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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH OVERVIEW

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH This page in the original is blank.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1 Introduction In his 1963 message to Congress, President John F. Kennedy drew the nation's attention to the critical problem of mental illness and championed prevention as a promising approach. He contended that prevention could proceed along two fronts: “Prevention will require both selected specific programs directed especially at known causes, and the general strengthening of our fundamental community, social welfare, and educational programs which can do much to eliminate or correct the harsh environmental conditions which often are associated with mental retardation and mental illness” (Kennedy, 1963). These prevention activities were designated to take place in part within the newly created, federally mandated system of community mental health centers. However, other agendas took precedence within the centers, and little prevention work was actually done (Torrey, 1988; Klein and Goldston, 1977). Thirty years after Kennedy's message, the problems of mental illness are still immense. In this country, it is estimated that 20 percent of adults suffer from an active mental disorder in a given year, and 32 percent can be expected to have such an illness sometime during their life (Robins and Regier, 1991). These estimates, which come from the National Institute of Mental Health's Epidemiologic Catchment Area (ECA) study, are the most current statistics based on government-supported research. The estimates are considerably higher than the 10 to 15 percent estimated as the annual prevalence of mental disorder by the President's Commission on Mental Health (1978) and reflect the growth of knowledge in this area. The ECA figures are larger—and probably more accurate—because of improve-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH ments in methodology and instrumentation. However, differences in diagnostic criteria may also account for some of the difference in the estimates. The ECA study defined active disorder as a disorder for which criteria (codified in the third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1980]) had been met at some time in the person's life and at least one symptom (or one episode) had been present in the year prior to interview. Mental disorders can occur throughout the life span, but the type and nature of the illnesses vary with age. At least 12 percent (or about 7.5 million) of our nation's 63 million children and adolescents suffer from one or more mental disorders—including autism, attention deficit hyperactivity disorder, severe conduct disorder, depression, and alcohol and psychoactive substance abuse and dependence (DHHS, 1991; IOM, 1989; OTA, 1986). Based on a review of seven epidemiological studies, the Office of Technology Assessment (OTA, 1991) reported that the prevalence of diagnosable mental disorders among individuals under age 20 may be closer to 20 percent. In 1990, suicide ranked as the third leading cause of death among 15- to 24-year-olds (National Center for Health Statistics, 1993). The American Academy of Child and Adolescent Psychiatry (1990) reported that growing numbers of children and adolescents are at exceptionally high risk for developing a mental disorder: for example, 1.5 million children and adolescents are reported abused or neglected each year, 300,000 are in the foster care system, and 7 million live with an alcoholic parent. In addition, more than 18,500 children and adolescents have been left motherless by the HIV/AIDS epidemic, and that number will more than double by 1995 (Michaels and Levine, 1992). Toward the other end of the life span are the 4 million older Americans who, according to a National Institute on Aging estimate, are likely to be suffering from Alzheimer 's disease (Evans, Scherr, Cook, Albert, Funkenstein, Smith et al., 1990) and the 15 to 25 percent of the elderly in nursing homes who are clinically depressed (NIH Consensus Development Panel on Depression in Late Life, 1992). Mental illness of this magnitude places an extraordinary burden on the financial and social resources of this country. Current expenditures in this area include not only core costs such as direct costs for treatment and indirect costs for lost worker productivity, but also related costs such as those resulting from investment of time while caring for mentally ill family members. One estimate put our annual total economic cost of drug abuse, alcohol abuse, and mental illness at just over $218 billion in 1985, of which $44 billion was for drug abuse, $70 billion for alcohol abuse, and $103 billion for other mental illness (Rice, Kelman, Miller, and Dunmeyer, 1990). Based on this study, using

