Journal of Primary Prevention, 7(4), Summer 1987
Starting Points: Definitions and Premises The members of the Commission on the Prevention of MentalEmotional D i s a b i l i t i e s - - a n d the m a n y experts consulted by them - - r e p r e s e n t diverse mental health and other specialties and possess different orientations toward prevention. To proceed with a m i n i m u m of theoretical and philosophical debate, the Commission discussed and reached consensus at the outset on a number of definitions and premises t h a t underlie its review of current knowledge, its conclusions and recommendations.
Definitions Prevention Prevention means literally to keep something from happening. Within the field of mental health, it means intervening in a deliberate and positive way to counteract harmful circumstances before they cause disorder or disability. Early identification and treatment are essential mental health services, but if treatment is needed, the disability has not been prevented. Mental-Emotional Disability The term mental-emotional disability refers to a spectrum of mental and emotional disorders. We have not used the term "mental illness" alone because neither professionals nor the general public agree on what it means. Some t h i n k it refers only to the schizophrenias and affective or major mood disorders; others include a wide range of diagnoses. We are addressing the spectrum of mental-emotional disorders, including schizophrenia, affective disorders, anxiety, substance abuse and other cognitive, emotional or behavioral disorders which seriously interfere with an individual's life and productivity whether in work, school, relationships or general ability to "carry on. "1 The disordered 1The A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n Diagnostic and Statistical Manual of Mental
Disorders III l i s t s 230 s e p a r a t e d i a g n o s e s . 195
~ National Mental Health Association1986
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person, to a significant degree and over an extended period, is unable to function as expected by himself or herself or by concerned and caring others. We emphasize, however, that by disability we mean something quite different from common responses to ordinary stressors or problems of daily life, something different from occasional feelings of unhappiness or distress.
Risk, Risk Factor, A t Risk The concept of risk refers to a statistical association between some experience, condition or behavior and the development of a disorder. Subgroups that are at risk--i.e., that have a higher than average incidence of d i s o r d e r - - a r e determined through epidemiological studies of large groups of individuals. Risk factors are those circumstances, including genetic, biological and social characteristics, experiences or behaviors that characterize the sub-groups that have a higher-than-average incidence. It is important to note that while risk factors are statistically linked to higher incidence of mental-emotional disability, they by no means indicate that a particular individual will develop mental-emotional problems. Many factors are involved. Promotion of mental health and prevention of mental-emotional disabilities. The field of prevention of mental-emotional disabilities is directed primarily toward at-risk groups. There is, however, considerable overlap with the area of promotion of mental health where efforts are directed to population groups without defined risk. Promotion and prevention form a continuum; distinctions are made in terms of conceptual and research design.
Premises Prevention and Treatment History confirms that the ultimate control of disorders is accomplished through prevention rather than treatment. Moreover, the estimated 4 0 - 5 0 million people with mental-emotional disorders is so large a number that there could never be enough trained personnel or money to treat those already suffering. Tested and sensible prevention approaches can reduce the number of people who develop disabilities.
Any new direction within a field will prompt serious questions and theoretical debate, as well as professional turf guarding and differences of opinion over distribution of scarce resources. The Commission recognized that critics of prevention efforts have argued that emphasis on prevention will direct resources away from the many in need of treatment. Yet, of the seriously disabled, only one in five receives treatment, and those who receive treatment are not necessarily those in greatest need. Certain groups--minorities, children and older p e r s o n s - - h a v e been chronically underserved. The National Mental Health Association and other organizations work hard to ensure appropriate treatment services and research to produce new knowledge about treatment. But treatment must be augmented by efforts to keep people from needing mental health services in the first place. Decreasing the number of new cases of a disorder will enable t r e a t m e n t professionals to serve better those who do become ill and disabled. Expanded research initiatives directed toward prevention are urgently needed, and interventions already known to be effective must be implemented.
Questions of Cause and Effect In the development of mental-emotional disabilities, there rarely is a one-to-one correspondence between a specific cause and a specific disorder. We might wish that a bacterium or virus could be identified, a single gene or clear biochemical marker. Instead, current knowledge clearly indicates complex interactions of a number of factors. For example, it is known that stressful life events, especially multiple stressors, often precede the onset of severe disorder. A major study by the Institute of Medicine of the National Academy of Sciences found that, for a significant number of people, bereavement is a predisposing condition for extended serious depression. Likewise, researchers are finding that emotional distress often is the springboard for seeking escape in alcohol and drugs. Disability often progresses along a continu u m from troublesome but not disabling symptoms to breakdown. The fact that emotional pain can give rise to physical and emotional disabilities of many different kinds may well be the most important twentieth century finding in the health field. Multiple and complex etiologies, together with the variety of possible resulting disorders, form a complicated picture. But the complexity of the task is no excuse for abdicating the job. Congress first voted money for cancer research almost 100 years ago, and this year more
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t h a n one billion dollars a year will be spent. We still cannot prevent or cure all forms of cancer, but we are much farther a l o n g - - a n d no one is talking about giving up. Mental-emotional disorders are as complex and devastating in effect; their prevention will be accomplished through such a serious commitment.
Scientific Basis Those who argue against prevention sometimes demand a level of scientific proof they do not require of their own or other fields. Our view is t h a t the highest standards for scientific inquiry be the rule for all mental health endeavors. Findings based on scientific research were the basis for determining current knowledge for this report.
Professional Roles We believe t h a t mental health clinicians have an important but not necessarily dominant role to play in prevention. Therapists can provide clues to focus efforts to develop preventive interventions and can be advocates for prevention. But therapists who have spent their lives learning how to treat disorders may have neither the interest nor the requisite skills for prevention activities. Prevention requires a particular attitude and some special abilities. The time has come to train new professionals and add a new dimension to existing professions in mental and physical health care, social service and education.
Individual Responsibility We are increasingly aware t h a t each of us has a major responsibility for our own health, t h a t our life-style, habits and behavior to a great extent determine whether our bodies and minds are healthy. The information brought to this Commission and the changes recommended will help us understand and meet t h a t personal and fundamental responsibility for our own and our children's mental health.