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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [55]-[59]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [55]-[59]
CHAPTER 3 Prevention of Depression and Bipolar Disorder
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The prevention of an individual's first episode of depression is worthy of greater study among investigators concerned with mood disorders. Not only is the first episode devastating for individuals and those around them but it is a major burden within our health system and society (Murray & Lopez, 1997). Once the first episode of major depressive disorder (MDD) occurs, the sequelae are substantial. Following an episode of MDD, the probability of subsequent episodes is significantly increased, even to the point that many now consider MDD to be a chronic disease. As noted in Chapter 1, the sequelae to MDD are numerous and include poorer social relationships, increased substance abuse, increased use of medical services, interference with long-term cognitive functioning, significant comorbidity with major health problems, and younger ages of death (even when deaths by suicide are taken into account). Most investigators of mood disorders believe that the first episode lays down neural pathways that are difficult to overcome and, without modification via medications or psychosocial interventions or their combination, are likely to be lasting pathways that impact individuals' lives. Even though prevention of MDD is an important topic, empirical work in this area is difficult and has been slow to progress. Some recent work has been conducted on the prevention of second and subsequent episodes (Craighead, Hart, Craighead, & Ilardi, 2002), but the work designed to prevent the first episode of MDD has been meager. Before addressing the empirical work on prevention of MDD, it is important to note again the conceptual and historical context in which general prevention research has been defined.
HISTORICAL CONTEXT AND DEFINITIONS
A Brief History of Prevention in Mental Health
During the last decade, three reports have established a historical context and defined the mental health prevention classification system:
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Reducing Risk for Mental Disorders: Frontiers for Prevention Intervention Research, Institute of Medicine ( 1994)
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Priorities for Prevention Research at NIMH: A Report by the National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, National Institutes of Health, National Institute of Mental Health (1998)
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Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services (US-DHHS), Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health (1999)
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In 1998, the National Institute of Mental Health (NIMH) established an ad hoc committee to review the progress of mental health prevention research. The committee's report, Priorities For Prevention Research at NIMH: A Report by the National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, traced the history of prevention in mental health and proposed the following generational taxonomy:
The first generation of efforts to prevent mental disorder began in the 1930s when, as an outgrowth of the turn-of-the-century mental hygiene movement, the focus gradually expanded beyond ameliorating the plight of those in asylums to include the prevention of many forms of social and emotional maladjustment. The new goal was to assure the well-being and “positive mental health” of the general population through primary-prevention interventions aimed at creating health-promoting environments for all. These efforts were based on humanitarian concern, but had few, if any, research underpinnings.
The second generation of interventions to prevent mental disorder, which began in the late 1960s, reflected the impact of a growing health and mental health research knowledge base. Some scientists retained their broad-based emphasis on primary prevention, while others began to target specific “at-risk” groups for study and intervention. During the 1960s there had been a burgeoning of research on the causes, mechanisms, and effects of stress on bodily and mental
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functioning. “At-risk” persons were defined as those who would predictably experience periods of substantial life stress, such as domestic violence, divorce, bereavement, or unemployment as precursors of mental distress or disorder. Changing behavior for health also became an active area of study and prevention during the same period. Those studies placed a strong emphasis on preventing lung cancer and heart disease through programs to prevent or reduce smoking, obesity, high cholesterol intake, and sedentary life styles.
NIMH, 1998
This NIMH committee observed that over the next decade mental health prevention interventions continued to proliferate. After reviewing progress in this field, however, the 1978 President's Commission on Mental Health determined that previous investigation had been “unfocused and uncoordinated.” As a remedy the commission recommended the establishment of a Center for Prevention at NIMH to coordinate and enhance research in mental health primary prevention research. The NIMH report determined that “during the last 20 years The NIMH Center for Prevention Research and its programmatic successors have stimulated considerable progress in building the scientific foundation of an interdisciplinary field of prevention research in areas of epidemiology, human develop-ment, and intervention research methodology” (NIMH, 1998). The committee concluded that sufficient progress had been made in establishing the scientific basis for mental health prevention science to declare that we were then in a third generation of prevention activity. Thus, prevention research could build on prior accomplishments of prior preventive interventions and integrate these with advances in the biomedical, behavioral, and cognitive sciences. Despite the described significance and need for prevention research and this sanguine view of the 1998 NIMH committee, the amount of work studying the prevention of an initial episode of depression has remained meager. In contrast, considerable progress has been made in the development of a nomenclature for prevention research. In order for the field to progress, it was
necessary to develop a clear terminology for investigators to follow.
Early Classification Systems
The Commission on Chronic Illness ( 1957) developed the original public health classification system of disease prevention. Three types of preventive interventions were identified: primary, secondary, and tertiary. During the last 40 years the definitions of these types of prevention have expanded to include an array of nuanced but related meanings.
In 1983 and in 1987, Robert Gordon proposed an alternative classification of prevention that was based on the empirical relationships found in practically oriented disease prevention and health promotion programs. These included programs which he labeled universal, selective, and indicated prevention. Although Gordon's classification system was to be distinct from that of the Commission on Chronic Health, the use of these two classification systems slowly deteriorated into a confusing, merging and mixing of definitions, e.g., “universal primary prevention.” This confusion was particularly problematic when this terminology was applied to the classification of the prevention of psychiatric disorders, because the classical public health prevention classification system and Gordon's reclassification were both designed for use in the description of the prevention of biological disorders, not of interventions to prevent psychiatric and psychological disorders. The 1994 Institute of Medicine (IOM) report, Reducing Risk for Mental Disorders: Frontiers for Prevention Intervention Research, presented a cogent discussion of the inherent pitfalls in applying general prevention classifications to problems in mental health:
One of the main problems has been the notion of “caseness” that is used in public health. It is often more difficult to document that a “case” of mental disorder exists than it is to document a physical health problem. Agreement regarding the occurrence of a
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case of mental disorder varies with time and with the instruments and diagnostic systems employed and with the theoretical perspective of the evaluators. Also symptoms and dysfunctions may exist even though criteria for a DSM-III-R diagnosis are not present. Finally, the outcomes in very young children (birth to age 5) are often not diagnosable as “psychiatric caseness” but rather as impairments in cognition and psychosocial development.
IOM, 1994
Recent Attempts to Define Prevention
The IOM report chose to resolve the confusion in terminology by using the term prevention to refer only to interventions that occur before the initial onset of a disorder. In this system, prevention included all three elements of Gordon's system ( 1983, 1987). Efforts to identify cases and provide care for known disorders were called treatment, and efforts to provide rehabilitation and reduce relapse and reoccurrence of a disorder were called maintenance/interventions. Further distinctions were made within the prevention category. We have employed these definitions throughout this chapter. The definitions are described in the following paragraphs.
Universal mental health prevention interven-tions are defined as efforts that are beneficial to a whole population or group. They are targeted to the general public or a whole population group that has not been designated or identified as being at risk for the disorder being prevented. The goal at this level of prevention is the reduction of the occurrence of new cases of the disorder.
Selective mental health prevention interven-tions are defined as those efforts that target individuals or a subgroup of the population whose risk for developing the mental health disorder is significantly higher than average. The risk may be immediate or lifelong. Biological, psychological, or social risk factors associated with or related to the specific mental health disorder are used to identify the individual or group level of risk. Those with the identified risk factors are referred to as those “at risk.”
Indicated prevention interventions are defined as
those efforts that target high-risk individuals who are identified as having minimal but detectable signs or symptoms that predict the mental disorder or biological markers indicating predisposition to the disorder. For example, individuals who have some symptoms of MDD but do not yet meet criteria for the disorder would fall into this group. Indicated prevention excludes individuals whose signs and symptoms meet diagnostic criteria for the disorder. The IOM identified three aims or desired outcomes for mental health prevention: (1) reduction in the number of new cases of the disorder; (2) delay in the onset of illness; and (3) reduction in the length of time the early symptoms continue as well as halting the progression of severity so that individuals ultimately do not meet diagnostic criteria. The 1999 Mental Health: A Report of the Surgeon General agreed with the IOM and defined prevention as the “prevention of the initial onset of a mental disorder or emotional or behavioral problem, including prevention of comorbidity” (US-DHHS, 1999). In addition, the report defined other terms that were often imprecisely used in discussions of prevention. They are listed below:
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First (initial) onset: the initial point in time when an individual's mental health problems meet the full criteria for a diagnosis of a mental disorder
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Risk factors: “characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, compared to someone selected at random from the general population, will develop a disorder” (US-DHHS, 1999). Although risk factors precede the first onset of a disorder, they may change in response to the disorder, development, or stressors.
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Protective factors: Factors that “improve a person's response to some environmental hazard resulting in an `adaptive outcome.' These factors can be found within the individual or within the family or community. They do not necessarily cause normal development in the absence of risk factors, but they may make an appreciable difference in the influence exerted by risk factors” (US-DHHS, 1999).
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Risk of onset vs. risk of relapse: The terminologies that refer to the risk of the development of a disorder are often used without specification of the risk of onset vs. the risk of relapse. This is a key distinction because “the risks for onset of a disorder are likely to be somewhat different from the risks involved in relapse of a previously diagnosed condition” (US-DHHS, 1999). Undoubtedly, this same distinction is true for factors that protect against onset or relapse. As will be noted later, not all “prevention” projects have made this distinction between initial and second or subsequent episodes of MDD.
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Goals of Prevention Programs
In addition to the IOM's goals of reducing the number of new cases and delaying the onset of MDD and the insidious nature of the onset and course of MDD, there are other ancillary and associated goals of prevention programs. For example, prevention of initial MDD is likely to have an impact on school and work performance, social skills, and quality of life, reduce the need of medical services, and reduce MDD-related substance abuse disorders. In the long run, prevention programs may actually extend the lives of individuals who were at risk but did not develop the disorder, by reducing both the risk of suicide completion and the behavioral and biological sequalae of the disorder. Another goal of prevention programs is to teach resiliency to the program participants. Individuals at risk for MDD are likely to experience negative and traumatic events, as are other individuals in our society. Prevention programs have a goal of teaching at-risk individuals to become more resilient—to develop skills and abilities to spring back from or adapt to adversity. A further goal of prevention programs is to enhance and enrich the positive aspects of living. By changing cognitive patterns, enhancing social skills, and increasing resiliency, individuals who otherwise might live a marginally happy life may have the opportunity to develop greater self-esteem and self-efficacy and live a more successful and adaptive life. This positive adaption in life may lead to the development of more
adaptive neurological pathways. Emotional intelligence (Goleman, 1995) may also be enhanced by successful preventive programs. The societal goals of depression prevention programs are also numerous. For example, even a modest reduction in new cases of MDD would reduce the economic burden of the disorder. The disorder itself would not have to be treated so frequently, nor would the associated (sometimes self-treatment) problems of alcohol, tobacco, and other forms of substance abuse. Each prevented case of MDD would increase the limited resources available to other health initiatives. Productivity would be increased in the workplace. Thus, the call for effective programs to prevent the first episode of MDD is a forceful and significant one—significant for individuals, families, and society as a whole.
RISK FACTORS FOR MAJOR DEPRESSION
To develop programs for individuals “at risk” for MDD, it is necessary to develop knowledge and understanding of factors and their interactions that render one likely to develop MDD. Chapter 1 provided evidence for many of the risk factors for MDD, so the details will not be reiterated here. These risk factors include dysfunctional parenting and family interactions; gender; personality and temperament; cognitive vulnerabilities; internal and external stress, including negative life events; and poor interpersonal relationships. In addition to the preceding risk factors, the following risk factors that have implications for prevention of MDD are important and worthy of further detailed review. These include subsyndromal depression, poverty, violence, and cultural factors.
Among adults, subsyndromal depression (two or more symptoms for 2 weeks or longer) appears to cause as much health impairment and economic burden as MDD, and these individuals are at increased risk for developing subsequent MDD (Fava, 1999; Johnson, Weissman, & Klerman,
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doi:10.1093/9780195173642.003.0004
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