Prevention in Psychiatry: Why Now?

Background
Advances in the prevention of medical illnesses have transformed the human experience and lengthened the human life span by several decades during the past two centuries (1). Examples of these advances include modern sanitation and clean water initiatives, early childhood and adult vaccines, antibiotics, and more recently, the range of clinical tools used for the early detection and prevention of heart disease and many types of cancer (2). 

Psychiatry, however, has lagged behind other fields of medicine in the domain of prevention, despite the fact that psychiatric disorders are extremely common (one in four people of the world’s population will experience a mental illness during their lives (3)), are associated with tremendous suffering, and account for a large portion of worldwide disability burden (4). 

Thus the lack of attention given to the prevention of psychiatric illnesses is puzzling. Some possible explanations include:

  • The fact that the precise biology of most psychiatric conditions continues to elude scientists (although the development of an effective prevention method does not require an understanding of the biological mechanisms of disease)
  • The persistence of the long-standing stigma associated with these conditions, which likely partially accounts for the limited financial support available for treatment of mental illnesses, leaving even fewer resources available for their prevention
  • An insufficient understanding of the specific risk factors associated with these illnesses and the aspects of mental health that can be improved, or that prevention of psychiatric conditions is even possible. 

Current Research
In fact, there is growing evidence that the onset of major psychiatric illnesses can be prevented or at minimum delayed, or the severity of these illnesses diminished, using a range of treatments during the earliest stages of illness or before illness onset (5). The strongest evidence for effective prevention exists for depression; numerous studies have shown that a variety of behavioral programs, such as a course of cognitive behavioral therapy or exercise, can prevent an episode of depression in youth or adults who have mild symptoms of depression and/or a previous history of depression (6).

Also, a wide range of school-based programs (teaching mindfulness, yoga or social-emotional skills) have been found to not only reduce symptoms of depression and anxiety, but also to improve social-emotional behavior and academic performance in at-risk students (7). The hope is that these improvements will protect the mental health of these students, leading to reductions in the incidence of psychiatric illnesses over time. 

Studies focused on the prevention of schizophrenia have had mixed results; currently there is no conclusive evidence supporting the effectiveness of a particular intervention to prevent schizophrenia in at-risk individuals (8). However, community-based outreach campaigns that educate people about the early signs of psychosis can reduce the length of time that psychotic symptoms are left untreated (the “duration of untreated psychosis”, DUP) in individuals who are experiencing their first psychotic symptoms (9). This reduction in DUP leads to better clinical outcomes (10). 

“…community-based outreach campaigns that educate people about the early signs of psychosis can reduce the …“duration of untreated psychosis”, DUP…and lead to better clinical outcomes…”

Intervention Accessibility
In order for community-based prevention programs (such as DUP-reducing ones) to be effective, they need to be highly accessible and part of people’s daily routines. This is particularly true for programs that are targeting young people who are fairly unconcerned about their mental health but have certain “silent” (i.e., not particularly impairing) risk factors for mental illnesses, such as mild, subclinical symptoms of an illness, a history of early childhood adversity or of perinatal complications or infections, a substance use disorder, a family history of a serious mental illness, or non-familial genetic risk factors (11; see Dr. Roffman’s article for additional details). Although each of these individual risk factors may be associated with only a small amount of risk, two or more in combination may substantially increase one’s vulnerability to developing a psychiatric condition.

The good news is that it is likely that some people can modify their risk level, for example by adopting certain stress-modifying strategies (12). However, currently most people in our society are unaware of their level of risk for psychiatric illnesses, so understandably have few reasons to try to reduce it (if necessary). Newly developed screening approaches, that can occur in schools, workplaces, doctors’ offices or online, may change this, allowing at-risk individuals who could most benefit from preventive interventions to gain greater access to them. But much more work is needed before we will have highly effective and practical approaches for preventing psychiatric conditions embedded throughout our society. There is reason to be optimistic, however, that we will soon have access to many different types of tools that can be tested for their ability to reduce risk for conditions that are clearly, in some cases, preventable. 

Daphne J. Holt, MD, PhD
Director, Resilience and Prevention Program and Emotion and Social Neuroscience Laboratory
Co-Director, MGH Psychosis Clinical and Research Program
Associate Professor, Harvard Medical School.

References

  1. Center for Disease Control. CDC the power of prevention: Chronic disease . . . the public health challenge of the 21st century.; 2009.
  2. JW Vaupel PNAS 2021 “Demographic perspectives on the rise of longevity”
  3. World Health Organization. (2001). The world health report : 2001 : Mental health : new understanding, new hope. World Health Organization. https://apps.who.int/iris/handle/10665/42390
  4. https://www.who.int/health-topics/mental-health#tab=tab_2
  5. Mendelson T, Eaton WW. Recent advances in the prevention of mental disorders. Soc Psychiatry Psychiatr Epidemiol. 2018;53(4):325-339. 
  6. Van Zoonen K, Buntrock C, Ebert DD, et al. Preventing the onset of major depressive disorder: A meta-analytic review of psychological interventions. Int J Epidemiol. 2014;43(2):318-329.
  7. Werner-Seidler A, Perry Y, Calear AL, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: A systematic review and meta-analysis. Clin Psychol Rev. 2017;51:30-47.
  8. Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of psychosis: Advances in detection, prognosis, and intervention. JAMA Psychiatry. 2020;77(7):755.
  9. Melle I, Larsen TK, Haahr U, et al. Reducing the duration of untreated first-episode psychosis: Effects on clinical presentation. Arch Gen Psychiatry. 2004;61(2):143. doi:10.1001/archpsyc.61.2.143
  10. McFarlane WR, Susser E, McCleary R, et al. Reduction in incidence of hospitalizations for psychotic episodes through early identification and intervention. Psychiatr Serv. 2014;65(10):1194-1200. 
  11. A systematic review of transdiagnostic risk and protective factors for general and specific psychopathology in young people. Lynch SJ, Sunderland M, Newton NC, Chapman C.Clin Psychol Rev. 2021 Jul;87:102036.
  12. Burke AS, Shapero BG, Pelletier-Baldelli A, Deng WY, Nyer MB, Leathem L, Namey L, Landa C, Cather C, Holt DJ. Rationale, methods, feasibility, and preliminary outcomes of a transdiagnostic prevention program for at-risk college students. Front. Psyciatry. 2020.
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