Primary prevention of psychiatric illness in special populations
Case Western Reserve University, School of Medicine, Departments of Psychiatry and Neurology, Neurological Outcomes Center, University Hospitals Case Medical Center, Cleveland, OH, USA
Department of Psychiatry, SUNY Downstate, Brooklyn, NY, USA
Department of Psychiatry, St. John’s Episcopal Hospital, Far Rockaway, NY, USA
Department of Psychiatry, SUNY Downstate, Brooklyn, NY, USASubramoniam Madhusoodanan, MD
Department of Psychiatry, St. John’s Episcopal Hospital, Far Rockaway, NY, USA
Department of Psychiatry, St. John’s Episcopal Hospital, Far Rockaway, NY, USA
BACKGROUND: Some populations appear to be particularly vulnerable to the development of psychiatric symptomatology related to life events and biologic or social/cultural factors. Such groups include individuals who have experienced traumatic events, military personnel, individuals with serious medical conditions, postpartum women, and immigrants. This study reviews the literature regarding primary prevention of psychiatric disorders in special populations and identifies a variety of universal, selective, and indicated prevention measures aimed at minimizing the psychiatric sequelae in these groups.
METHODS: The authors reviewed the literature regarding the prevention of psychiatric symptoms in trauma/abuse victims, individuals in the military, oncology patients, patients with diabetes, pregnant/postpartum women, and immigrants.
RESULTS: The literature on primary prevention of psychiatric illness in the special populations identified is rather limited. Universal prevention may be beneficial in some instances through public awareness campaigns and disaster planning. In other instances, more specific and intensive interventions for individuals at high risk of psychiatric illness may improve outcomes, for example, crisis counseling for those who have experienced severe trauma.
CONCLUSIONS: Primary prevention of psychiatric illness may be an attainable goal via implementation of specific universal, selected, and indicated primary prevention measures in special populations.
KEYWORDS: primary prevention, special populations, psychiatric illness
ANNALS OF CLINICAL PSYCHIATRY 2010;22(4):262–273
Individuals in some populations are particularly vulnerable to developing mental disorders based on personal characteristics, life stage (genetics/biology, temperament, sociocultural context), and life experience. As noted in the Editorial of this issue, the Institute of Medicine has recommended a model of primary prevention in order to reduce the incidence of illness in a community, with efforts directed at groups who are at particular risk of developing a disorder. Primary prevention is comprised of universal interventions (directed toward the entire population), selective interventions (directed toward individuals who are at the greatest risk of developing the disorder), and indicated preventions (directed toward those who have subsyndromal symptoms of the disorder).1 This paper will review primary prevention in several representative special populations in psychiatry, specifically, populations who have experienced a natural or man-made disaster, victims of trauma/abuse, individuals in the military/armed forces, selected medically ill populations, pregnant/postpartum women, and immigrants. Although this is by no means an all-inclusive list of special populations who may experience psychiatric illness, these groups illustrate the issue of primary prevention in psychiatry and point to both a growing literature and a need for future research in this area.
Victims of trauma
Natural and man-made disasters. A vast array of traumatic events, including natural and man-made disasters, can affect communities and individuals. Some individuals who experience trauma will go on to experience mental disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety. The Epidemiologic Catchment Area (ECA) survey found lifetime PTSD rates of 0.5% among men and 1.3% among women in the general population, however substantially more people (15% of men and 16% of women) experience some PTSD symptoms after trauma.2
Research on prevalence of PTSD after the September 11, 2001 World Trade Center (WTC) attacks showed geographic and temporal patterns. Rates of PTSD spiked nationally and regionally during the first few months following the attacks. One study found that 11.2% of residents in the New York City metropolitan area had probable PTSD during the month following September 11, 2001. Six months later only 0.6% reported having PTSD.3 Proximity to the attacks appeared to be an important risk factor.4 A high prevalence of PTSD was seen among individuals in the WTC towers on the day of the attacks (16.4%), residents caught in the dust cloud (17.2%), people injured on the day (38%), and individuals who witnessed the event (16.7%).5 Prevalence of PTSD fell rapidly as geographic distance from the disaster increased. Ten studies of Hurricane Katrina (August 2005) survivors published to date show that the prevalence of PTSD is as high as 62.5% in preschool children directly affected by the storm, and >50% in some groups of adults, including female caregivers and parents of children with new mental health problems.6
The identification of “at risk” individuals is an essential element of any successful intervention. Identified risk factors associated with elevated risk for PTSD after major disasters include severity of exposure to trauma, secondary stressors such as financial difficulties, female sex, minority ethnicity, and limited psychosocial resources to cope with stress.7,8
Universal prevention for trauma exposure. Primary prevention of psychiatric sequelae following natural or man-made disasters must begin with a realistic recognition of potential threats, followed by developing a planned response, practicing that response, and the provision of appropriate funding and logistic facilities in support of the plan.9,10 The psychiatrist or mental health provider may consult with medical providers and disaster agencies, assisting in primary prevention of potential psychiatric sequelae by ensuring that available resources match the anticipated needs for services.7
