REVIEW URRENT C OPINION
Prevention of common mental disorders: conceptual framework and effective interventions Carl D’Arcy a,b and Xiangfei Meng a
Purpose of review Mental disorders take a major toll, economically, socially, and psychologically, on individuals, families, and societies. Prevention provides an important and realistic opportunity to overcome this major health problem. This review outlines a conceptual framework for mental health prevention and effective strategies and programs for the prevention of mental disorders. Recent findings Risk and protective factors for mental illness provide leverage points for prevention interventions. A life course perspective, looking at disease from conception, pregnancy, parenting, infancy, childhood, adolescence, adulthood to aging, emphasizes the importance of targeting prevention efforts as early as possible in life. Currently available effective and realistic preventions targeting major phases of life including both universal (community) and selective high-risk approaches are noted. The Internet and its associated technologies are seen to have great potential for prevention. Summary Common mental disorders are preventable, and prevention is cost-effective. Although the evidence base for the prevention of mental disorders needs to be expanded with rigorous large-scale pragmatic trials of promising effective programs, we have at our disposal strong evidence and effective tools on which to base prevention efforts. These facts need to be fully communicated to providers, policy makers, and the population at large, and acted upon. Keywords interventions, mental disorders, prevention, risk factors
INTRODUCTION Mental disorders are an immense economic, psychological, and social burden to society and individuals. They are the leading cause of disability worldwide and linked to increased physical illness and premature mortality [1 ]. Developed countries have made great strides in reducing morbidity and mortality caused by some major chronic diseases, for example, cardiovascular and cerebrovascular diseases, and some cancers, through prevention strategies aimed at the general population. However, similar population initiatives on the same scale aimed at common mental disorders are lacking though there are many smaller scale innovative initiatives continuing a century long tradition. Given the limitations in the effectiveness of available treatments [2], the only sustainable avenue for reducing the occurrence and burden of mental disorders is prevention. Effective prevention will also contribute to altering the stigma surrounding mental illness. This article provides a prevention framework for common mental disorders, outlines &
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effective programs, and calls for an expansion of the prevention evidence and wider implementation of known effective prevention programs.
CONCEPTUAL FRAMEWORK Why we prevent? The reasons for preventing diseases are economic, practical, and humanitarian. Limitations to the economic argument are success in preventing disease may really be postponement rather than prevention and there may not be a reduction in healthcare costs. The practical argument is that the need for services far outstrips the clinical manpower and resources available. The a Department of Psychiatry and bSchool of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Correspondence to Carl D’Arcy, PhD, Department of Psychiatry, Ellis Hall, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada. Tel: +1 306 844 1279; e-mail: [email protected] Curr Opin Psychiatry 2014, 27:294–301 DOI:10.1097/YCO.0000000000000076 Volume 27 Number 4 July 2014
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Prevention of common mental disorders D’Arcy and Meng
KEY POINTS Prevention provides an effective and economic approach to bridge between the high prevalence and burden of mental disorders and the limited amount of resources, including personnel, available to treat. The well-established risk and protective factors associated with mental illness/health provide leverage points for prevention. Decreasing the level risk in a population or increasing the prevalence of a protective factor reduces occurrence of mental illness. Prevention theory favors large-scale universal interventions that change a population’s risk profile. Although risks for mental health occur throughout the life, there are critical periods for altering a person’s health/illness trajectory. A life-course perspective on the development of mental disorders suggests that we should intervene early. There is strong evidence for the effectiveness of a wide range of prevention interventions. An overview of interventions targeted at conception and pregnancy, parenting and early childhood, adolescence and school, adults and the workplace, and old age is provided. Behavioral intervention technologies based on the Internet, computer, and associated technologies are briefly reviewed. Although there is a need to expand the evidence base for effective interventions with large-scale pragmatic trials that are rigorously evaluated, we currently have strong evidence and effective tools on which to base mental health/illness promotion and prevention efforts.
humanitarian perspective is that it is better to be healthy and well rather than ill and dead. It is perhaps the best argument [3].
should limit the occurrence and impact of disease, be less disabling and harmful than the disease itself, be cost-effective, and be acceptable to the general public and target populations.
Risk factors of mental disorders Risk and protective factors for disease provide leverage points for prevention. Reducing the level of a risk factor or increasing the prevalence of a protective factor should lead to a reduction in the occurrence of disease. Various biological, psychological, and social risk and protective factors for mental disorders have been reported in the literature [4 ,5 ] (see Fig. 1). Risk factors are characterized as modifiable (malleable) or nonmodifiable. Nonmodifiable factors; genetic background, age, sex, early childhood experiences, etc., are highly resistant to change. Modifiable factors; physical inactivity, diet, cigarette smoking, excessive alcohol consumption, can be changed [6]. Some nonmodifiable risk factors, for example gender roles, may in fact be amenable to change but the process may be long and difficult. Epigenetics teaches us that gene expression or cellular phenotypes can be modified by environmental exposure that can occur early in pregnancy [7]. Generic risk and protective factors are common to several different diseases. Disease-specific factors relate to a specific disease [5 ]. Childhood abuse contributes to depression, anxiety, and substance abuse. Negative thinking is closely tied to depression. Risk factors can be cumulative [8]. Risk and protective factors occur throughout a person’s life and in critical periods. Figure 2 presents a life-course overview of risk factors for mental disorders [5 ,9–11]. Development of effective prevention strategies requires the translation of modifiable risk factors into programs and policies. &
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Prevention of common mental disorders All the parameters of a disease do not need to be known in order to effectively intervene. It is sufficient to know that a risk factor is part of the causal nexus. Effective prevention can occur in the absence of detailed knowledge of the causes of a disease, for example, Snow and cholera, smoking and lung cancer. Certainly, greater knowledge improves the chances for more effective prevention. Public mental health is primarily interested in health promotion and primary prevention and some secondary prevention. Public health does not treat the individual but rather groups, communities, and populations. Not all diseases are amenable to public health interventions. Common mental disorders, depression, anxiety, phobias, and alcohol abuse may be more amenable to public health interventions than psychotic disorders. Prevention
What should be the focus? A life course perspective alerts us to the pivotal role of early life risk exposure in setting a trajectory for health and illness [12–14]. It forces us to look ‘upstream’ at the importance of early interventions before risk factors and disease take hold. Early life, conception to adolescence, is a formative period protecting individuals from harm and building strengths and resilience. Ideally, the prevention of mental disorders starts early in life.
Targeting and the prevention paradox Prevention efforts are usually categorized as universal, selective, and indicated: universal targets the
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Individual attributes
Social circumstances
Environmental factors
Low self-esteem
Self-esteem, confidence
Cognitive/emotional immaturity
Ability to solve problems and manage stress or adversity
Difficulties in communicating
Communication skills
Medical illness, substance use
Physical health, fitness
Loneliness, bereavement
Social support of family and friends
Neglect, family conflict
Good parenting/family interaction
Exposure to violence/abuse
Physical security and safety
Low income and poverty
Economic security
Difficulties or failure at school
Scholastic achievement
Work stress, unemployment
Satisfaction and success at work
Poor access to basic services
Equality of access to basic services
Injustice and discrimination
Social justice, tolerance, integration
Social and gender inequalities
Social and gender equality
Exposure to war or disaster
Physical security and safety
FIGURE 1. Biological, psychological, and social risk and protective factors for mental disorders [5 ]. &&
general population, selective targets individuals or population subgroups who have a significantly increased risk of developing a mental disorder, indicated targets those at high risk who have detectable symptoms of illness or biological markers [5 ]. The prevention paradox shows somewhat counterintuitively that the majority of cases of a disease in a population arise from those at moderate &&
Setting
Home/family
or low risk and only a minority from those at high risk [3]. Thus, a large-scale effective health prevention may have relatively small but perceptible benefits on the health of most. A widely distributed risk factor with a relatively low or modest impact on a disease is a worthwhile target, as small changes in its prevalence will have a large payoff because of its high prevalence. The prevention paradox argues for
Media/ information
School
Work
Community/home
Discrimination/social inequalities
Culture Low socioeconomic status
Adverse media influences
Community
Parental mental illness
Peer pressure
Family violence or conflict Trauma or maltreatment
Insecure attachment Poor nutrition Malnutrition Low self-esteem
Prenatal period and early childhood
Job intensity or insecurity
Difficulties at school
Substance use in pregnancy
Individual
Poor civic amenities
Neighbourhood violence/crime Poor housing/ living conditions
Family
Social exclusion
Adverse learning environment
Childhood
Unemployment Debt/poverty
Criminal or anti-social behaviour Psychoactive substance use
Bereavement
Harmful alcohol use
Elder abuse
Physical ill-health
Physical ill-health
Adolescence
Adulthood
Other adulthood
FIGURE 2. Life-course overview of risk factors for mental disorders [5 ,9–11]. &&
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large-scale action targeting important and widely distributed risks. The essence of prevention is to shift the risk profile of whole populations. Such strategies have been very successful in reducing heart disease, stroke and lung and stomach cancers by using refrigeration, altering diets, reducing smoking, etc. For mental disorders, successful prevention needs to be both universal and selectively indicated to high-risk subgroups.
and developmental problems – lower intelligence quotient, Attention Deficit Hyperactivity Disorder, conduct problems, and poor school achievement [27–29]. Encouraging pregnant women to abstain from alcohol and smoking has long-term health benefits, including having heavier babies [30]. Preconception and pregnancy provide important opportunities for primary mental health prevention [31 ].
Using population attributable fractions
Focus on parenting
Which risk factors are more important? Population attributable fraction (PAF) methodology attempts to estimate the proportional reduction in the occurrence of a disease that would occur if exposure to risks in a population was reduced to an ideal exposure scenario (e.g. no cigarette smoking). However, many diseases are caused by numerous risk factors and there may be interaction among the factors. Current PAF formulas assume a cumulative effect up to 100% and no interactions [15]. PAFs have been used to quantify the potential effects of risk factors modification on mental disorders [16,17]. Recent analyses of a national cohort over 16 years showed that three risk factors accounted for almost 40% of incident depression: low income (5.5%), regular cigarette smoking (6.6%), and having a chronic disease (30.9%) [18 ].