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH socioeconomic indexes, Rice and colleagues have estimated that for 1990 the totals were over $66 billion for drug abuse, $98 billion for alcohol abuse, and $147 billion for other mental illness (D. Rice, personal communication, April 1993). The concomitant cost in human suffering and lost opportunity is incalculable. Mental and physical health are closely linked, and beyond the costs just described, the contribution of mental health to physical well-being has to be considered. Physical disorders can cause serious mental disorders, and physical disorders can have their origin in psychosocial processes (IOM, 1982). Studies estimate that 60 percent of visits to physicians for medical symptoms are due in part or whole to psychosocial problems (Regier, Goldberg, and Taube, 1978), and the frequency of diagnosable mental disorder found in studies of general practice ranges from 11 to 36 percent (Eisenberg, 1992; Barrett, Barrett, Oxman, and Gerber, 1988). In a comparison of the functioning of patients with depression and patients with chronic medical conditions, only chronic heart disease produced more disability than depressive symptoms (Wells, Stewart, Hays, Burnam, Rogers, Daniels et al., 1989). Contrary to the current rigid arbitrary separation of research on mental and physical disorders, the human condition is one in which the mental and physical processes inexorably intertwine. Despite enormous expenditures attempting to contain the problem of mental illness, it is estimated that only 10 to 30 percent of those in need receive appropriate treatment (DHHS, 1991; IOM, 1989; NMHA, 1986). Thus it is time to take a fresh look at prevention to see if it can be made to function as a full partner with new treatment approaches in addressing our nation's mental health care crisis. A NEW EMPHASIS ON PREVENTION: OPPORTUNITIES AND STRENGTHS Several forces are coming together to enhance the timeliness of a new emphasis on research to prevent mental disorders. As is detailed in the chapters to come, the knowledge base for preventive interventions, which had been scanty in the 1960s, has undergone a remarkable expansion, fueled by a considerable research effort within the past decade. Fundamental advances in our understanding of the biological substrates and genetics underlying numerous mental disorders and of the role of environmental factors in the onset of specific disorders have been made. There is also a promising variety of new interventions that offer a much more optimistic view for the future of prevention of some specific mental disorders.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH The concept of risk reduction is at the heart of prevention research. Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected from the general population, will develop a disorder (Werner and Smith, 1992; Garmezy, 1983). In this report a broad definition of risk factors is used, encompassing biological (including genetic), psychological, and social factors in the individual, family, and environment. Recent research has demonstrated that many at-risk individuals also have variables in their background or life that serve as protective factors. A well-documented description of the interplay between risk and protective factors is a critical scientific first step in establishing successful preventive intervention programs. Such a description is now available for some disorders, and research is under way to identify such factors for a number of others. The next step is to identify causal risk factors that may be malleable, that is, that can be altered through interventions. Then the effects of these interventions are tested in systematic, empirical, and rigorous ways, most often in preventive intervention trials. This step also contributes to the fundamental knowledge base through the determination of causality and malleability. One way to determine causality and malleability of risk factors for specific disorders is through examination of preventive interventions aimed at a single factor or a cluster of factors. If risk factors can be decreased or in some way altered, and/or if protective factors can be enhanced, the likelihood that at-risk individuals would eventually develop the mental disorder would decrease. This risk reduction model is widely used for prevention of physical illness. As described in Chapter 3 of this report, to prevent physical disorders due to complex multiple causes, such as cardiovascular disease, the strategy is to determine risk factors and then to target interventions to such risk factors or to people with these risk factors. As with any disorder with multiple causes, it is difficult to document that any specific physical illness can be prevented in a given individual by risk reduction. However, indirect evidence from matching trends of risk reduction across populations with decreases in mortality or morbidity in groups that have changed behaviors is highly consistent with this theory, and results are encouraging. For example, through behavioral changes in diet and smoking, declines in the risks of morbidity have been achieved. The study of mental disorders is at the stage where the knowledge base is comparable to the knowledge base prior to the large trials in the prevention of physical illnesses. Because of the power of the risk reduction model, this report is entitled Reducing Risks for Mental Disor-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH ders: Frontiers for Preventive Intervention Research. A large body of knowledge exists today about the risk factors associated with many major mental disorders, the preventive interventions directed at reducing these risk factors and improving protective factors, and the research methods