A major component of community predisaster planning is to develop a comprehensive disaster preparedness plan that addresses all “most likely” scenarios. Such plans should include ways that individuals can protect themselves, evacuation protocols, a system for tracking people, a plan for notifying and educating affected families, a plan for reducing traumatic reminders, and plan for handling the media. Inclusion of psychiatrists or other mental health professionals as part of disaster planning efforts may assist in preventing or mitigating psychiatric sequelae following a disaster.11 Psychiatrists and other mental health professionals can also play a role in psychoeducation—teaching people what to expect after traumatic events, which also may minimize psychiatric sequelae after disasters.12
Selective prevention for individuals who have experienced trauma. Crisis counseling and appropriate support immediately after traumatic events may avoid or reduce psychiatric sequelae. Such interventions may be implemented in all trauma victims and in other high-risk groups, including victims’ families, displaced individuals, emergency and recovery workers, the elderly, children, members of certain cultural and ethnic groups, people with limited financial and social support resources, or individuals with pre-existing mental illness.13-15 This approach is demonstrated by Project Liberty, a Federal Emergency Management Agency (FEMA)-funded crisis counseling program, which was developed and implemented to alleviate the psychological distress that large numbers of New Yorkers experienced after the WTC attacks.15 The program provided free and anonymous community-based disaster mental health services to help individuals recover from their psychological distress and regain their predisaster level of functioning. The assumptions underlying this broad-based response strategy were that most persons’ stress reactions, although personally disturbing, constitute normal responses to a traumatic event and will be short term in duration.15 Corresponding interventions emphasized helping people identify their trauma responses, understand them as normal reactions, and reconnect with preexisting social supports.
A study of canine search and rescue handlers involved in the WTC attacks compared 82 deployed handlers with 32 non-deployed handlers on measures of PTSD, depression, anxiety, stress, and clinical diagnoses.16 Not surprisingly, deployed handlers reported more PTSD and general psychological distress 6 months after the attacks. Prior mental health diagnoses and peri-traumatic reactions were associated with psychological distress, whereas receipt of social support and greater job training was protective.16
Another report noted the helpful role of a mental health professional in the care of vulnerable populations in a Red Cross shelter in Jackson, MS, after Hurricane Katrina.14 In this case, a mental health nurse volunteer assessed individuals, intervened through advocacy, referral, and crisis intervention, and provided general support and education. A recent study of psychiatric consultation with medical evacuees of Hurricane Katrina found that psychiatrists are likely to play a critical role in providing emergency mental health services for both medical evacuees and evacuated medical professionals.17 Available evidence, while rather limited by a lack of rigorous or controlled outcomes assessment, supports the key role of psychiatrists, mental health nurses, or other mental health specialists in immediate disaster response teams. Preliminary data suggest that early and appropriate assistance from mental health specialists may improve the care of disaster victims.14,17 Appropriate assistance may be general or focused on mental health.
Finally, there is a role for the consultation-liaison psychiatrist in treating individuals who have sustained physical injury and are at risk for subsequent PTSD, particularly in the area of coordinated medical and psychological care. For example, a recent report suggests that early and appropriate use of morphine to manage pain in cases of acute traumatic injury-related pain may limit fear conditioning in the aftermath of injury and is associated with reduced rates of PTSD.18
Indicated prevention for trauma victims. Individuals with early or subsyndromal psychiatric symptoms related to disasters may need intensive intervention in order to reduce psychiatric risk. Literature suggests that prophylactic or early pharmacologic treatment such as the beta-blocker propranolol or selective serotonin reuptake inhibitor antidepressants may prevent or minimize more PTSD severe cases.19
Domestic violence/abuse against women. Despite the common cultural conception of home as a safe haven, it can be a dangerous place for many individuals, especially women who are experiencing domestic trauma/ abuse. Violence against women and girls is most likely to occur at home.20 The United Nations’ Declaration on the Elimination of Violence against Women defines violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts as coercion or arbitrary deprivation of liberty, whether occurring in public or private life.21 Physical violence is estimated to occur in 4 to 6 million intimate relationships each year in the United States.22 In addition to physical injuries, abused women often experience somatic and stress-related illnesses, chronic pain syndromes, depression, PTSD, and substance abuse disorders.23 Compared with women with no history of abuse, abused women have higher levels of health care use,24 comprising 31% to 54% of female patients seeking emergency services25 and 21% to 66% of those seeking general medical care.26 Up to 20% of women seeking prenatal care report experiencing intimate partner abuse.27 Despite the high prevalence of intimate partner abuse, <15% of women report being asked about abuse by health care professionals or disclosing abuse to them.28
Primary prevention of victimization of women includes: 1) raising public awareness 2) promoting early recognition of individuals/groups at risk, 3) providing safety and support programs, and 4) implementing legal policy that protects the rights of women and minimizes potential for violence and abuse.
Universal prevention of violence/abuse against women. Raising public awareness of violence against women may reduce the stigma associated with reporting abuse and may increase detection and appropriate intervention in families and the community. Public awareness campaigns can be conducted through mass media formats, such as radio or TV advertising, and recorded or written information distributed in libraries, physicians’ offices, community centers, housing projects, churches, and woman’s clubs. Public campaigns, community advocacy, and legislation such as the Brady Bill to promote gun control are examples of universal preventive interventions that may reduce risk of violence towards women in homes and communities.29
Selective prevention in victimized women. In many cases, health care professionals come into early and frequent contact with women who are at high risk for abuse.30 Yet studies show that health care professionals fail to recognize and intervene because of lack of training, societal misconceptions about abuse, and lack of awareness of community resources. Educational initiatives for health care providers, screening tools, and policy initiatives are all necessary to improve the ability of health professionals to identify, assess, and intervene in cases of family violence. It has been advocated that mandatory courses on violence toward women be included in the curricula of health professional training programs.31
Indicated prevention for abuse victims. Women who have previously experienced domestic violence may have difficulty escaping their abusive situations, thus exacerbating on-going stressors and putting them at further risk for depression, anxiety, and PTSD. Safety and support systems such as shelter services, house surveillance, monitoring devices, rape crisis centers, and low-income housing certificates should be available immediately after the occurrence of trauma to diminish acute effects and to prevent re-victimization. Critical elements of safety are peer support, from other women who have successfully removed themselves from past violent situations, and professional support, from therapists and counselors who can help victims process conflicting emotions and feelings of guilt or isolation. Psychiatrists and other mental health providers who can identify abused women with subsyndromal symptoms of psychiatric disorders are ideally positioned to facilitate appropriate referrals for psychiatric treatment, support groups, and social services.
Legal policies that minimize barriers to filing legal complaints in formal but confidential and private settings are critical in empowering women to reduce future violence and minimize the potential for resultant PTSD and depression. Restraining orders and appropriate support should be readily available. Abused women should receive financial assistance for costs such as housing and childcare in order to avoid being trapped in abusive home settings because of lack of financial resources. Finally, communication channels between health professionals, social workers, and the law enforcement system need to be strengthened.31
In summary, individuals may experience trauma in relation to natural or man-made disasters as well as domestic violence that lead to psychiatric illness. Primary preventative measures can be implemented at many levels to avoid or minimize mental health sequelae such PTSD or depression. Measures targeted towards the general population include involving mental health professionals in disaster preparedness planning, public awareness campaigns, and comprehensive training of health professionals who are part of disaster teams. Training programs for primary care providers focused on evaluating mental health status and minimizing the most severe physical effects of trauma such as physical pain and use of psychiatric consultants immediately posttrauma may better serve individuals at risk for psychiatric disorders. Finally, timely psychiatric referral for appropriate management can benefit victims of disaster or domestic abuse who show early or subsyndromal psychiatric symptoms. Psychiatrists clearly have a role in educating, advocating, and assisting in primary prevention of psychiatric illness in victims of trauma.
A RAND corporation report released in 2008 noted that 300,000 individuals or 18.5% of US service staff who returned from Afghanistan and Iraq report current symptoms of PTSD or depression.32 Since 2001, approximately 1.6 million US troops have been deployed to Iraq or Afghanistan. If nearly 1 in 5 returning troops continues to experience PTSD or depression, this mental health burden is likely to severely stress the military, the Department of Veterans Affairs, and the civilian health care system. Suicide rates are particularly high in individuals with PTSD/depression or traumatic brain injury commonly seen in combat-exposed military personnel.32
Universal prevention in the military. Perhaps the most appealing prevention strategy involves identifying those at risk, which can be done in pre-deployment screening. Unfortunately, risk factors that are statistically significant for at-risk populations are all relatively weak individual predictors of future problems.33 Furthermore, excluding people who have these risk factors would have many untoward consequences, such as stigmatizing excluded individuals and perhaps unnecessarily reducing recruitment.34
There has been a move in the general population to raise awareness of depression and anxiety as “no fault” medical conditions that are amenable to prevention, early recognition, and treatment. Public awareness campaigns in the community and targeted education of primary care providers can focus on lifestyle choices that promote mental health, such as substance avoidance and appropriate stress reduction behaviors. Prevention strategies known to help reduce mental disorders in general may be similarly helpful for active military personnel, particularly when implemented in military primary care clinics.35
Selective prevention in the military. Important issues in preventing mental disorders in military personnel are reducing the barriers to and stigma of seeking mental health services, as well as monitoring and assessing at-risk individuals. The relationship between combat and psychiatric symptoms has been recognized for decades. Psychological debriefing is an approach that may prevent development of permanent emotional injury by enabling cognitive appraisal and emotional processing of the traumatic experience; however, evidence regarding the effectiveness of this approach is mixed.32,36
Some work also has shown that cognitive-behavioral therapy (CBT) can be used early to prevent or target PTSD for people who may have experienced discrete events, such as an accident. Finally, the beta-blocker propranolol can decrease the likelihood of a physiological response when a patient thinks about trauma if it is administered shortly after the trauma occurs.32
Indicated prevention in the military. Suicide is a tragic outcome of complex etiology, a leading cause of death worldwide, and a tremendous problem in the military environment. One successful approach to avoid or minimize suicide in the military is the Suicide Prevention Program,37 which resulted in a 4-fold reduction in the suicide rate for soldiers compared with the male civilian population. The ability of military staff and health professionals to recognize pre-suicidal mental states is a key component of a broad initiative to reduce military suicides.37 A comprehensive model of suicide prevention includes multiple levels of integrated mental illness monitoring and intervention as appropriate. The first level is associated with a target soldier/professional staff friend who has been trained to recognize the symptoms of pre-suicidal syndrome. Soldiers receive education on adaptation and maladjustment problems including suicide and psychoactive substance abuse. The second level consists of the primary mental health team in a military unit: the physician, psychologist, and officer monitor soldiers/professional staff from the first day of joining a military unit. The third level consists of the secondary mental health team situated in the Military Medical Center. It includes the psychiatrist and psychologist who further assess the suitability of soldiers/professional staff for military service. The fourth level consists of the tertiary mental health team situated in the Military Medical Academy, including the psychiatrist and clinical psychologist who direct soldiers/professional staff to treatment or rehabilitation and supervise readiness or capacity to participate in military duty.37
Among US Army soldiers attempting or completing suicide in 2005, the use of alcohol and drugs was present during 57% of suicide attempts and 17% of completed suicides.38 Acute alcohol intoxication is a risk factor for suicide and seems to be associated with impulsive, rather than planned, suicides.39 Because the use of alcohol and drugs in an individual with subsyndromal depression may impair judgment and lower inhibitions against impulsive self-harm, limiting access to substances and treating individuals with substance use problems may reduce suicide risk.40
In summary, psychiatrists, psychologists, and other mental health professionals, as well as military leadership and enlisted staff, are all important in preventing psychiatric disorders and suicide among military personnel. Promoting appropriate stress management in primary and specialty health care settings is a universal measures for all military staff. Selective measures include identification and mental health monitoring of individuals at risk (particularly staff with combat exposure or those who have experienced accidents), psychological debriefing, psychotherapies such as CBT, and possible use of pharmacotherapies such as beta-blockers to minimize behavioral effects of an acute stress response. Finally novel and integrated monitoring approaches may identify and appropriately triage soldiers who have subsyndromal psychiatric illness and may be at risk for suicide.
Populations with medical conditions
Individuals with cancer. Cancer is responsible for 1 in 4 deaths in the United States.41 The most common fatal cancers are those of the lung and bronchus, prostate, and colon and rectum in men, and cancers of the lung and bronchus, breast, and colon and rectum in women.42 Psychiatric disorders, including depression, anxiety, and PTSD, are highly prevalent among cancer patients.43 If left untreated, psychiatric disorder in cancer patients may result in poor treatment outcomes, including elevated suicide risk, reduced treatment adherence, increased hospital stays, and reduced quality of life.44
Among psychiatric disorders, depression has received the most attention in individuals with cancer. Cancer, regardless of site, is associated with rates of depression that exceed rates in the general population.45 The risk of depression appears particularly high in oropharyngeal (22% to 57%), pancreatic (33% to 50%), breast (1.5% to 46%), and lung (11% to 44%) cancers.46 In oncology patients, depressive symptoms result from many factors, including the stress related to the cancer diagnosis and treatment, the treatment itself, and medical complications such as nutritional deficiencies, endocrine disturbances, and brain metastasis. Advanced stages of illness, inadequately controlled pain, and other significant life stresses also are associated with a higher risk of depression in cancer patients.45 Glover and colleagues have found that depression may directly affect the course of illness in cancer patients because it results in poorer pain control.47 In addition, depression has been linked to cancer treatment adherence48 and reduced desire for life-sustaining treatment.49
Anxiety is another common psychiatric symptom seen in oncology patients. A recent study of cancer patients noted that 48% of subjects reported significant anxiety symptoms50; women and individuals with poor social support are particularly likely to experience anxiety symptoms. Although studies of PTSD in cancer patients find that the diagnostic rates are low, ranging from 3% to 14%, subsyndromal PTSD occurs in approximately 50% of patients.51
There is a relatively limited literature about the specific efficacy of universal, selective, or indicated primary prevention of psychiatric disorders in cancer patients. However, the extant literature suggests several preventative measures that might prove useful in preventing psychiatric sequelae in this population, especially from a public health perspective.
Universal prevention in cancer patients. As with the general populations, stigma and lack of awareness may make individuals reluctant to discuss their emotional stress with their health care providers, so efforts to educate patients about expected emotional reactions to a cancer diagnosis and treatment may reduce possible psychiatric sequelae. Specific measures to increase knowledge (such as seminars, presentations, brochures, and other publications) and provide psychosocial support (through in-person or online support groups) may be extremely helpful for the general public, families, and individuals with cancer. The American Cancer Society’s comprehensive Web site52 provides useful information about cancer, coping with diagnosis and treatment, and resources for local/community support.
Selective prevention in cancer patients. Keller and colleagues recommend that screening for anxiety and depression should be included in the preliminary clinical interview prior to treatment.53 Cancer patients with pain may be at increased risk for psychiatric sequelae. Some authors have found that increased pain, specifically with metastasis, is associated with depression.54 Other studies have shown that appropriate analgesic control in populations with cancer and an oncologist’s awareness of early depressive or anxiety symptoms may lead to less frequent psychiatric sequelae.45 In addition to contributing to depression, pain also is a significant predictive variable for anxiety, according to reports from Keller and colleagues.53 Uncontrolled pain is associated with acute and chronic anxiety, including PTSD.45 Therefore, adequate pain control might be a protective factor in the development of psychiatric symptoms.
Lydiatt and colleagues55 recently conducted a small (N = 36) randomized, controlled trial of the antidepressant citalopram vs placebo for the prevention of major depressive disorder in patients undergoing therapy for head and neck cancer. Patients received citalopram, 40 mg/d, or matching placebo for 12 weeks with a final visit at 16 weeks. The numbers of subjects who met predefined cutoff criteria for depression during the 12 weeks of active study were 5 of 10 (50%) taking placebo and 2 of 12 (17%) taking citalopram (Fisher exact test, P = .17). The citalopram group also had better quality of life and global psychiatric and physical well-being compared with placebo-treated patients. Although the small sample size, relatively high drop-out rate (36%), and study design limitations warrant cautious interpretation, the report suggests the potential utility of pharmacotherapies for primary prevention in some subpopulations of cancer patients.
Indicated prevention in cancer patients. Psychiatric symptoms in cancer patients often are underdiagnosed and undertreated.56 Passick and colleagues56 reported on a large depression screening project in cancer patients that evaluated physicians’ ability to recognize various levels of depressive symptoms and described the patient characteristics that influence accuracy of physicians’ perceptions of their depressive symptoms. The authors concluded that standardized depression assessments, such as the Zung Self-Rated Depression Scale (ZSDS), and use of brief follow-up interviews would help to identify patients who with subsyndromal depression and in whom appropriate and early treatment might prevent full-blown or more severe depression.56
Delgado-Guay and colleagues57 found that patients with either mood or anxiety symptoms expressed higher frequency of drowsiness, nausea, pain, dyspnea, worse appetite, and reduced well-being. Similarly, Lloyd-Williams and colleagues58 found a close association between physical symptoms and the presence of depression in palliative care patients. Patients expressing high frequency and intensity of physical symptoms should be screened for mood disorders in order to provide the earliest treatment for these conditions.57
Although relatively few cancer patients commit suicide, they may be at greater risk than the general population.58 Increased risk of suicide in oncology populations is thought to be associated with advanced stage of cancer, poor prognosis, inadequately controlled pain, and male sex.45 Among the most common methods of suicide, overdosing with analgesics and sedatives was highly prevalent.41 It has been suggested that the severity of the cancer increases the suicide risk.59 Undiagnosed/ untreated depression is a known risk factor for suicide. For the patients who are most at risk (for example, patients with pain due to metastatic cancer that cannot be adequately controlled, past depression, or other significant life stresses and losses), early and appropriate use of psychotropics and psychotherapeutic interventions may prevent full-blown depressive episodes and possibly reduce suicide risk. However, additional research in this area is needed.
Individuals with diabetes. According to the American Diabetes Association, 23.6 million people in the United States, or 8% of the population, have some type of diabetes.60 The total prevalence of diabetes increased by 13.5% from 2005 to 2007.60 Type 1 diabetes is a chronic autoimmune disease that affects an estimated 500,000 to 1 million people in the United States.45 Type 2 diabetes is the most common form of diabetes.60 It encompasses a variety of abnormalities involving blood glucose metabolism and affects approximately 20 million people in the United States.45
There are several studies examining the relationship of type 1 and type 2 diabetes and psychiatric disorders.61,62 Among the most common psychiatric comorbidities in diabetic populations are depression, anxiety, eating disorders, schizophrenia, and bipolar disorder.45 Among psychiatric comorbidities, depression in diabetes has been most comprehensively studied. The American Diabetes Association60 notes that the prevalence of depression in diabetic populations is 2 to 3 times higher than that found in the general population.
Universal prevention in populations with diabetes. As with oncology patients, programs aimed at achieving increased awareness of mental health for the general population as well as individuals with pre-diabetes and diabetes may help to minimize the stress of coping with diabetes and its attendant problems. The American Diabetes Association’s60 Web site provides useful tips on maintaining health and wellness, community programs and local events, and information on specialized programs for parents and children.
Selective prevention in patients with diabetes. For individuals with diabetes and family/personal histories of mood or anxiety disorders, screening and on-going assessments may avoid or minimize psychiatric sequelae. However depression screening may be under-utilized. Jones and Doebbeling63 found that screening for depression among veterans with diabetes was considerably lower than the proportion of general population veterans screened nationally.
Indicated prevention in patients with diabetes. Several studies suggest that patients with depressive symptoms have worse glycemic control and heightened risk of diabetes complications.64,65 Based on findings by Lustman and colleagues,64 the relationship between hyperglycemia and depression might be a reciprocal one, in which hyperglycemia is provoked by depression, and also contributes independently to exacerbation of depression. A recent study by Richardson and colleagues65 examined the longitudinal effects of depression on glycemic control in veterans with type 2 diabetes. This group found that there is a significant longitudinal relationship between depression and glycemic control as measured by HbA1c and that depression is associated with persistently higher HbA1c levels over time. Similarly, de Groot and colleagues66 demonstrated a significant and consistent association of diabetes complications and depressive symptoms. Therefore, tightening glucose control may prevent the onset or worsening of depression in patients with diabetes. Additionally, individuals with early or subsyndromal depressive symptoms may benefit from treatment with appropriate psychotropic agents and/or psychotherapeutic interventions potentially to improve both diabetic and mood outcomes.
In summary, there is evidence to support the use of universal, selective, and indicated prevention for psychiatric disorders in patients with medical disorders such as cancer or diabetes. Universal prevention, which targets the general population and individuals with cancer and diabetes, is represented by the educational efforts of the American Cancer Society and the American Diabetes Association. Psychiatrists and other practitioners may find referral to these entities useful for patients and families, particularly with respect to print and electronic media that educate, inform, and provide links to potential supports in the community. Depression screening should occur with the initial clinical evaluation/diagnosis of cancer or pre-diabetes/diabetes. Interventions to minimize physical and psychological stress that attend disease complications (for example, aggressive management of cancer-related pain) can potentially avoid or reduce subsequent psychiatric sequelae. Healthy lifestyle promotion such as appropriate diet, exercise, and sleep may minimize poor mental health outcomes. Finally, preliminary evidence shows the possible utility of pharmacotherapy in preventing depression with prophylactic use of antidepressant agents in some medical subgroups.
There has been considerable attention given to the study of depression after childbirth, which may range from mild dysphoria/emotional lability to a severe depressive syndrome, referred to as postpartum depression. Approximately 13% of women across diverse cultures experience postpartum depression within the first 12 weeks after childbirth.67
Postpartum depression affects the mother’s capacity to care for her child and is associated with delayed or impaired attachment to the infant, rejection of the infant, obsessional thoughts of harming the infant, and even infanticide. Children of mothers with postpartum depression have been found to have significant impairments including sleep and eating disorders, temper tantrums, delayed language development, intellectual deficits, impaired social functioning, poor attention skills, and vulnerability to depression.68
Universal prevention of postpartum depression. Universal preventive interventions may be implemented via the mass media to change societal views of the mother’s role, responsibilities, and expected behaviors.69 While constant representations of “super moms” in the media have raised the standards of motherhood to near-impossible ideals, other public awareness campaigns that raise awareness of depression related to childbirth have increased the opportunities to identify women at risk for postpartum disorders. Recent high-profile cases of mothers with postpartum depression and the resultant media attention offer an opportunity to reduce stigma and facilitate help-seeking among the general population and among women planning pregnancies or already pregnant.70
Selective prevention of postpartum depression. The literature demonstrates the effectiveness of programs directed at pregnant woman in reducing risk for postpartum depression. Risk factors known with moderate to strong association with postpartum depression include experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, infant temperament, self-esteem, marital status, socioeconomic status, poor marital adjustment, unplanned/unwanted pregnancy, and abuse of the mother.71 A study by Shields and Reid72 involving 1,299 pregnant women in the United Kingdom found that a midwife program focused on continuity of care, individualization, and emotional support was beneficial. The UK program provided personalized care to women in the hospital or at home after childbirth and ensured that visits were attended by the same midwife.72 Positive results of the study72 provide a good example of prevention in psychiatry that could be implemented in health care settings where there is a single payer for both inpatient and outpatient care (for example, large HMOs or group health plans).
In a South African study involving 189 women without supportive companions, Wolman and colleagues73 found that an intervention involving a community volunteer providing support during labor and delivery successfully reduced postnatal depression. A study by Armstrong and colleagues involving 181 postpartum women at risk for depression reported that extended home nursing visits significantly decreased the proportion of depressed cases at 6 weeks.74 The visits focused on facilitating trust within the family, enhancing a sense of efficacy regarding parenting skills, providing guidance, and improving use of community services.
A US study by Gordon and Gordon found that adding two 40 minute-long antenatal classes focusing on social and psychological adjustment to standard prenatal classes was effective for prevention of postpartum emotional problems.75 Chabrol and colleagues76 established that a single brief intervention that focuses on education, support, and modification of maladaptive thoughts reduced the incidence of postnatal depression in 241 high-risk women.76
An important consideration is screening for depression in all pregnant women, including those who may be at higher risk due to social, personal, or genetic circumstances. In addition to a comprehensive clinical interview, standardized screening tools for depression such as the Edinburgh Postnatal Depression Scale (EPDS) may be useful in obstetric and primary care settings.77
Indicated prevention of postpartum depression. As noted above, underrecognized and undertreated postpartum depression may have disastrous consequences. Screening and close monitoring of women with antenatal depression is essential, and women who are experiencing subsyndromal depressive symptoms should be closely evaluated by psychiatrists or other mental health practitioners. Breastfeeding women may elect to avoid selected pharmacotherapies, but may benefit from psychological and psychosocial therapies that have been demonstrated to reduce depressive symptoms postpartum.78 The evidence base is not clear on best psychotherapies or pharmacotherapies for women with either antenatal depression or subsyndromal symptoms postdelivery. While postpartum depression is believed to have hormonal etiology, a recent Cochrane review79 suggests that synthetic progestogens should be used with significant caution in the postpartum period. Norethisterone enanthate, a synthetic progestogen, administered within 48 hours of delivery was associated with a significantly higher risk of developing postpartum depression.
In summary, the popular press and extant scientific literature supports the utility of universal prevention in raising general public awareness regarding the seriousness of postpartum depression and possible approaches to identifying and minimizing postpartum psychiatric risk. Approaches that appear promising include enhanced support of mothers with fragile or incomplete social networks and use of midwives, other support staff, peers, or even volunteers during pregnancy and after childbirth. Given the potentially tragic consequences of unrecognized (and untreated) postpartum depression, close clinical monitoring is key for all pregnant women, but particularly those at risk for postpartum mood disorders. Screening tools such as the EPDS may be particularly useful in primary care settings. Studies involving antenatal and postnatal interventions require rigorous scientific evaluation, including confirmation that the intervention is delivered as planned and an appropriate measure of mental health outcome. Future studies should define a realistic and clinically important reduction effect from the intervention, define the sample size on that basis, and build in the necessary adjustments for attrition and loss to follow-up. Finally, multicenter collaboration is necessary to answer generalizability questions about the effectiveness of perinatal interventions.
Migration or change in the location of residence is a universal phenomenon and has occurred in all nations at all times. The process of immigration may involve 1 individual who moves to study, seek better employment, improve his or her future, avoid political and religious persecution, or join family members or other individuals who have already immigrated. Migration also may involve a group of refugees moving together to avoid religious or political persecution or to seek religious or political freedom. Thus the process of migration is extremely heterogeneous, and not all immigrants are likely to face similar experiences before or after migration.80
The foreign-born population of the United States is approximately 9.5% of the total population.81 Although the volume of illegal immigrants is difficult to precisely determine, the rate of illegal immigration is estimated to be 250,000 to 300,000 per year. More than half of illegal immigrants enter the United States legally and over-stay their visas. There is also geographic concentration of minority groups in certain regions and metropolitan areas. This holds true especially for Hispanics and Asians, who enter and often remain in US “gateway cities” such as Los Angeles and New York.82
Psychiatric studies of immigrants have found inconsistent results concerning rates of mental illness. There is evidence suggesting that rates of schizophrenia among immigrant groups are low compared with native-born populations when the native and receiving countries are socially and culturally similar. The rates for psychiatric disorders among immigrants may be higher when native and receiving countries are different.83 European studies have found that schizophrenia is 3 times more frequent in some immigrant groups than in native-born individuals.84 Immigrant status may be an important environmental risk factor not only for schizophrenia but also for other psychoses.85,86
Universal prevention with immigrants. To reduce migration-related stress and emotional trauma, a number of universal prevention interventions have been suggested, including language training, adequate safe housing, promotion of general health, education, and job seeking in accordance with level of qualification and education.80,82
Some evidence suggests that acculturation may be associated with increased likelihood of psychiatric disorder, and that immigrant status may be protective against psychiatric illness. Escobar, Nervi, and Gara,87 found significant evidence in support of a negative effect of “acculturation” or “Americanization” on the mental health of persons of Mexican descent in the United States. Additionally, Boydell and colleagues88 reported ethnic density to be a protective factor: in South London, the incidence of schizophrenia decreased significantly as the proportion of such minorities in the local population rose. It has been suggested that the optimal situation would not be full or even moderate acculturation but rather true “biculturalism,” with the individual being able to function well in both cultures.87
Selective prevention with immigrants. Social psychiatric research has greatly expanded our knowledge of the mental health of immigrants and refugees. Fenta and colleagues89 suggested that the risk of developing depression for immigrant population was associated with younger age, premigration trauma, no clear motive for migration, frequency of postmigration stressful events, lower level of education, and unemployment. Satisfaction with emotional support and higher native identity scores were significantly associated with lower rates of depression.89
Many studies have documented low rates of utilization of mental health services by immigrants and refugees. Outreach programs and culturally sensitive services may improve mental health outcomes.90 It is important for the clinician to ascertain the patient’s concepts of self, cultural identity, and the degree of comfort in the recipient culture. Religion or spiritual practices may play a role in the coping strategies the individual utilizes in the often stressful process of immigration and adjustment to the new life setting. To promote sensitive assessment for this population, psychiatrists should receive training in transcultural psychiatry. Unfortunately, limited financial resources restrict basic psychiatric service in many settings where immigrants may access care, and culturally sensitive care may be in even shorter supply.
Indicated prevention in immigrants. Refugees often have had extremely traumatic experiences before immigration, which may result in PTSD and sometimes chronic impairment. Asylum seekers who arrive illegally to seek refuge in a foreign country also experience further distress from their uncertain residency and risk of deportation.83 In the United States, asylum seekers are not eligible for services or a work permit until they receive a hearing, a process that can take many months. Steel and colleagues91 reported that asylum seekers did not differ from refugees in premigration trauma or symptoms but had higher postmigration stress related to insecurity about their residency status. Variance in trauma symptoms could be attributed to premigration exposure and to postemigration status.91 Unfortunately, the groups that are the most impaired may have the least access to services. Research on strategies for providing practical and cost-effective psychiatric services to this vulnerable population is urgently needed.83
In conclusion, there is an emerging literature on primary prevention in reducing mental disorders in immigrants, a substantial population in the United States. Factors that facilitate economic and occupational acculturation such as skills and language training and access to adequate housing may reduce psychiatric sequelae, while culturally sensitive health care services of all types can promote early and appropriate identification of mental disorders, particularly in high-risk groups of immigrants.
As noted in the preceding review, primary prevention efforts may prevent or minimize psychiatric disorders. Subpopulations at high risk for psychiatric disorders such as PTSD, depression, and anxiety include victims of trauma, individuals with medical illness, postpartum women, and immigrants. Universal prevention efforts such as inclusion of psychiatrists and other mental health professionals in disaster planning efforts and public awareness campaigns may facilitate raising awareness of psychiatric disorders and may encourage individuals to seek treatment. Selected prevention efforts involve a focus on individuals within the subpopulations at higher risk for psychiatric illness. An emerging literature suggests specific strategies to identify these individuals, provide appropriate support, and facilitate access to care. For example, brief screens for depression such as the ZSDS or EPDS may identify cancer patients with depression or women with postpartum depression, respectively. Specific psychosocial approaches—and in some cases pharmacotherapies—may reduce the risk of depression or anxiety. Examples include crisis counseling for those who have experienced severe trauma or the preventative use of antidepressants in those with selected medical illness such as cancer or stroke.56,92 In many of the selective prevention efforts, careful coordination between primary care and psychiatric or mental health practitioners is essential. Indicated prevention efforts involve populations exhibiting early/subsyndromal mental symptoms, and include such interventions as judicious use of psychotherapies or pharmacotherapies and engaging individuals, families, and social networks in on-going care. Integrated efforts such as suicide prevention plans in individuals with depressive symptoms and/or substance abuse such as the US Army’s Suicide Prevention Program, have demonstrated significant benefit.
In spite of the old adage, “An ounce of prevention is worth a pound of cure,” in most instances the amount of literature and research on treatment exceeds the literature on prevention. Although the literature base on primary prevention is growing on the representative populations discussed above and the larger population at risk for psychiatric disorder, there is a critical need for more evidence on effective primary prevention in psychiatry.
DISCLOSURES: Dr. Sajatovic receives grant/research support from GlaxoSmithKline and AstraZeneca and is a consultant for GlaxoSmithKline. Drs. Sanders, Alexeenko, and Madhusoodanan report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
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CORRESPONDENCE: Martha Sajatovic, MD, Case Western Reserve University, School of Medicine, W.O. Walker Center, 10524 Euclid Avenue, Cleveland, OH 44106 USA, E-MAIL: firstname.lastname@example.org
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