Universal Intervention

Prevention of behavioral and health problems
in children later in life
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Target population: New mothers

Intervention: Counseling sessions aimed at
enhancing self worth of the new mother,
fostering gentle interactions with the baby
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Illustration: Selective Intervention

Prevention of alcohol abuse among college
students
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Target population: Students with high-risk
drinking behavior

Intervention: Motivational interviewing and
skill-based training to help students “mature
out” of high-risk drinking
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Illustration: Selective Intervention
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Prevention of protracted bereavement,
depression, and social withdrawal
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Target population: New widows
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Intervention: Widows are paired with a
widow contact who provides emotional
support and practical assistance
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Illustration: Selective Intervention
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Prevention of behavioral and attitude
problems
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Target population: Children with parents
who have affective disorders
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Intervention: Parent, child, and family
sessions performed with semi-structured
interviews
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Illustration: Indicated Intervention
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Delaying or preventing the onset of
schizophrenia
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Target population: Patients with subthreshold (prodromal) symptoms
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Intervention: Low dose atypical antipsychotic and cognitive-behavioral therapy
(or other psychosocial interventions)
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General Principles for Effective
Prevention Programs
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Address factors that play causal roles.
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Reverse or reduce risk factors.
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Enhance protective factors to increase
competency in multiple domains.
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Age-specific, developmentally appropriate, and
culturally sensitive.
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Prevention-minded Treatment
Intervention for a whole family in which an
individual with a mental disorder
receives treatment and other family
members (parents, children, spouse,
etc.) receive preventive interventions.
[NYS-OMH, Koilpillai (2000)]
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Roles for Mental Health Professionals
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Incorporate knowledge of risk and protective
factors into clinical practice.
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Promote awareness of the benefits of
prevention.
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Consult with schools and community agencies.
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Collaborate with prevention groups to work
together at reducing common risk factors and
promoting protective factors.
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References
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World Health Organization. Prevention of Mental Disorders: Effective
Interventions and Policy Options. Summary Report:
http://whqlibdoc.who.int/publications/2004/924159215X.pdf.
World Health Organization. Promoting Mental Health: Concepts, Emerging
Evidence, Practice. Summary Report:
http://whqlibdoc.who.int/publications/2004/9241591595.pdf.
Hosman C, Jane Llopis E, Saxena S, Eds. Prevention of Mental Disorders:
Effective Interventions and Policy Options. Oxford University Press, 2005.
Mrazek PJ, Haggerty RJ, Eds. Reducing the Risk for Mental Disorders:
Frontiers for Preventive Intervention Research. Washington, DC: National
Academy Press, 1994.
Kellermann AL, Rivara FP. Suicide in the home in relation to gun
ownership. N Engl J Med 1992;327:467-472.
Hawkins JD, Catalano RF, Miller JY. Communities that Care: Risk-focused
Prevention Using Social Development Strategies, Development Research
and Programs, Inc. Psycholog Bull 1993;112:1-23.
Durlak JA. Common risk and protective factors in successful prevention
programs. Am J Orthopsychiatry 1998;68:512-520.
References
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Felitti VJ, Anda RF, Nordenberg D, et al. Relationship
of childhood abuse and household dysfunction to many of the leading causes
of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J
Prev Med 1998;14:245-258.
Substance Abuse and Mental Health Services Administration, Center for
Mental Health Services (2007). Promotion and Prevention in Mental Health:
Strengthening Parenting and Enhancing Child Resilience, DHHS Publication
No. CMHS-SVP-0175. Rockville, MD.
Markman HJ, Renick MJ, Floyd FJ, et al. Preventing marital distress through
communication and conflict management training: A 4- and 5-year follow-up.
J Consult Clin Psychol 1993;61:70-77.
Olweus D. Bullying at school: Basic facts and effects of a school based
intervention program. J Child Psychol Psychiatry 1994;35:1171-1190.
Dolan LJ, Kellam SG, et al. The short-term impact of two classroom-based
preventive interventions on aggressive and shy behaviors and poor
achievement. J Applied Devel Psychol 1993;14:317-345.
Hawkins JD, Catalano RF, Kosterman R, et al. Preventing adolescent healthrisk behaviors by strengthening protection during childhood. Arch Pediatr
Adolesc Med 1999;153:226-234.
Cullen KJ, Cullen AM. Long-term follow-up of the Busselton six-year
controlled trial of prevention of children’s behavior disorders. J Pediatr
1996;129:136-139.
References
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Baer JS, Kivlahan DR, Blume AW, et al. Brief intervention for heavydrinking college students: 4-year follow-up and natural history. Am J
Public Health 2001;91:1310-16.
Vachon ML, Lyall WA, Rogers J, et al. A controlled study of self-help
intervention for widows. Am J Psychiatry 1980;137:1380-1384.
Beardslee WR. Out of the Darkened Room: When a Parent is Depressed:
Protecting the Children and Strengthening the Family. Boston, MA: Little,
Brown, and Company, 2002.
McGorry PD, Yung AR, Phillips LJ, et al. Randomized controlled trial of
interventions designed to reduce the risk of progression to first-episode
psychosis in a clinical sample with subthreshold symptoms. Arch Gen
Psychiatry 2002;59:921-928.
Compton MT, McGlashan MD, McGorry PH. Toward prevention approaches
for schizophrenia: An overview of prodromal states, the duration of
untreated psychosis, and early intervention paradigms. Psychiatr Ann
2007;37:340-348.
Addington J, Francey S, Morrison AP (Eds.) Working with People at High
Risk of Developing Psychosis: A Treatment Handbook. Wiley, 2007.
Group for the Advancement of Psychiatry (GAP) website:
http://www.groupadpsych.org.
Group for the Advancement of Psychiatry

The Group for the Advancement of Psychiatry (GAP) was founded
in 1946 by a group of physicians under the dynamic leadership of
the late Dr. William C. Menninger. Their wartime experiences had
brought them to realize the urgency of greater public awareness
of the need for new programs in mental health for the people of
the United States.
 Over the ensuing years, GAP has had a tremendous influence in
shaping psychiatric thinking, public programs, and clinical
practice in mental health. It continues today to pioneer the
exploration of issues and ideas on the frontiers of psychiatry and
in applying psychiatric insights into the general medical, social,
and interpersonal problems of our times.
 GAP analyzes significant data in psychiatry and human relations,
reevaluates old concepts, develops new ones, and applies this
knowledge for the advancement of mental health.