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Summary Prevention of Mental Health Problems (Master Health Sciences VU)
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Summary of all articles used in the course Prevention of Mental Health Problems, course in the master Health Sciences (VU).
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Prevention of Mental Health ProblemsLiterature Summary
1 Introduction
Preventive strategies for mental health
Arango C et al., (2018). Preventive strategies for mental health. Lancet Psychiatry; 5: 591-604
Previously, a major focus on tertiary prevention of mental health deterioration within clinical
practice. However, scientific evidence could help to move towards universal prevention of
vulnerability, selective prevention in high-risk groups, and indicated prevention of full or more severe
expression of illness in individuals showing early signs.
Prevention in mental health aims to reduce incidence, prevalence and recurrence of mental health
disorders and their associated disability. Preventive interventions aim to modify risk exposure and
strengthen coping mechanisms of the individual. Effective interventions require identification of
causal risk factors and can target generic risk factors and disease-specific factors. Preventive
programs usually involve a combination of strategies: reducing exposure to risk factors, enhancing
protective factors and targeting causal mechanisms.
Different degrees of heritability. Pathogenic genetic variation is a major risk factor. Most
environmental risk factors have small effect sizes, increasing susceptibility, but not sufficient to
explain the occurrence of a disorder. Risk factors include: prenatal environment, birth complications,
preterm delivery, brain trauma, social risks, trauma, insufficient stimulation, general adversity and
stressful life events, and drug abuse. Many risk factors interrelate and have synergistic effects. Once
an individual becomes vulnerable, they are more likely to experience other risk factors (vicious cycle):
facilitation effect, which is supported by epigenetic changes (in brain receptors).
Identification of risk and protective factors is difficult due to interaction between the individual and
environment. This is a challenge, however, provides an opportunity for different levels of
intervention at different developmental stages.
Prevention during development
During development, the cumulative effect of risk and absence of protective factors can lead to
mental illness. Targeted prevention in high-risk individuals by reducing exposure to risk factors and
enhancing protective factors (e.g. reduce bullying in schools, providing educational and family
support, promoting resilience). Resilience is a multidimensional construct conceptualized as the
ability to adapt well after experiencing stressors; interventions targeting resilience in children include
enhancing social and emotional competence skills and promoting self-efficacy.
Developmental psychopathology model and staging model both suggest that severe mental disorders
develop from at-risk preclinical states, pass through undifferentiated general symptoms, and lead to
increasing clinical specificity and functional decline. Both suggest the possibility of a preventive
approach by detecting early risk markers of developmental deviance (subtle language, motor delays,
extreme temperament traits etc.).
During life, there are sensitive periods when risk and protective factors have greater effects and
longer-lasting consequences: prenatal period, childhood, and adolescence through early adulthood.
These are periods of major developmental brain changes. Prevention in these periods might be more
effective and longer-lasting.
Factors that hamper advancement of prevention in psychiatry
, - Limitations of using diagnoses of specific mental disorders as outcome measures of preventive
interventions. Factors do not seem to be specific.
- Barriers to identification and care in those at risk. No reliable biomarkers. Access to care.
- Methodological and ethical challenges of preventive interventions.
- Long-term benefits do not seem to motivate health authorities or political decisions.
- Challenges of rebalancing investment in prevention and treatment of mental disorders.
- Stigma.
Evidence primary
prevention in
psychiatry
Universal prevention
addresses generic risk
and protective factors in
the general population.
A holistic approach to
health, integrating
psychosocial and
physical aspects of
wellbeing might be
valuable. The WHO
Health Promoting
School framework
appears to have had
significant positive
effects. Also, promoting
healthy lifestyles could
have positive effects on
cognitive development,
scholastic achievement
and mental health
vulnerability.
Key targets include the
prenatal and perinatal
periods. During
pregnancy:
supplementation of
vitamin D and
phosphatidylcholine,
and improving overall
maternal nutrition.
Furthermore, school-based programs to reduce bullying, improve social and emotional skills,
attitudes, behavior, and academic performance, as well as self-regulation change techniques.
Psychosocial universal preventive interventions might be effective, as well as additional
supplementation strategies.
Selective preventive interventions are aimed at high-risk individuals. Especially children of parents
with mental illness or substance use disorders are at high risk. Therefore, successful management of
parental psychopathology could improve outcomes in their children. Children with genetic disorders
,might benefit from universal school-based or community-based programs, but also selective
interventions targeting social stress and emotional problems, promoting resilience and facilitating
early detection.
Psychosocial selective interventions show to be effective to prevent externalizing disorders in
children, PTSD, eating disorders, post-partum depression and depression or anxiety disorders.
Additionally, some pharmacotherapy strategies might be effective to prevent PTSD.
Indicated preventive interventions are aimed at individuals showing subthreshold manifestations of
mental health disorders. These interventions might be more cost-effective.
Worth it to invest in mental health prevention?
There is still a gap between research evidence and clinical and public health practices. Improving
long-term outcomes and reducing long-term adverse consequences of poor mental health make
early interventions cost-effective for society. Savings might be higher than for other medical
conditions due to the earlier onset, which increases the number of years that services are needed.
Additionally, there is a bidirectional association between mental and physical health, thus, altering
risk factors for psychiatric disorders could help preventing other medical conditions.
Role of mental health professionals
Universal interventions require a public mental health approach, and probably needs to be delivered
by professionals from other medical specialties or other sectors. Mental health professionals should
increase awareness about the importance of preventions and mental health promotion, and the
evidence of cost-effective interventions. Also, professionals could adopt an at-risk oriented focus into
clinical practice by enhancing screening and promoting training among professionals. Furthermore,
strengthening coordination between child and adolescent and adult services is valuable, as well as
transition between services.
Key areas of mental health prevention that should be prioritized
- Translating scientific evidence for cost-effective preventive interventions into public health
initiatives, clinical practice, and service delivery systems.
- Increasing social, professional and political awareness of importance of mental health
prevention and promotion.
- Moving towards at-risk-oriented detection and intervention in clinical practice.
- Providing interventions designed for each developmental stage aimed at minimizing the impact
of risk factors.
- Promoting interventions with a multidisciplinary and multilevel approach.
- Promoting healthy lifestyles.
- Encouraging school-based interventions for early detection of developmental deviation,
reduction of bullying, protection and promotion of resilience, prevention of health risk
behaviors, and promotion of mental and physical health.
Conclusion
Universal, indication and selective prevention strategies might be effective. Needed is investigation
of early stages of mental disorders integrating different dimensions and including complex
interactions throughout developmental periods.
, The Economic Case for the Prevention of Mental Illness
McDaid D, & Wahlbeck K. (2019). The economic case for the prevention of mental illness. Annual Review of Public Health; 40: 373-389.
Introduction
Mental health problems have negative consequences for the individual, but also for families, peers,
employers and overall society. It also has profound economic consequences, with major health
system costs. Poor mental health also increases the risks of physical morbidities, increasing
healthcare costs. Other costs include the reduction of contribution to national economic output,
mainly due to less participation in employment as well as lower levels of volunteering and informal
caring. Therefore, emphasis on prevention in policy, practice and research is needed. Susceptibility is
higher when exposed to multiple risk factors, and prevention could focus on reducing the chances of
exposure to this risk factors, not only during child hood, but also across the life course.
Economic arguments to support the focus on prevention
Economic evaluation involves analysis of costs derived and outcomes achieved from delivering one or
more interventions either against no action or against potential uses of those resources. This analysis
can be conducted in multiple ways:
- Cost utility analysis measures changes in quality of life.
- Cost benefit analysis places a monetary value on benefits of improved outcomes; intervention
is considered effective if benefits outweigh the costs.
Economic evaluation can be linked to a trial, or alternatively data on costs and effects from multiple
sources can be synthesized to model economic impacts.
Areas with a strong economic evidence base for action
- Maternal and infant mental health.
o Better management of mental health during pregnancy (also for men). Poor perinatal
mental health can have long-lasting adverse impacts on the child’s health.
o Lifetime costs of perinatal depression and anxiety to mother and child, which suggest
investing in measures to identify risk of depression in new and expectant mothers.
o Several economic evaluations show the cost-effectiveness of measures to prevent and/or
intervene early on perinatal depression.
- Children and adolescents.
o Strong economic evidence on protection of mental health of children and adolescents,
including parenting programs.
o Both universal and targeted programs are shown to be effective.
o Many school-based programs show to have a positive effect.
- Workplaces.
o Poor mental health contributes to lower productivity at work, greater likelihood of
absence due to sickness, and higher probability of unemployment.
o If improved mental well-being, or prevention of mental illness, increases productivity and
reduces sick leave, it has potential great economic and societal benefits.
o Both organizational level measures, as well as actions targeted at individuals, could be
effective.
- Suicide and self-harm.
o Evidence base on cost-effective actions to prevent suicide and self-harm is limited.
- Older age.
o Not as much attention for protection of mental health in older ages (other than
dementia).
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