to assess the effectiveness of these interventions. This body of knowledge reflects the major advances that have been made in the field of mental disorder prevention. OBSTACLES TO PROGRESS Despite these recent advances in the prevention field and the fact that the history of mental health efforts related to prevention dates back many decades (see Table 1.1), progress has been limited because the efforts have been sporadic and have often lacked focus. Why hasn't the field received more concentrated attention? In response to a request from Congress and the National Institute of Mental Health (NIMH), the Institute of Medicine's Committee on Prevention of Mental Disorders examined this question as part of a broad review of the status of prevention research. The committee found several apparent reasons for this inattention, some of which reflect problems that are shared with the larger field of treatment of mental disorders. One of the most important is that mental disorders have long carried a stigma. Because many people consider such illnesses to arise from a defect in character or will, patients and their families still try to hide the disorder and thus never seek or receive needed attention. Even some federal agencies heavily involved in the prevention and treatment of mental disorders (e.g., agencies supporting interventions aimed at alcohol and substance abuse and dependence) do not use the term mental disorder. Another difficulty is that even though research has shown that a number of effective treatment interventions are available—such as those for depression and anxiety disorders—this information is not generally known by the public. Also, many believe that unless treatment for a particular disorder is highly effective, nothing can be done in regard to prevention. In fact, for some disorders, such as conduct disorder, prevention may have a particularly important role because treatment has been so ineffective. Another problem has been the lack of an organizing theoretical framework in the prevention of mental disorders. Only recently has the concept of risk reduction begun to take hold. Also, current understanding of the mechanisms that link risk and protective factors with proximal and distal outcomes is not well established for mental disorders. A great deal more is known about how to prevent some physical diseases (e.g.,

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 1.1 Time Line of Events Related to Prevention of Mental Disorders 1909 The Mental Health Association was founded; subsequently it became the National Association for Mental Health and then the National Mental Health Association (NMHA). Since its inception, it has advocated for prevention of mental illness and promotion of mental health. 1910 Public meeting on “Prevention of Insanity” organized by the New York Committee on Mental Hygiene. Topics included alcoholism, syphilis, drug addiction, head injuries, infectious diseases such as meningitis, and influences of fatigue and stress. 1915 The Proceedings of the National Conference of Charities and Correction contained papers on prevention of mental illness and mental retardation. The ideas included sterilization, reduced immigration, and more institutions to lower the numbers of “feeble-minded” in the community. 1920s The child guidance movement and the mental hygiene movement (fostered by the National Committee for Mental Hygiene that was organized by Clifford Beers) were begun. Both movements were committed to prevention as well as treatment of mental illness and highly valued the role of local communities in solving problems, including prevention of juvenile delinquency. 1930 The White House Conference on Child Health and Protection issued a report with an expanded focus that included social and environmental factors that affect the physical and mental health of children. 1930s The national commitment to prevention decreased, and the treatment-oriented approach began to dominate. Insurance plans created at this time reinforced the illness/treatment approach. 1946 Passage of the National Mental Health Act (P.L. 487) authorized the creation of the National Institute of Mental Health (NIMH). 1948 The World Federation for Mental Health, an independent organization with close ties to the United Nations, was created and included prevention within its purview. 1948 The Mental Health Study Center, a small NIMH community laboratory, was established in Prince Georges County, Maryland, to apply public health principles to the practice of mental health at the community level. For the next 34 years, research was done and treatment and prevention services were provided. 1954 The first organized training program in mental health consultation, which included a prevention component, began at the Harvard School of Public Health, Laboratory of Community Psychiatry. 1955 The Mental Health Study Act directed the Joint Commission on Mental Illness and Health to analyze and evaluate the needs and resources of the mentally ill and make recommendations for a national mental health program. 1961 The Joint Commission on Mental Illness and Health released Action for Mental Health to the Senate and House of Representatives. 1963 President John F. Kennedy, in a message to Congress, championed prevention as an approach to the problem of mental illness.  

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1963 The Community Mental Health Centers Act listed mental health consultation and education, which included prevention, as one of the five essential services necessary for such centers to qualify for federal funds. This was the first time in any federal health statute that a preventive service was declared mandatory. 1969 The Joint Commission on Mental Health of Children produced a report saying that millions of children were in need of services, and millions were at risk. 1973 NMHA formed a Prevention Task Force. 1975 The first Vermont Conference on the Primary Prevention of Psychopathology was sponsored by the World Federation for Mental Health, NIMH, and the John D. and Catherine T. MacArthur Foundation. 1976 The Conference on Primary Prevention sponsored by NIMH resulted in Primary Prevention: An Idea Whose Time Has Come. 1978 The President's Commission on Mental Health reported that (1) efforts to prevent mental illness and promote mental health were unstructured, unfocused, and uncoordinated and (2) preventive efforts received insufficient attention at the federal, state, and local levels. The commission recommended establishing a Center for Prevention in NIMH. 1978 The position of Coordinator for Disease Prevention and Health Promotion was established at the National Institutes of Health (NIH). 1979 The first annual Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Conference on Prevention was held. 1980 The NIH Prevention Coordinating Committee was formed, with the NIH Coordinator for Disease Prevention and Health Promotion as the designated prevention coordinator. 1980 The Public Health Service Act (in response to the presidential endorsement of the 1978 President's Commission on Mental Health) was amended to give special attention to efforts to prevent mental disability. Among other requirements, this act and a 1983 amendment (1) established the Office of the Deputy Director for Prevention and Special Projects in NIMH, and (2) designated an Associate Administrator for Prevention within ADAMHA to promote and coordinate prevention programs, including those run by NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Associate Administrator was made responsible for an annual report to Congress describing the prevention activities undertaken by ADAMHA and its agencies. 1980 NIDA established its Prevention Research Branch. 1981 The Select Panel for Promotion of Child Health (established by Public Law 95–626) presented its findings to the U.S. Congress and the Secretary of Health and Human Services. The panel reported a need for better coordination of mental health and health services due to the frequent concomitance of health and mental health problems in children. 1981 The Omnibus Budget Reconciliation Act folded the community mental health centers into alcohol, drug abuse, and mental health block grants to the states and introduced large cuts in all human service appropriations.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1982 The Center for Prevention Research (CPR) was established at NIMH. This was a step toward consolidation of preventive intervention research throughout NIMH into one unit. 1983 NIMH Center for Prevention Research established its first Prevention Intervention Research Center (PIRC). 1983 ADAMHA Associate Administrator for Prevention was appointed, as mandated by an amendment to the Public Health Service Act, to promote and coordinate the research programs of its component agencies—NIAAA, NIDA, and NIMH. 1984 NMHA established the Commission on the Prevention of Mental-Emotional Disabilities. 1985 NIMH appointed its first Deputy Director for Prevention, mandated by the 1980 Public Health Service Act. 1985 The Office of Substance Abuse Prevention (OSAP) was established. 1985 NIDA published the first of several monographs dealing with preventing drug abuse. 1985 The Center for Prevention Research reorganized into the Prevention Research Branch within the newly created Division of Clinical Research in NIMH. 1986 A prevention initiative was undertaken by the American Academy of Child and Adolescent Psychiatry, and a Project Prevention Steering Committee was formed. The initiative resulted in a series of prevention monographs published by OSAP. 1986 NIAAA established the Prevention Research Branch within the Clinical and Prevention Research Division, created at the same time. 1986 The position of Assistant Director for Disease Prevention at the Office of Director level was established within NIH. 1986 The Office of Technology Assessment (OTA) issued a report entitled Children's Mental Health: Problems and Services. The report concluded that there was a substantial theoretical and research base to show that mental health interventions were effective for children. 1986 NMHA released a report by the Commission on the Prevention of Mental-Emotional Disabilities, The Prevention of Mental-Emotional Disabilities. 1987 NIMH published Preventing Mental Disorders: A Research Perspective. 1987 The National Prevention Coalition was established within NMHA. 1989 The U.S. General Accounting Office issued a report to Senator Inouye, Mental Health: Prevention of Mental Disorders and Research on Stress-Related Disorders, a critique of the implementation of prior recommendations in the prevention field. 1989 The Institute of Medicine (IOM) issued Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders: Mobilizing a National Initiative. Prevention was not emphasized. 1990 Because of a congressional mandate, NIMH entered into an agreement with IOM so that IOM could prepare an integrated report of current prevention research, with policy-oriented and detailed long-term recommendations for a prevention research agenda.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1990 The American Psychiatric Association published a report prepared by the Task Force on Prevention Research of the Council on Research with a review of research on the prevention of psychiatric disorders. 1990 The American Academy of Child and Adolescent Psychiatry published Prevention in Child and Adolescent Psychiatry: The Reduction of Risk for Mental Disorders. 1990 A National Plan for Research on Child and Adolescent Mental Disorders (National Advisory Mental Health Council) emphasized scientific research concerning biomedical risk factors and capacity building for scientific researchers. 1990 NIMH held its first National Conference on Prevention Research, and a NIMH Steering Committee on Prevention was established to write a report on the current status of prevention research within NIMH. 1992 The ADAMHA Reorganization Act abolished ADAMHA, organized the three research institutes (NIAAA, NIDA, and NIMH) under NIH, and provided for an Associate Director for Prevention in each research institute. The service components from ADAMHA were reorganized into the Substance Abuse and Mental Health Services Administration (SAMHSA) as the Center for Substance Abuse Treatment, the Center for Substance Abuse Prevention, and the Center for Mental Health Services. 1992 The IOM Committee on Prevention of Mental Disorders was formed in accordance with the NIMH agreement. 1993 NIMH Steering Committee on Prevention released The Prevention of Mental Disorders: A National Research Agenda at the third NIMH National Conference on Prevention Research. through immunizations for specific infections). The lack of clarity regarding risk mechanisms for mental disorders has contributed to a reluctance to launch preventive interventions without additional research (Sameroff, 1990). However, it is not generally realized that at the beginning of many large intervention programs to prevent physical diseases, such as heart disease, the part of the knowledge base regarding risk mechanisms was also small. Large-scale prevention efforts were instituted with clear concepts but a modest knowledge base with regard to mechanisms, and the resulting research has yielded important information about the etiology of these diseases, the malleability of identified risk factors, and the risk mechanisms in multiple causal chains. Difficulties in identifying, defining, and classifying mental disorders also present barriers to successful prevention. A culture of the bacteria establishes the diagnosis of a streptococcal sore throat. In contrast, mental disorders rarely have a single cause and do not have such a “gold standard” confirmatory diagnostic test. Mental disorders are currently defined by a description of a cluster of symptoms associated with clinical

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH dysfunction. These have been codified in an evolving classification system called the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. The first edition was published in 1952, the current edition is the third revised (DSM-III-R), and a fourth edition is expected imminently. This system conceptualizes each mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (American Psychiatric Association, 1987). Valid and reliable classification of disorders is a prerequisite for advances in the scientific understanding of mental disorders across the life span. The goal is for the nosologic system to be reliable enough to ensure that different investigators assign diagnoses according to the same criteria so that cross-study comparisons can be made with confidence. At the same time, diagnostic categories aim to be as discrete as possible so that when an individual is diagnosed, a standardized treatment is available. These systems of classification are of course empirically derived and somewhat arbitrary, and they do not necessarily improve the process of making a diagnosis for a particular individual. Major and continuing advances have been made in the validity and reliability of psychiatric classification over the past 30 years, especially for adult disorders. Despite these advances, many problems with the classification of mental disorders remain, all of which will increasingly affect the prevention field as it more specifically focuses not only on the reduction of risk factors but also on the reduction of initial onset of disorders: Not all scientists whose work is relevant to preventive interventions agree on which diseases to include in the category of mental disorders, and, for a few diagnoses, what constitutes a mental disorder. For example, despite general consensus on their psychiatric status and the fact that they are officially codified in DSM-III-R, alcohol and psychoactive substance abuse and dependence and Alzheimer's disease are sometimes classified as addictive and neurological disorders, respectively, rather than as mental disorders. In addition, conduct disorder as a diagnosis continues to raise controversy. Some clinicians and researchers say that it should be examined as a “social diagnosis ” rather than as a mental disorder. It should be noted that there are behavioral, psychological, and social problems that may merit intervention that, nonetheless, are not mental disorders themselves, nor are they necessarily attributable to mental

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH disorders. For example, mild, transient depressive or anxiety symptoms, which are common throughout the life span, are not mental disorders. Likewise, teenage pregnancy is not a mental disorder, although mental disorders such as bipolar disorder or substance abuse are sometimes associated with it. Classification of children's mental disorders poses particular problems. Far too often, children 's unique expression of complicated behaviors and feelings has not been appreciated, and children have been saddled with adult diagnostic criteria. To address this issue, a national epidemiological study of the status of children's mental health is needed. Methodological issues related to the design of such a study are currently being addressed prior to its full implementation. Another problematic area in diagnosis is the considerable co-occurrence of two or more different mental disorders in an individual and the ambiguity of classification in such instances. DSM-III-R recognizes this and makes no claim that each mental disorder as described is a discrete entity. In addition to DSM, there is another classification system, The International Classification of Diseases (ICD, 1992). Whereas DSM has been widely accepted in the United States, ICD is well established throughout Europe. Having two systems that had many differences has made comparison of international data more difficult. However, much progress has been made in increasing the compatibility of these two systems, and DSM-IV and ICD-11 promise to be quite similar for most diagnoses. The DSM and ICD classification systems for mental disorders have changed frequently, and they will continue to evolve as more is learned about these illnesses. Essentially, the disorders are “moving targets ” as diagnostic power advances. Long-term follow-up studies that use diagnostic codes become more complicated as a result of these changes. Confusion about terminology extends to the terms prevention and prevention research, which mean different things to different federal agencies, advocacy groups, and professionals (see Chapter 2). Even scientists within federal research institutes are unlikely to agree as to what constitutes prevention of mental disorders. Although this problem has been recognized for many years, it has remained intractable. Because of this semantic confusion, it is difficult to compare data derived from different sources or to estimate the nature and scope of prevention services and research regarding mental disorders. Accordingly, it is also challenging, if not impossible, to obtain reasonably accurate estimates of the level of support of these activities. The lack of clarity has contributed to a manipulation of terminology to secure funds

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH earmarked for prevention. This, in turn, has culminated in an intense, and at times antagonistic, competition for funds among agencies, research institutes, and advocacy groups. LOOKING FORWARD Despite the obstacles, there has been an expansion in the knowledge base for prevention of mental disorders, an increase in methodology, and the development of some promising preventive interventions. Circumstances have combined to present an extraordinary opportunity to investigate the prevention of mental disorders much more seriously. It is time for a new emphasis on a sophisticated prevention research agenda and a new stature for such research. To achieve this, the field will need to attract good people from a broad range of disciplines and be able to support their research endeavors. Currently, society at large is placing greater emphasis on personal health and disease prevention. Many people are striving to improve their physical and mental well-being, not just to avoid illness but to achieve what they consider greater personal rewards, including a more active life and a generally more positive disposition (Breslow, 1990). People are beginning to recognize that their physical health and mental health are intertwined. Some government and business organizations are advocating prevention programs, not only to improve health, but also with the hope of reducing the nation's health care bill, now approximately 14 percent of the gross domestic product (Burner, