have mental disorders when the intervention begins. However, if they are selected into the intervention on the basis of being in a high-risk group (selective) or for having early symptoms (indicated), then the intervention is considered preventive. The report also acknowledged that good treatment should often include preventive elements to reduce the likelihood of relapse or of disability, but it emphasized that interventions selected on the basis of an existing disorder should be considered treatment rather than prevention.
A significant modification of the classification system developed in the 1994 IOM report was proposed by the National Advisory Mental Health Council (NAMHC) Workgroup on Mental Disorders Prevention Research (1998). This report argued that the IOM system was too narrow because it excluded “all individuals with full-blown disorder” (National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, 1998, p. 16). The workgroup recommended expanding the definition of preventive intervention research to include (National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, 1998, p. 18):
trials involving participants who (1) have no current symptoms of mental disorder and were never symptomatic; (2) have current sub-clinical symptoms; (3) have a currently diagnosed disorder and/or were previously symptomatic—for them the emphasis is on prevention of relapse or recurrence; or (4) have a currently diagnosed disorder, with the emphasis on prevention of comorbidity or disability.
Despite the broadening of the definition of prevention, the report specifically stated that the expanded research agenda “does not represent a decreased commitment to preventing mental disorders in people currently without symptoms or those who have never been mentally ill” (National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, 1998, p. 20).
Comments on the report proposed that the broadened definition had several problems. One concern was that it failed to make distinctions between prevention and treatment, and therefore all treatment could essentially be considered prevention (Greenberg and Weissberg, 2001). Another concern was that the potential relabeling of treatment studies as prevention could dilute resources for prevention research for populations without a diagnosed disorder (Shinn and Toohey, 2001; Heller, 2001; Reiss, 2001). Despite criticisms of the broadened definition, others noted that regardless of where the line between prevention and treatment is drawn, benefits could be gained