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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
REDUCING RISKS FOR Mental Disorders
FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Patricia J. Mrazek and Robert J. Haggerty Editors
Committee on Prevention of Mental Disorders
Division of Biobehavioral Sciences and Mental Disorders
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
1994
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
NATIONAL ACADEMY PRESS
2101 Constitution Avenue, NWWashington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for the appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is the president of the Institute of Medicine.
The work on which this project is based was performed pursuant to Contract No. NIMH-OD-91–0014 with the National Institute of Mental Health.
Library of Congress Cataloging-in-Publication Data
Reducing risks for mental disorders: frontiers for preventive intervention research/Committee on Prevention of Mental Disorders, Division of Biobehavorial Sciences and Mental Disorders, Institute of Medicine; Patricia J. Mrazek and Robert J. Haggerty, editors.
p. cm.
Prepared at the request of the U.S. Congress.
Includes bibliographical references and index.
ISBN: 0–309–04939–3
1. Mental illness—Prevention—Research—Government policy—United States. 2. Mental health promotion—Research—Government policy—United States. 3. Mental illness—United States—Prevention. 4. Mental health promotion—United States. I. Mrazek, Patricia Beezley. II. Haggerty, Robert J. III. Institute of Medicine (U.S.). Committee on Prevention of Mental Disorders. IV. United States. Congress.
[DNLM: 1. Mental Disorders—prevention & control—United States. 2. Risk Factors. 3. Preventive Psychiatry. WM 100 R321 1994]
RA790.6.R44 1994
362.2′0425′0973—dc20
DNLM/DLC
for Library of Congress
92-47911
CIP
Copyright 1994 by the National Academy of Sciences. All rights reserved.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
Printed in the United States of America.
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Committee on Prevention of Mental Disorders
ROBERT J. HAGGERTY * (Chair), Professor of Pediatrics Emeritus,
University of Rochester School of Medicine and Dentistry, Rochester, New York
BEATRIX A. HAMBURG * (Vice-Chair), President,
William T. Grant Foundation, New York, New York
WILLIAM R. BEARDSLEE, Associate Professor of Psychiatry,
Harvard Medical School, Boston, Massachusetts
ROLAND D. CIARANELLO, Professor of Psychiatry and Behavioral Sciences,
Stanford University Medical Center, Stanford, California
JOSEPH T. COYLE, * Eben S. Draper Professor of Psychiatry and of Neuroscience, Chair of the Consolidated Department of Psychiatry,
Harvard Medical School, Belmont, Massachusetts
WILLIAM W. EATON, Professor,
Department of Mental Hygiene, School of Hygiene and Public Health, The Johns Hopkins University Hospital, Baltimore, Maryland
J. DAVID HAWKINS, Professor and Director,
Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington
FRITZ A. HENN, Professor and Chairman,
Department of Psychiatry and Behavioral Medicine, State University of New York at Stony Brook, Stony Brook, New York
ROBERT P. LIBERMAN, Professor of Psychiatry, UCLA School of Medicine; Director,
Clinical Research Center for Schizophrenia, Los Angeles, California
BEVERLY B. LONG, Chair,
International Committee on Primary Prevention, and
President-Elect,
World Federation for Mental Health, Atlanta, Georgia
SPERO M. MANSON, Professor and Director,
National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, Denver, Colorado
DAVID MECHANIC, * † Director,
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
RICARDO F. MUÑOZ, Professor of Psychology,
University of California, San Francisco, San Francisco General Hospital, San Francisco, California
HERBERT W. NICKENS, Vice-President of
Minority Health, Education, and Prevention, Association of American Medical Colleges, Washington, D.C.
RICHARD H. PRICE, Professor of Psychology and Research Scientist,
Institute for Social Research, University of Michigan, Ann Arbor, Michigan
NAOMI RAE GRANT, Professor and Head, Division of Child Psychiatry, Department of Psychiatry,
The University of Western Ontario, London, Ontario, Canada
*IOM Member
†NAS Member
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Institute of Medicine Staff
ROBERT M. COOK-DEEGAN, Director,
Division of Biobehavioral Sciences and Mental Disorders
CONSTANCE M. PECHURA, Associate Director,
Division of Biobehavioral Sciences and Mental Disorders
PATRICIA J. MRAZEK, Study Director
CAROLYN E. PETERS, Research Assistant
CAROL M. HOSPENTHAL, Project Assistant
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Preface
Mental disorders cause an enormous burden on affected individuals, their families, and society. While impressive advances have been made in the past two decades in defining, diagnosing, and treating many of the major mental illnesses once they become full blown, many of these disorders are characterized by a chronic or relapsing course that has high personal and economic costs to all concerned. Cures are rare. Therefore, the logic of trying to prevent the occurrence of mental disorders is clear. Yet, in sharp contrast to the situation in the physical diseases, efforts to prevent mental disorders have had low priority. Many voices have been raised to correct this gap, including Congress, who charged the Institute of Medicine to prepare an integrated report of current research with policy-oriented and detailed long-term recommendations for a prevention research agenda for mental disorders.
The committee appointed by the IOM to carry out this task provided the diversity, the wide view, and the expert knowledge that this field demands. It included a range of disciplines, including adult and child psychiatry, psychology, pediatrics, epidemiology, sociology, anthropology, and public advocacy (see Appendix B).
The committee's process was a multipronged effort. It involved extensive review of a literature that is large in volume but limited in rigorous evaluation of interventions. Conferences were convened with experts who had conducted large-scale interventions to prevent physical diseases, and with experts in the fields of ethics and cultural diversity; and there were spirited committee meetings, in which the form and
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
substance of the report were debated with an eye towards forging consensus in the final report. The committee examined some agency budget figures, but it was difficult to get firm data. In addition, several background papers were commissioned (see Appendix D). Committee members themselves contributed to many of the technical sections of the report. The conclusions and recommendations the committee makes in this report are based on its best judgment of the information and data that were available for review.
The committee concludes that the federal government should take several actions. For some mental disorders there have now been sufficient advances in knowledge to warrant the prompt mounting of intensive interventions designed to prevent mental disorders, so long as these programs are rigorously evaluated. For other conditions there is still the need for development of an adequate knowledge base before sound theoretically-based interventions are warranted. For the field in general there needs to be support for training of a cadre of investigators and for coordination of the currently fragmented efforts in prevention of mental disorders across the many departments of government and the private sector.
The committee recognized early that disparate definitions of the field of prevention were causing confusion in preventing mental disorders. The committee, therefore, developed a set of definitions to provide common terminology and to help achieve a common understanding of what is being done in the field. To date, the definitions have been so broad and flexible that almost everything has been labeled prevention at one time or another. The committee's more restrictive definition excludes interventions aimed at reducing recurrences among patients with diagnosed illnesses. Instead, we have labeled such programs as a part of good treatment. While there are honorable differences of opinion as to whether this should be called prevention, the committee recommends that for purposes of monitoring federal research and demonstration efforts, prevention research be limited to processes that occur before there is a diagnosable mental illness. When the new definition of prevention is used, we will be able to understand better what is being done in prevention per se. Our estimate is that the field of research on true prevention of mental illness, by our definition, is very small.
The committee recognizes the considerable barriers to progress in the prevention field. Currently there is little evidence from research that any specific mental disorder can be prevented. There is, however, considerable evidence that certain risk factors (some of which are causal of and some only markers of mental disorders) have been clearly identified. Using the model found effective in the prevention of physical disorders,
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
it seems quite appropriate to initiate interventions designed to reduce these identified risk factors (and also to enhance known protective factors) with rigorous evaluations of outcomes. One advantage of targeting interventions on risk factors is that certain clusters of them are common to several disorders, and the potential for reducing more than one disorder by comprehensive intervention is appealing and is likely to be more cost effective.
For other disorders the knowledge base is yet too small and must be further developed before theoretically sound interventions can be tested. Promising areas of research are delineated. For many mental disorders, there is now convincing evidence for a genetic predisposition, but in practically all disorders there is also evidence that the genetic factors do not act alone, and that environmental factors can precipitate, or delay, onset. Therefore, research on understanding the causes of mental disorders must integrate biologic and behavioral sciences. In addition, there is considerable evidence that many mental disorders are brought on by physical diseases and that behavioral factors initiate or delay onset of physical disease. The committee urges more research in the interactions between physical and mental disorders.
The quality of the Institute of Medicine staff was crucial to the development of this report. Dr. Patricia J. Mrazek, the study director, brought a background in both service experience and research expertise, together with her organizational skills and uncompromising attention to scientific evidence, to all aspects of the committee's work. She did most of the writing of the report, ably assisted by Carolyn Peters and Carol Hospenthal. We are very grateful for their skills and dedication.
We believe that the U.S. Congress was wise to initiate this timely review of the field of prevention of mental disorders. The field is so important that the nation must invest the relatively small amounts recommended in this report to capitalize on the advances already made and to develop the knowledge base necessary for future advances. The one-third of our nation who today face the threat of mental disorder during their lifetime will be immediate beneficiaries when effective prevention programs are implemented, and the nation as a whole will ultimately benefit from the lifting of the burden mental disorders placed upon it. The time is right to move ahead with a national agenda to prevent mental disorders.
ROBERT J. HAGGERTY, M.D., Chair
BEATRIX A. HAMBURG, M.D., Vice-Chair
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Acknowledgments
The Committee on Prevention of Mental Disorders expresses its appreciation to the agencies within the Department of Health and Human Services that co-funded this 24-month study: the National Institute of Mental Health (NIMH); the Administration on Children, Youth, and Families; the Maternal and Child Health Bureau; the Center for Substance Abuse Prevention; the Office of the Assistant Secretary for Planning and Evaluation; the Office of the Assistant Secretary for Health; and the Office of Disease Prevention and Health Promotion.
Many people outside of the committee contributed to this study in various ways. The committee gratefully acknowledges the enthusiastic support of Dr. Juan Ramos, Deputy Director of Prevention at NIMH and project officer for this study; the excellent assistance of Roseanne Price, who collaborated in the editing and writing of the report; and all of those who contributed by writing commissioned background papers, providing technical reviews of drafts of chapters, and making presentations to the committee. Many others contributed by providing preventive intervention research or service program materials, technical and funding information, and moral support. To all of you, the committee offers its sincere gratitude. The names and affiliations of contributors are listed in Appendix B; additionally, authors of commissioned papers are acknowledged in the relevant chapters. To anyone who was overlooked, please accept the committee's apologies and appreciation.
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Abstract
Hardly a family in America has been untouched by mental illness. As many as one third of American adults will suffer a diagnosable mental disorder sometime in their life, and 20 percent have a mental disorder at any given time. Although research on the causes and treatment of mental disorders remains vitally important—and indeed major advances are leading to better lives for increasing numbers of people—much greater effort than ever before needs to be directed to prevention.
The Senate Appropriations Committee of the U.S. Congress believed that a strategic approach to the prevention of mental disorders was warranted. The Congress mandated the National Institute of Mental Health to enter into an agreement with the Institute of Medicine (IOM) to prepare an integrated report of current research with policy-oriented and detailed long-term recommendations for a prevention research agenda.
The specific tasks of the IOM committee, as negotiated with NIMH and the co-funding agencies, were as follows:
Review the status of current research on the prevention of mental illness and problem behaviors and on the promotion of mental health throughout the life span. This should include an understanding of available research knowledge, research priorities, and research opportunities in the prevention research area.
Review the existing federal presence in the prevention of mental disorders and the promotion of mental health, spanning the continuum from research to policy and services.
Provide recommendations on federal policies and programs of
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
Models for Understanding Risk and Protective Factor Interaction,
185
Major Findings and Promising Leads,
191
7 ILLUSTRATIVE PREVENTIVE INTERVENTION RESEARCH PROGRAMS
215
Criteria for Examining Preventive Intervention Programs Described in the Literature,
217
Description of the Risk and Protective Factors Addressed,
217;
Description of the Targeted Population Group,
219;
Description of the Intervention Program,
220;
Description of the Research Methodologies,
221;
Description of the Evidence Concerning the Implementation,
221;
Description of the Evidence Concerning the Outcomes,
222
A Developmental Perspective,
222
Interventions for Infants,
223
Physical Health Interventions with Applications to Mental Health,
225;
Programs Aimed at Improving Parenting and Reducing Risks for Infants,
234;
Evidence from a Quasi-Experimental Study,
239;
An Example from Prevention Services,
239;
Findings and Leads,
240
Interventions for Young Children,
241
Programs Aimed at Improving Parenting and Enhancing Child Development,
242;
Programs Aimed at Enhancing Social Competence,
246;
Findings and Leads,
248
Interventions for Elementary-Age Children,
249
Programs Aimed at Enhancing Parenting Skills and Family Functioning,
249;
An Example from Prevention Services: Family Preservation Services,
250;
Programs Aimed at Enhancing Social Competence,
251;
Programs Aimed at Enhancing Academic Achievement,
256;
An Example from Prevention Services: School Reorganization,
257;
Evidence from Quasi-Experimental Studies,
258;
Findings and Leads,
259
Interventions for Adolescents,
261
Program Aimed at Enhancing Academic Achievement and School Behavior,
262;
Programs Aimed at Preventing Substance Abuse,
262;
Programs Aimed at Preventing Conduct Disorder,
269;
Evidence from Quasi-Experimental Studies: Altering School Organization and Social Environments,
270;
Evidence from a Quasi-Experimental Study: Programs Aimed at Violence Prevention,
273;
Findings and Leads,
274
Interventions for Adults,
275
Programs Aimed at the Marital Relationship,
276;
Programs Aimed at the Challenges of Childbearing and Childrearing,
279;
Programs Aimed at Occupational Stress and Job Loss,
282;
Programs Aimed at Preventing Depressive Disorders Among Adults at Risk Because of Poverty and Minority Status,
286;
Program Aimed at Supporting Adult Children Providing Care for Ill Parents,
289;
Findings and Leads,
291
Interventions for the Elderly,
292
Evidence from a Quasi-Experimental Study: Relieving Caregiver
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Burden,
293;
Programs Aimed at Enhancement of Coping with Widowhood and Bereavement,
294;
Evidence from a Quasi-Experimental Study: Mutual-Help Groups for Widowed Persons,
296;
Findings and Leads,
297
A New Generation of Developmental Studies,
297
Major Findings and Promising Leads,
298
8 TREATMENT RESEARCH AND PREVENTION RESEARCH: A COLLABORATIVE FRONTIER
315
Intervention Program Design,
317
Risk and Protective Factors and Etiological Chains,
317;
Co-morbidity of Disorders,
319;
Progressive Course of Maladaptive Behavior,
320;
Individual Differences,
321;
Multimodal Interventions,
322;
Timing, Duration, and Environment of Interventions,
323;
Intervention Effects on Family Members,
325
Methodological Research Issues,
326
Ethical and Cultural Considerations,
326
Dissemination Issues,
328
Findings and Leads,
328
9 MENTAL HEALTH PROMOTION
333
Conceptual Underpinnings,
335
Health Promotion Programs,
339
Gaps in Our Knowledge,
345
Findings and Leads,
348
AN AGENDA FOR THE NEXT DECADE
10 DESIGNING, CONDUCTING, AND ANALYZING PROGRAMS WITHIN THE PREVENTIVE INTERVENTION RESEARCH CYCLE
359
The Preventive Intervention Research Cycle,
360
Identification of the Problem or Disorder(s) and Review of Information Concerning Its Extent,
361;
Review of Risk and Protective Factors and Relevant Information from the Knowledge Base,
364;
Pilot Studies and Confirmatory and Replication Trials,
365;
Large-Scale Field Trials,
370;
Facilitation of Large-Scale Implementation of the Preventive Intervention Program in the Community,
372
Methodological Issues,
373
Structure and Duration of the Trial and Follow-up Period,
373;
Sampling,
376;
Measurement,
378;
Statistics and Analysis,
385
Documentation Issues,
389
Issues of Culture, Ethnicity, and Race,
391
Ethical Issues,
397
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Economic Issues,
405
Conclusion,
408
11 THE KNOWLEDGE EXCHANGE PROCESS: FROM RESEARCH INTO PRACTICE
415
The Role of the Community,
416
Defining the Problem and Assessing the Needs,
417;
Ensuring the Readiness of the Host Organization,
417;
Selecting a Model Program,
417;
Balancing Fidelity and Adaptability While Implementing the Program,
427;
Evaluating the Program's Effectiveness,
428;
Providing Feedback to the Researchers,
429
Strategies for Overcoming Barriers to the Knowledge Exchange Process,
430
Barriers in the Prevention Program,
430;
Barriers Related to the Practitioner, Clinician, Educator, or Administrator,
430;
Barriers Within the Host Organization,
431
Improving Community Access to Research Knowledge,
432
Conclusion,
434
12 INFRASTRUCTURE FOR PREVENTION: FUNDING, PERSONNEL, AND COORDINATION
437
Funding,
437
Data from an NIH Retrieval System,
438;
Data from an ADAMHA Draft Report and from the PRBs,
440;
Overview of Government Involvement in Preventive Intervention Research,
448;
Private Foundations,
449;
Conclusions,
449
Personnel,
454
Probable Demand for Trained Prevention Researchers,
454;
Educational Background of Current Researchers,
455;
The Current Research Training Picture,
456;
A Model for Training Prevention Researchers,
458;
Conclusions,
461
Coordination,
463
Conclusions,
465
13 CONCLUSIONS AND RECOMMENDATIONS: AN AGENDA FOR THE NEXT DECADE
