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 EDITORIAL

Preventive psychiatry: We are getting closer to fulfilling the promise of reducing mental illness

GUEST EDITOR — Subramoniam Madhusoodanan, MD

St. John’s Episcopal Hospital, Far Rockaway, NY, USA
SUNY Downstate Medical Center, Brooklyn, NY, USA

“An ounce of prevention is worth a pound of cure” goes the adage. The concept of primary prevention in psychiatry has been under-recognized until recently. In 1994, David F. Duncan, DrPH, described in an ironic manner the barriers that have kept primary prevention of mental illness from realizing its potential.1 Congress passed the Community Mental Health Centers Act in 1963 in response to an address by President John F. Kennedy calling for better mental health care and emphasizing the possibility of preventing psychiatric illness. However, community mental health centers (CMHCs) were mandated to provide only negligible preventive efforts such as consultation and education. More than a decade later, primary prevention occupied <5% of CMHC staff time nationally.2

In 2008 the National Institute of Mental Health (NIMH) laid out a 5-year plan to defeat mental illness,3 which includes prevention and early intervention strategies. We are seeing a paradigm shift from prevention to preemption of mental illness. According to Thomas R. Insel, MD, director of NIMH, preemptive interventions target those at greatest risk for mental illness and those with subdiagnostic signs or symptoms, and provide what previously had been labeled “selective” and “indicated” prevention.4 The progress in psychiatric research had advanced from the “Decade of Brain” in the 1990s to the present “Decade of Discovery.” The NIMH hopes to identify “malleable and robust” risk factors for different phases in the trajectory of mental illnesses, thereby facilitating discovery of preventive strategies.

Our submission follows a landmark report from the Institute of Medicine that paves the road to prevention. The report recommended that “the White House should create an ongoing mechanism involving federal agencies, stakeholders (including professional associations), and key researchers to develop and implement a strategic approach to the promotion of mental, emotional, and behavioral health and the prevention of mental, emotional, and behavior disorders and related problem behavior in young people.”5

Primary prevention aims to reduce the incidence of an illness in the community,6 and is directed at individuals who are at risk for developing a particular disorder. Evidence of cognitive deficits in adolescents years before the first psychotic episode helps clinicians develop cognitive interventions to prevent the later phases of schizophrenia.7,8 Prophylactic use of antipsychotics for subsyndromal schizophrenia is being explored as a primary prevention strategy. Another example is the use of cognitive-behavioral therapy (CBT) after a traumatic event to reduce the incidence of posttraumatic stress disorder (PTSD) in those who are at greatest risk.9

Primary prevention can be subdivided into universal, selective, and indicated prevention.10 Universal prevention measures are directed to the entire population, examples include healthy eating and exercise. Selective prevention measures are targeted to those with higher-than-average risk factors, such as providing support for socially isolated elderly persons. Indicated prevention measures are for individuals with subsyndromal symptoms of a disorder, such as low-dose atypical antipsychotics and CBT for patients with prodromal symptoms of schizophrenia to delay or prevent disease onset. All primary prevention measures do not fall exactly in this framework; there are overlaps, which will be evident as you read through the articles in this issue.

In this special section of Annals of Clinical Psychiatry we cover selected primary prevention strategies in psychiatry across the lifespan and in different disease spectrums—childhood and adolescence, adult and geriatric populations, and special populations including military personnel and developmentally disabled patients. Because secondary and tertiary prevention strategies have been emphasized in the last several decades, we decided to highlight the current status of primary prevention in psychiatry. Psychiatry residents in the United States receive very limited training in preventive strategies, therefore we have included resident authors for all articles in this section to improve awareness of this important topic among early-career physicians.

Mark Opler, PhD, and his group discuss the current status of the primary prevention strategies for children and adolescents. Addressing adults, Ronald Brenner, MD, and colleagues discuss current developments in subsyndromal schizophrenia, bipolar disorders, and other psychiatric disorders. Focusing on geriatric patients, my colleagues and I look at various strategies to prevent dementia, depression, and other late-life psychiatric disorders. Lastly Martha Sajatovic, MD, and coauthors discuss the preventive strategies for special populations including individuals who experienced trauma, military personnel, postpartum women, immigrants, and medically ill populations. Because psychiatric illnesses can occur in all age groups, some redundancies may be noted among these articles. The field of preventive psychiatry is evolving and the authors have attempted to collect data from many sources, categorize them into the respective divisions of primary prevention, and present them in a cohesive and concise manner.

Also in this issue, Alina Surís, PhD, ABPP, and colleagues report that glucocorticoid administration improved symptoms of PTSD in a sample of veterans with combat-related PTSD. In a small study of 21 patients, Heather M. Brandt, PharmD, and coauthors show that augmenting valproate with omega-3 fatty acids does not increase valproate plasma concentrations. Gerald A. Maguire, MD, and his group present a case of stuttering onset after streptococcal infection in a 6-year-old boy.

    REFERENCES

  1. Duncan DF. The prevention of primary prevention, 1960-1994: notes toward a case study. J Prim Prev. 1994;15:73–79.
  2. Klein DG, Goldston SE. eds. Primary prevention: an idea whose time has come. DHEW Publication No. [ADM] Washington, DC: U.S. Government Printing Office; 1977:77–447.
  3.  National Institute of Mental Health National Institute of Mental Health strategic plan. Bethesda, MD: National Institute of Mental Health; 2008.
  4. Insel TR. From prevention to preemption: a paradigm shift in psychiatry. Psychiatric Times. 2008;25:13–14.
  5.  Institute of Medicine Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Washington, DC: National Academies Press; 2009.
  6. Caplan GP. Principles of preventive psychiatry. New York, NY: Basic Books; 1964.
  7. Sorenson HJ, Mortensen EL, Parmas J, et al. Premorbid neurocognitive functioning in schizophrenia spectrum disorder. Schizophr Bull. 2006;32:578–583.
  8. Niendam TA, Bearden CE, Rosso IM, et al. A prospective study of childhood neurocognitive functioning in schizophrenic patients and their siblings. Am J Psychiatry. 2003;160:2060–2062.
  9. Bryant RA, Moulds M, Guthrie R, et al. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003;160:585–587.
  10. Gordon RS. An operational definition of disease prevention. Public Health Reports. 1983;98:107–109.

CORRESPONDENCE: Subramoniam Madhusoodanan, MD, Department of Psychiatry, St. John’s Episcopal Hospital, 327 Beach 19th Street, Far Rockaway, NY 11691 USA, E-MAIL sdanan@ehs.org