Fryers and Brugha’s review of longitudinal studies of childhood determinants of adult psychiatric disorder found 10 factors: psychological disturbance; genetic influences; neurological deviance; neuroticism; behavioral problems; school performance; adversity, childhood abuse/neglect; parenting and parent–child relationships; disrupted and dysfunctional families were associated with later life mental ill-health [32 ]. The European DataPrev initiative examining the effectiveness of interventions targeting parenting concluded that parenting programs had great potential for improving the mental health of the general population [21]. Both universal (generic and less stigmatizing) and indicated approaches were effective. Universal low-cost programs include promoting parental abdominal massage during pregnancy, skin-to-skin contact immediately following delivery, encouraging infant carrying through kangaroo care, guidance on infant development and managing common problems, and promoting infant massage. Indicated high-risk programs include programs for postnatal depression, short sensitivity focused practices for high-risk infants, multicomponent long-term home visiting for higher risk parents, a range of parenting practices for high-risk children to prevent behavioral problems, and parenting support in families at high risk of emotional or physical abuse. High-risk interventions require support by healthcare providers, training for providers in nonjudgmental approaches, and adequate resources to deliver the programs [21]. Using Delphi methodology, an expert consensus produced a set of evidence-based parenting strategies to protect adolescents from depression and anxiety disorders [33 ]. These types of programs may be applicable in low-income and middleincome countries [34 ].
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EFFECTIVE PREVENTIONS: WHAT WORKS? There are a number of well-documented national and trans-national sources of evidence-based effective mental illness prevention programs and policies [6,9,19–24]. Readers are encouraged to consult these sources directly. These prevention programs have been found to be ‘good value for the money’ with many interventions being low cost [25]. However, a consistent refrain is the need for more large-scale high-quality intervention trials to be implemented and rigorously evaluated. The following outlines effective prevention programs throughout the life course.
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Intervention early in life The development origins of health and disease are well established [12–14,26]. The in-utero environment, quality of early parenting, and parent–infant relationships are pivotal in setting the mental health trajectory for life. Alcohol use, binge drinking, cigarette smoking, and illicit and prescription drug use during pregnancy increase the likelihood of low birth weight, prenatal mortality, and neurological
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Children and adolescents Schools provide a unique opportunity for prevention and mental health promotion. Weare and Nind’s systematic review of school-based mental health programs found that both universal and
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indicated approaches are effective. More effective interventions taught skills, focused on positive mental health, balanced universal and indicated approaches, started early with the youngest children, and continued with older ones. Effective programs operated over a long period of time and embedded the prevention within a multimodal school approach linking with academic learning, improving school ethos, parent involvement and education, community involvement, and coordination with outside agencies. Interventions need to be consistently implemented with fidelity and intensity, well defined goals, a rationale, a focus on explicit outcomes and guidelines, and practical training and quality control [22]. A Cochrane review found that compared with no intervention, psychologically based prevention programs effectively prevented depression with studies showing a 1-year decrease in depressive episodes [35]. Similarly, a review of randomized control trial (RCT) studies of school-based programs for adolescent depression and anxiety found that most programs were effective in reducing or preventing mental disorders [36 ]. The analyses supported both indicated and universal programs. ‘Real world’ testing of prevention programs was recommended. Kutcher and Wei [37 ] noted that the evaluation of school-based programs is hampered by the lack of strong research designs, the heterogeneity of schools, and the complexities of multisector collaboration. Mental health literacy is seen as a good starting point for school-based promotion and prevention programs. &
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Adults and workplace interventions It is evident that interventions aimed at adult modifiable risk factors can prevent common mental disorders [38 ,39]. Physical activity as a prevention and treatment is seen as promising [40]. A review of reviews concluded that exercise as treatment for depression is more effective than no treatment and is as effective as traditional interventions, at least in the short-term, although it can be limited by high remission rates, commitment, and patients’ motivational commitment [41]. A recent systematic review of RCTs found that exercise is moderately more effective than control interventions for reducing symptoms of depression, but methodologically robust trials showed smaller effects. Exercise was judged to be no more effective than psychological or pharmacological therapies, though this conclusion was based on a few small trials [42 ]. Workplaces, like schools, provide opportunities to improve physical and mental health. Studies have shown that a negative work environment increases &
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the risk of mental disorders mainly depression [43]. Job stress interventions, focusing on working conditions and individual skills and behaviors, have been found to improve workers’ health [44–46]. One RCT found meditation a low-cost effective tool for reducing job stress, depression, and anxiety [47]. Czabala et al. [23] reviewing the literature on workplace mental health interventions identified five intervention aims: stress management and better coping, mental health improvement, increased job satisfaction, job effectiveness improvement, and absenteeism reduction. Similar interventions: skills training, improvement of occupational qualifications and working conditions, relaxation, physical exercise, and multicomponent interventions were used to attain the different aims. Stress inoculation training [48] and stress management programs delivered by clinical psychologists were seen as the most promising workplace interventions [49]. Bhui et al. [50] found that organizational interventions showed mixed benefits. Individual interventions such as cognitive behavioural therapy (CBT) produce relatively large effects improving individuals’ mental health. Physical exercise as organizational activity reduced absenteeism. Again the literature stresses a need for more and better workplace interventions and more rigorous evaluation of their impact particularly their economic impact [23,51 ]. &
Older adults Meaningful social activities, tailored to individual abilities and preferences, have been consistently found to improve the mental health of older adults [20]. Programs to support social activities, and peer support and skills training have been found to reduce depressive symptoms and prevent depression in older people [24]. Time-limited, small groupbased psycho-educational and skill-training interventions based on CBT principles reduced depressive symptoms and improved quality of life [52,53]. Meaningful social activities and peer group support are doubly important in long-term care facilities. Reynolds et al. [54 ], in their review of RCTs for the selective and indicated prevention of depression using psycho-educational and psychological interventions to promote protective factors such as enhancing coping strategies, better sleep, etc. and conducted in high income countries, showed that rates of incident depression in older adults can be reduced 20–25% over a 1-year to 2-year period. For older adults suffering from chronic diseases and consequent functional limitations interventions should provide information about available aids and external resources and promote personal &&
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resources and coping strategies while limiting negative thoughts [55–58]. Group discussions and exchanges of experiences are also helpful [59]. Programs that increase social contacts among older adults improve their psychological well-being and decreases loneliness [60–62].