467
Building an Enhanced Infrastructure for Preventive Intervention Research,
468
The Coordination Role and Structure,
469;
Research Training,
473;
Funding,
474
Expanding the Knowledge Base,
475
Funding,
478
Conducting Well-Evaluated Interventions,
478
Funding,
483
A Final Word,
483
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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH
APPENDIXES
A SUMMARY
487
B CONTRIBUTORS
555
C WORKSHOPS
571
D BACKGROUND MATERIALS
579
E JOURNALS PUBLISHING PREVENTION ARTICLES RELATED TO MENTAL DISORDERS
583
INDEX
589
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List of Boxes, Figures, and Tables
BOXES
4.1
Illustrations from the Behavioral and Social Sciences,
63
6.1
Children of Parents with Schizophrenia: Family History as a Risk Factor,
143
6.2
Children of Parents with Alcohol Abuse and Dependence: Multiple Psychosocial Risk Factors for Their Development,
160
6.3
Children of Parents with Mood Disorders: Opportunities for Prevention,
169
6.4
Low Birthweight as a General Risk Factor,
183
6.5
Quality of Interaction with Parents as a General Protective Factor,
185
6.6
Child Maltreatment,
188
11.1
Case Study: Replication of the Prenatal/Early Infancy Project,
428
12.1
Maternal and Child Health Bureau,
451
FIGURES
1.1
The Preventive Intervention Research Cycle,
16
2.1
The Mental Health Intervention Spectrum for Mental Disorders,
23
5.1
Annual Incidence of DIS/DSM-III Alcohol Abuse/Dependence,
78
5.2
Age of Onset of DIS/DSM-III Alcohol Abuse and Dependence,
79
5.3
Age of Onset of DIS/DSM-III Antisocial Personality Disorder,
82
5.4
Age of Onset of DIS/DSM-III Major Depressive Disorder,
91
5.5
Age of Onset of DIS/DSM-III Schizophrenia,
102
5.6
Age of Onset of DIS/DSM-III Cognitive Impairment,
107
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7.1
A Framework for Examining Preventive Interventions,
218
7.2
Developmental Tasks and Social Fields for Preventive Interventions Over the Life Course,
224
10.1
The Preventive Intervention Research Cycle,
362
10.2
Measurement Points Along the Time Line for the Intervention Trial and Follow-up Period,
381
10.3
Survival Function Estimates,
387
11.1
The Process by Which Practitioners and Policymakers Access Knowledge Based on Prevention Research,
433
TABLES
1.1
Time Line of Events Related to Prevention of Mental Disorders,
8
2.1
U.S. Public Health Service Definition of Prevention Research,
28
5.1
DSM-III-R Diagnostic Criteria for Conduct Disorder,
81
5.2
DSM-III-R Diagnostic Criteria for Antisocial Personality Disorder,
85
5.3
DSM-III-R Diagnostic Criteria for Major Depressive Episode and for Major Depression,
88
5.4
DSM-III-R Diagnostic Criteria for Dysthymia,
90
5.5
DSM-III-R Diagnostic Criteria for Psychoactive Substance Abuse and Psychoactive Substance Dependence,
94
5.6
DSM-III-R Diagnostic Criteria for Schizophrenia,
100
5.7
DSM-III-R Diagnostic Criteria for Primary Degenerative Dementia of the Alzheimer Type and Dementia,
106
5.8
Prevalence Data on DSM-III Major Depressive Disorder in the General Population by Age: A Review of Selected Studies of Children and Adolescents,
113
7.1
Illustrative Preventive Intervention Programs Using Randomized Controlled Trial Design,
226
11.1
Journals Cited Most Often in the NIMH Prevention Bibliography, 1983 to 1991,
422
11.2
Publications from the NIMH Preventive Intervention Research Centers (as of August 1993),
423
11.3
Clearinghouses That Provide Information Related to the Prevention of Mental Disorders,
425
12.1
Prevention Research Projects Funded by Agencies of NIH and the Former ADAMHA According to CRISP Definitions and Files,
441
12.2
Prevention Activities Funded by NIMH, NIDA, and NIAAA,
443
12.3
Support Received for the NIMH PRB Preventive Intervention Research Centers (PIRCs),
445
12.4
Support Received for the NIDA Epidemiology and Prevention Research Centers,
446
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12.5
Breakdown of NIMH Prevention Research Branch Budget for FY 1992,
447
12.6
Federal Agencies Involved in Preventive Intervention Research and/or Preventive Intervention Services Related to Mental Disorders,
448
12.7
Department of Health and Human Services Agencies Reporting Prevention Activities in Priority Areas, 1991,
450
12.8
NIMH Grant Mechanisms That Can Be Used for Research Training or Related Activities,
457
13.1
Recommendations for Federal Government Support Above 1993 Level of Support,
475
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