from closer integration of prevention and treatment research, so that methodological advances in one area could be applied to the other (Pearson and Koretz, 2001). Similarly, it was suggested that a more unified approach to improving the public health could be developed with interventions that incorporate elements of targeted screening and treatment in a broader preventive approach (Weisz, Sandler, et al., 2005; Brown and Liao, 1999).
Recently, a related health care concept—personalized medicine—has emerged. The adjectives “predictive,” “preventive,” and “preemptive” are frequently attached to this concept (Zerhouni, 2006), suggesting that prediction based on early information about an individual can lead to the avoidance of disorder, a form of prevention. Personalized medicine was spawned in large part by new and enabling technologies of genomic analysis and involves the use of information about individual-level risks, including genetic or other biomarkers, to identify and intervene in incipient medical disorders. This concept can and has been applied to prevention and preemption of MEB disorders. While equating it with indicated and selective prevention, Insel (2008) termed this approach “preemptive psychiatry,” positing that it offers the greatest potential for the prevention of both physical and mental disorders. The committee views this concept to be a promising dimension of indicated prevention, but as only one component of a broader spectrum of needed approaches.
As discussed in Chapter 5, there have been substantial developments in identifying genetic and epigenetic information that may contribute to MEB disorders, as well as increased recognition that environmental exposures, particularly during early development, can interact with genetic characteristics to affect gene expression. Similarly, as discussed in Chapter 4, a variety of adverse childhood events, such as early trauma (Anda, Brown, et al., 2007) and other family and community adversities, have been associated with later adverse mental, emotional, and behavioral outcomes. This information is beginning to be used in predictive models for physical as well as MEB disorders; for example, as discussed later in this report, its application to potential indicated prevention of schizophrenia is very promising.
However, this approach is in its early stages and likely to evolve over the next decade or two. Before preemptive psychiatry based primarily on genetic information can be considered ready for widespread implementation, a number of substantial hurdles and risks to implementation must be recognized and addressed, such as the issues of creating a “genetic underclass” and differential access to health care and psychopharmacologies (Evans, 2007). More fundamentally, understanding of the causal role of genetic contributors to MEB disorders must be substantially improved. The committee’s call for collaborations between prevention scientists and clinical developmental neuroscientists is aimed at better understanding