CONCLUSION
Improving mental health literacy and selfcare: the Internet plus
Acknowledgements None.
It is well established that self-help can reduce the symptoms of depression and anxiety, sleep problems, headaches, etc. [63–68]. The Internet and associated technologies including smartphones are transforming the way in which the people access healthcare information, seek help, and engage in self-care. The online treatment of depression and anxiety in both adults [69–72,73 ] and adolescents [74,75] is effective. A systematic review of computerized anxiety and depression intervention for youths found that 60% of anxiety and 83% of depression programs improved at least one outcome measure [75]. Yap et al. [76] has outlined a parenting program to prevent adolescent alcohol abuse. A US expert technical panel reviewing behavioral intervention technologies (BITs) concluded that video-conferencing and standard telephone technologies are well validated, web-based interventions have shown effectiveness, social media such as online support groups have produced disappointing results when used alone, mobile technologies have received little attention in terms of mental health, virtual reality has shown good efficacy for anxiety and pediatric disorders, but the use of gaming has received little attention [77 ]. These Internet plus programs have high levels of consumer acceptance and adherence [78] and are seen to have great mental health literacy potential [79 ]. Australia has been very active in this area with several treatment websites for both youths and adults [80]. &&
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WHERE DO WE GO FROM HERE? The evidence-based strategies for the prevention of common mental disorders need to be expanded through further development of pragmatic highquality intervention programs and real world trials rigorously evaluated, multisite studies to expand knowledge on the robustness of programs, highquality replication studies implemented with fidelity to the original programs, longitudinal studies to demonstrate the long-term impact of early interventions, and interventions aimed at the population at large that maximize impact and acceptability [81 ]. &
Common mental disorders are preventable. Prevention is cost-effective. We have strong evidence and powerful effective tools on which to base prevention programs. These facts need to be fully communicated to providers, policy makers, and the population at large, and most importantly, acted upon.
Conflicts of interest There are no conflicts of interest.
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The role of primary and secondary control in adaptation to age-related vision loss: a study of older adults with macular degeneration. Psychol Aging 2004; 19:235–239. 56. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment. A randomized trial. Ann Intern Med 1990; 113:188–194. 57. Riemsma RP, Kirwan JR, Taal E, et al. Patient education for adults with rheumatoid arthritis. Cochrane Database Syst Rev 2003; 2:; CD003688. 58. Wahl HW, Kammerer A, Holz F, et al. Psychosocial intervention for agerelated macular degeneration: a pilot project. J Visual Impair Blin 2006; 100:533–544. 59. Birk T, Hickl S, Wahl HW, et al. Development and pilot evaluation of a psychosocial intervention program for patients with age-related macular degeneration. Gerontologist 2004; 44:836–843. 60. Stevens N, Tilburg T. Stimulating friendship in later life: a strategy for reducing loneliness among older women. Educ Gerontol 2000; 26:15–35. 61. Stevens NL, Martina CM, Westerhof GJ. Meeting the need to belong: predicting effects of a friendship enrichment program for older women. Gerontologist 2006; 46:495–502. 62. Onrust S, Smit F, Willemse G, et al. Cost-utility of a visiting service for older widowed individuals: randomised trial. BMC Health Serv Res 2008; 8:128. 63. Gregory R, Canning S, Lee T, et al. Cognitive bibliotherapy for depression: a meta-analysis. Prof Psychol Res Pract 2004; 35:275–280. 64. Menchola M, Arkowitz H, Burke B. Efficacy of self-administered treatments for depression and anxiety. Prof Psychol Res Pract 2007; 38:421–429. &
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Prevention of common mental disorders D’Arcy and Meng 65. Spek V, Cuijpers P, Nyklicek I, et al. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med 2007; 37:319–328. 66. Van Straten A, Cuijpers P. Self-help therapy for insomnia: a meta-analysis. Sleep Med Rev 2009; 13:61–71. 67. Haddock CK, Rowan AB, Andrasik F, et al. Home-based behavioral treatments for chronic benign headache: a meta-analysis of controlled trials. Cephalalgia 1997; 17:113–118. 68. Hirai M, Clum GA. A meta-analytic study of self-help interventions for anxiety problems. Behav Ther 2006; 37:99–111. 69. National Institute for Health and Clinical Medicine (NICE). Computerised cognitive behavior therapy and depression and anxiety (Review of Technology Appraisal 51). http://guidance.nice.org.uk/TA97. [Accessed 25 January 2014] 70. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PLoS One 2010; 5:e13196. 71. Cuijpers P, Donker T, Johansson R, et al. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One 2011; 6:e21274. 72. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004; 328: 265. 73. Christensen H, Batterham P, Calear A. Online interventions for anxiety && disorders. Curr Opin Psychiatry 2014; 27:7–13. This article updates knowledge regarding the evidence base for online interventions for anxiety disorders. Recent studies have confirmed the value of computerized therapy for anxiety. Future trials are required to elucidate the active elements of effective programs for specific groups and ascertain optimal degree of guidance required.
74. Calear AL, Christensen H. Review of Internet-based prevention and treatment programs for anxiety and depression in children and adolescents. Med J Aust 2010; 192 (11 Suppl):S12–S14. 75. Christensen H, Pallister E, Smale S, et al. Community-based prevention programs for anxiety and depression in youth: a systematic review. J Prim Prev 2010; 31:139–170. 76. Yap M, Jorm A, Bazley R, et al. Web-based parenting program to prevent adolescent alcohol misuse: rationale and development. Australas Psychiatry 2011; 19:339–344. 77. Mohr DC, Burns MN, Schueller SM, et al. Behavioral intervention technolo&& gies: evidence review and recommendations for future research in mental health. Gen Hosp Psychiatry 2013; 35:332–338. This is a report of a techinical expert committee convened by US agencies and charged with reviewing the state of research on BITs in mental health and identifying top research priorities. 78. Gun SY, Titov N, Andrews G. Acceptability of Internet treatment of anxiety and depression among older adults. Australas Psychiatry 2011; 19:259–264. 79. Christensen H, Petrie K. Information technology as the key to accelerating & advances in mental healthcare. Aust N Z J Psychiatry 2013; 47:114–116. Information and communication technologies are just as likely to be as important as biotechnology, particularly in population and mental health prevention. 80. Medical Journal of Australia. 2010 supplement. Delivering timely interventions: the impact of the Internet on mental health. https://www.mja.com.au/ journal/supplements. [Accessed 25 January 2014] 81. Jacka FN, Reavley NJ, Jorm AF, et al. Prevention of common mental disorders: & what can we learn form those who have gone before and where do we go next? Aust N Z J Psychuatry 2013; 47:920–929. This article provides a brief overview of the existing literature on the prevention of common mental disorders and a commentary on the way forward for prevention research and implementation.
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Prevention of common mental disorders: conceptual framework and effective interventions Carl D’Arcy a,b and Xiangfei Meng a
Purpose of review Mental disorders take a major toll, economically, socially, and psychologically, on individuals, families, and societies. Prevention provides an important and realistic opportunity to overcome this major health problem. This review outlines a conceptual framework for mental health prevention and effective strategies and programs for the prevention of mental disorders. Recent findings Risk and protective factors for mental illness provide leverage points for prevention interventions. A life course perspective, looking at disease from conception, pregnancy, parenting, infancy, childhood, adolescence, adulthood to aging, emphasizes the importance of targeting prevention efforts as early as possible in life. Currently available effective and realistic preventions targeting major phases of life including both universal (community) and selective high-risk approaches are noted. The Internet and its associated technologies are seen to have great potential for prevention. Summary Common mental disorders are preventable, and prevention is cost-effective. Although the evidence base for the prevention of mental disorders needs to be expanded with rigorous large-scale pragmatic trials of promising effective programs, we have at our disposal strong evidence and effective tools on which to base prevention efforts. These facts need to be fully communicated to providers, policy makers, and the population at large, and acted upon. Keywords interventions, mental disorders, prevention, risk factors
INTRODUCTION Mental disorders are an immense economic, psychological, and social burden to society and individuals. They are the leading cause of disability worldwide and linked to increased physical illness and premature mortality [1 ]. Developed countries have made great strides in reducing morbidity and mortality caused by some major chronic diseases, for example, cardiovascular and cerebrovascular diseases, and some cancers, through prevention strategies aimed at the general population. However, similar population initiatives on the same scale aimed at common mental disorders are lacking though there are many smaller scale innovative initiatives continuing a century long tradition. Given the limitations in the effectiveness of available treatments [2], the only sustainable avenue for reducing the occurrence and burden of mental disorders is prevention. Effective prevention will also contribute to altering the stigma surrounding mental illness. This article provides a prevention framework for common mental disorders, outlines &
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effective programs, and calls for an expansion of the prevention evidence and wider implementation of known effective prevention programs.
CONCEPTUAL FRAMEWORK Why we prevent? The reasons for preventing diseases are economic, practical, and humanitarian. Limitations to the economic argument are success in preventing disease may really be postponement rather than prevention and there may not be a reduction in healthcare costs. The practical argument is that the need for services far outstrips the clinical manpower and resources available. The a Department of Psychiatry and bSchool of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Correspondence to Carl D’Arcy, PhD, Department of Psychiatry, Ellis Hall, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada. Tel: +1 306 844 1279; e-mail: [email protected] Curr Opin Psychiatry 2014, 27:294–301 DOI:10.1097/YCO.0000000000000076 Volume 27 Number 4 July 2014
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Prevention of common mental disorders D’Arcy and Meng
KEY POINTS Prevention provides an effective and economic approach to bridge between the high prevalence and burden of mental disorders and the limited amount of resources, including personnel, available to treat. The well-established risk and protective factors associated with mental illness/health provide leverage points for prevention. Decreasing the level risk in a population or increasing the prevalence of a protective factor reduces occurrence of mental illness. Prevention theory favors large-scale universal interventions that change a population’s risk profile. Although risks for mental health occur throughout the life, there are critical periods for altering a person’s health/illness trajectory. A life-course perspective on the development of mental disorders suggests that we should intervene early. There is strong evidence for the effectiveness of a wide range of prevention interventions. An overview of interventions targeted at conception and pregnancy, parenting and early childhood, adolescence and school, adults and the workplace, and old age is provided. Behavioral intervention technologies based on the Internet, computer, and associated technologies are briefly reviewed. Although there is a need to expand the evidence base for effective interventions with large-scale pragmatic trials that are rigorously evaluated, we currently have strong evidence and effective tools on which to base mental health/illness promotion and prevention efforts.
humanitarian perspective is that it is better to be healthy and well rather than ill and dead. It is perhaps the best argument [3].
should limit the occurrence and impact of disease, be less disabling and harmful than the disease itself, be cost-effective, and be acceptable to the general public and target populations.
Risk factors of mental disorders Risk and protective factors for disease provide leverage points for prevention. Reducing the level of a risk factor or increasing the prevalence of a protective factor should lead to a reduction in the occurrence of disease. Various biological, psychological, and social risk and protective factors for mental disorders have been reported in the literature [4 ,5 ] (see Fig. 1). Risk factors are characterized as modifiable (malleable) or nonmodifiable. Nonmodifiable factors; genetic background, age, sex, early childhood experiences, etc., are highly resistant to change. Modifiable factors; physical inactivity, diet, cigarette smoking, excessive alcohol consumption, can be changed [6]. Some nonmodifiable risk factors, for example gender roles, may in fact be amenable to change but the process may be long and difficult. Epigenetics teaches us that gene expression or cellular phenotypes can be modified by environmental exposure that can occur early in pregnancy [7]. Generic risk and protective factors are common to several different diseases. Disease-specific factors relate to a specific disease [5 ]. Childhood abuse contributes to depression, anxiety, and substance abuse. Negative thinking is closely tied to depression. Risk factors can be cumulative [8]. Risk and protective factors occur throughout a person’s life and in critical periods. Figure 2 presents a life-course overview of risk factors for mental disorders [5 ,9–11]. Development of effective prevention strategies requires the translation of modifiable risk factors into programs and policies. &
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Prevention of common mental disorders All the parameters of a disease do not need to be known in order to effectively intervene. It is sufficient to know that a risk factor is part of the causal nexus. Effective prevention can occur in the absence of detailed knowledge of the causes of a disease, for example, Snow and cholera, smoking and lung cancer. Certainly, greater knowledge improves the chances for more effective prevention. Public mental health is primarily interested in health promotion and primary prevention and some secondary prevention. Public health does not treat the individual but rather groups, communities, and populations. Not all diseases are amenable to public health interventions. Common mental disorders, depression, anxiety, phobias, and alcohol abuse may be more amenable to public health interventions than psychotic disorders. Prevention
What should be the focus? A life course perspective alerts us to the pivotal role of early life risk exposure in setting a trajectory for health and illness [12–14]. It forces us to look ‘upstream’ at the importance of early interventions before risk factors and disease take hold. Early life, conception to adolescence, is a formative period protecting individuals from harm and building strengths and resilience. Ideally, the prevention of mental disorders starts early in life.
Targeting and the prevention paradox Prevention efforts are usually categorized as universal, selective, and indicated: universal targets the
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Individual attributes
Social circumstances
Environmental factors
Low self-esteem
Self-esteem, confidence
Cognitive/emotional immaturity
Ability to solve problems and manage stress or adversity
Difficulties in communicating
Communication skills
Medical illness, substance use
Physical health, fitness
Loneliness, bereavement
Social support of family and friends
Neglect, family conflict
Good parenting/family interaction
Exposure to violence/abuse
Physical security and safety
Low income and poverty
Economic security
Difficulties or failure at school
Scholastic achievement
Work stress, unemployment
Satisfaction and success at work
Poor access to basic services
Equality of access to basic services
Injustice and discrimination
Social justice, tolerance, integration
Social and gender inequalities
Social and gender equality
Exposure to war or disaster
Physical security and safety
FIGURE 1. Biological, psychological, and social risk and protective factors for mental disorders [5 ]. &&
general population, selective targets individuals or population subgroups who have a significantly increased risk of developing a mental disorder, indicated targets those at high risk who have detectable symptoms of illness or biological markers [5 ]. The prevention paradox shows somewhat counterintuitively that the majority of cases of a disease in a population arise from those at moderate &&
Setting
Home/family
or low risk and only a minority from those at high risk [3]. Thus, a large-scale effective health prevention may have relatively small but perceptible benefits on the health of most. A widely distributed risk factor with a relatively low or modest impact on a disease is a worthwhile target, as small changes in its prevalence will have a large payoff because of its high prevalence. The prevention paradox argues for
Media/ information
School
Work
Community/home
Discrimination/social inequalities
Culture Low socioeconomic status
Adverse media influences
Community
Parental mental illness
Peer pressure
Family violence or conflict Trauma or maltreatment
Insecure attachment Poor nutrition Malnutrition Low self-esteem
Prenatal period and early childhood
Job intensity or insecurity
Difficulties at school
Substance use in pregnancy
Individual
Poor civic amenities
Neighbourhood violence/crime Poor housing/ living conditions
Family
Social exclusion
Adverse learning environment
Childhood
Unemployment Debt/poverty
Criminal or anti-social behaviour Psychoactive substance use
Bereavement
Harmful alcohol use
Elder abuse
Physical ill-health
Physical ill-health
Adolescence
Adulthood
Other adulthood
FIGURE 2. Life-course overview of risk factors for mental disorders [5 ,9–11]. &&
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large-scale action targeting important and widely distributed risks. The essence of prevention is to shift the risk profile of whole populations. Such strategies have been very successful in reducing heart disease, stroke and lung and stomach cancers by using refrigeration, altering diets, reducing smoking, etc. For mental disorders, successful prevention needs to be both universal and selectively indicated to high-risk subgroups.
and developmental problems – lower intelligence quotient, Attention Deficit Hyperactivity Disorder, conduct problems, and poor school achievement [27–29]. Encouraging pregnant women to abstain from alcohol and smoking has long-term health benefits, including having heavier babies [30]. Preconception and pregnancy provide important opportunities for primary mental health prevention [31 ].
Using population attributable fractions
Focus on parenting
Which risk factors are more important? Population attributable fraction (PAF) methodology attempts to estimate the proportional reduction in the occurrence of a disease that would occur if exposure to risks in a population was reduced to an ideal exposure scenario (e.g. no cigarette smoking). However, many diseases are caused by numerous risk factors and there may be interaction among the factors. Current PAF formulas assume a cumulative effect up to 100% and no interactions [15]. PAFs have been used to quantify the potential effects of risk factors modification on mental disorders [16,17]. Recent analyses of a national cohort over 16 years showed that three risk factors accounted for almost 40% of incident depression: low income (5.5%), regular cigarette smoking (6.6%), and having a chronic disease (30.9%) [18 ].
Fryers and Brugha’s review of longitudinal studies of childhood determinants of adult psychiatric disorder found 10 factors: psychological disturbance; genetic influences; neurological deviance; neuroticism; behavioral problems; school performance; adversity, childhood abuse/neglect; parenting and parent–child relationships; disrupted and dysfunctional families were associated with later life mental ill-health [32 ]. The European DataPrev initiative examining the effectiveness of interventions targeting parenting concluded that parenting programs had great potential for improving the mental health of the general population [21]. Both universal (generic and less stigmatizing) and indicated approaches were effective. Universal low-cost programs include promoting parental abdominal massage during pregnancy, skin-to-skin contact immediately following delivery, encouraging infant carrying through kangaroo care, guidance on infant development and managing common problems, and promoting infant massage. Indicated high-risk programs include programs for postnatal depression, short sensitivity focused practices for high-risk infants, multicomponent long-term home visiting for higher risk parents, a range of parenting practices for high-risk children to prevent behavioral problems, and parenting support in families at high risk of emotional or physical abuse. High-risk interventions require support by healthcare providers, training for providers in nonjudgmental approaches, and adequate resources to deliver the programs [21]. Using Delphi methodology, an expert consensus produced a set of evidence-based parenting strategies to protect adolescents from depression and anxiety disorders [33 ]. These types of programs may be applicable in low-income and middleincome countries [34 ].
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EFFECTIVE PREVENTIONS: WHAT WORKS? There are a number of well-documented national and trans-national sources of evidence-based effective mental illness prevention programs and policies [6,9,19–24]. Readers are encouraged to consult these sources directly. These prevention programs have been found to be ‘good value for the money’ with many interventions being low cost [25]. However, a consistent refrain is the need for more large-scale high-quality intervention trials to be implemented and rigorously evaluated. The following outlines effective prevention programs throughout the life course.
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Intervention early in life The development origins of health and disease are well established [12–14,26]. The in-utero environment, quality of early parenting, and parent–infant relationships are pivotal in setting the mental health trajectory for life. Alcohol use, binge drinking, cigarette smoking, and illicit and prescription drug use during pregnancy increase the likelihood of low birth weight, prenatal mortality, and neurological
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Children and adolescents Schools provide a unique opportunity for prevention and mental health promotion. Weare and Nind’s systematic review of school-based mental health programs found that both universal and
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indicated approaches are effective. More effective interventions taught skills, focused on positive mental health, balanced universal and indicated approaches, started early with the youngest children, and continued with older ones. Effective programs operated over a long period of time and embedded the prevention within a multimodal school approach linking with academic learning, improving school ethos, parent involvement and education, community involvement, and coordination with outside agencies. Interventions need to be consistently implemented with fidelity and intensity, well defined goals, a rationale, a focus on explicit outcomes and guidelines, and practical training and quality control [22]. A Cochrane review found that compared with no intervention, psychologically based prevention programs effectively prevented depression with studies showing a 1-year decrease in depressive episodes [35]. Similarly, a review of randomized control trial (RCT) studies of school-based programs for adolescent depression and anxiety found that most programs were effective in reducing or preventing mental disorders [36 ]. The analyses supported both indicated and universal programs. ‘Real world’ testing of prevention programs was recommended. Kutcher and Wei [37 ] noted that the evaluation of school-based programs is hampered by the lack of strong research designs, the heterogeneity of schools, and the complexities of multisector collaboration. Mental health literacy is seen as a good starting point for school-based promotion and prevention programs. &
&
Adults and workplace interventions It is evident that interventions aimed at adult modifiable risk factors can prevent common mental disorders [38 ,39]. Physical activity as a prevention and treatment is seen as promising [40]. A review of reviews concluded that exercise as treatment for depression is more effective than no treatment and is as effective as traditional interventions, at least in the short-term, although it can be limited by high remission rates, commitment, and patients’ motivational commitment [41]. A recent systematic review of RCTs found that exercise is moderately more effective than control interventions for reducing symptoms of depression, but methodologically robust trials showed smaller effects. Exercise was judged to be no more effective than psychological or pharmacological therapies, though this conclusion was based on a few small trials [42 ]. Workplaces, like schools, provide opportunities to improve physical and mental health. Studies have shown that a negative work environment increases &
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the risk of mental disorders mainly depression [43]. Job stress interventions, focusing on working conditions and individual skills and behaviors, have been found to improve workers’ health [44–46]. One RCT found meditation a low-cost effective tool for reducing job stress, depression, and anxiety [47]. Czabala et al. [23] reviewing the literature on workplace mental health interventions identified five intervention aims: stress management and better coping, mental health improvement, increased job satisfaction, job effectiveness improvement, and absenteeism reduction. Similar interventions: skills training, improvement of occupational qualifications and working conditions, relaxation, physical exercise, and multicomponent interventions were used to attain the different aims. Stress inoculation training [48] and stress management programs delivered by clinical psychologists were seen as the most promising workplace interventions [49]. Bhui et al. [50] found that organizational interventions showed mixed benefits. Individual interventions such as cognitive behavioural therapy (CBT) produce relatively large effects improving individuals’ mental health. Physical exercise as organizational activity reduced absenteeism. Again the literature stresses a need for more and better workplace interventions and more rigorous evaluation of their impact particularly their economic impact [23,51 ]. &
Older adults Meaningful social activities, tailored to individual abilities and preferences, have been consistently found to improve the mental health of older adults [20]. Programs to support social activities, and peer support and skills training have been found to reduce depressive symptoms and prevent depression in older people [24]. Time-limited, small groupbased psycho-educational and skill-training interventions based on CBT principles reduced depressive symptoms and improved quality of life [52,53]. Meaningful social activities and peer group support are doubly important in long-term care facilities. Reynolds et al. [54 ], in their review of RCTs for the selective and indicated prevention of depression using psycho-educational and psychological interventions to promote protective factors such as enhancing coping strategies, better sleep, etc. and conducted in high income countries, showed that rates of incident depression in older adults can be reduced 20–25% over a 1-year to 2-year period. For older adults suffering from chronic diseases and consequent functional limitations interventions should provide information about available aids and external resources and promote personal &&
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resources and coping strategies while limiting negative thoughts [55–58]. Group discussions and exchanges of experiences are also helpful [59]. Programs that increase social contacts among older adults improve their psychological well-being and decreases loneliness [60–62].
CONCLUSION
Improving mental health literacy and selfcare: the Internet plus
Acknowledgements None.
It is well established that self-help can reduce the symptoms of depression and anxiety, sleep problems, headaches, etc. [63–68]. The Internet and associated technologies including smartphones are transforming the way in which the people access healthcare information, seek help, and engage in self-care. The online treatment of depression and anxiety in both adults [69–72,73 ] and adolescents [74,75] is effective. A systematic review of computerized anxiety and depression intervention for youths found that 60% of anxiety and 83% of depression programs improved at least one outcome measure [75]. Yap et al. [76] has outlined a parenting program to prevent adolescent alcohol abuse. A US expert technical panel reviewing behavioral intervention technologies (BITs) concluded that video-conferencing and standard telephone technologies are well validated, web-based interventions have shown effectiveness, social media such as online support groups have produced disappointing results when used alone, mobile technologies have received little attention in terms of mental health, virtual reality has shown good efficacy for anxiety and pediatric disorders, but the use of gaming has received little attention [77 ]. These Internet plus programs have high levels of consumer acceptance and adherence [78] and are seen to have great mental health literacy potential [79 ]. Australia has been very active in this area with several treatment websites for both youths and adults [80]. &&
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&
WHERE DO WE GO FROM HERE? The evidence-based strategies for the prevention of common mental disorders need to be expanded through further development of pragmatic highquality intervention programs and real world trials rigorously evaluated, multisite studies to expand knowledge on the robustness of programs, highquality replication studies implemented with fidelity to the original programs, longitudinal studies to demonstrate the long-term impact of early interventions, and interventions aimed at the population at large that maximize impact and acceptability [81 ]. &
Common mental disorders are preventable. Prevention is cost-effective. We have strong evidence and powerful effective tools on which to base prevention programs. These facts need to be fully communicated to providers, policy makers, and the population at large, and most importantly, acted upon.
Conflicts of interest There are no conflicts of interest.
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Prevention of common mental disorders D’Arcy and Meng 65. Spek V, Cuijpers P, Nyklicek I, et al. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med 2007; 37:319–328. 66. Van Straten A, Cuijpers P. Self-help therapy for insomnia: a meta-analysis. Sleep Med Rev 2009; 13:61–71. 67. Haddock CK, Rowan AB, Andrasik F, et al. Home-based behavioral treatments for chronic benign headache: a meta-analysis of controlled trials. Cephalalgia 1997; 17:113–118. 68. Hirai M, Clum GA. A meta-analytic study of self-help interventions for anxiety problems. Behav Ther 2006; 37:99–111. 69. National Institute for Health and Clinical Medicine (NICE). Computerised cognitive behavior therapy and depression and anxiety (Review of Technology Appraisal 51). http://guidance.nice.org.uk/TA97. [Accessed 25 January 2014] 70. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PLoS One 2010; 5:e13196. 71. Cuijpers P, Donker T, Johansson R, et al. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One 2011; 6:e21274. 72. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004; 328: 265. 73. Christensen H, Batterham P, Calear A. Online interventions for anxiety && disorders. Curr Opin Psychiatry 2014; 27:7–13. This article updates knowledge regarding the evidence base for online interventions for anxiety disorders. Recent studies have confirmed the value of computerized therapy for anxiety. Future trials are required to elucidate the active elements of effective programs for specific groups and ascertain optimal degree of guidance required.
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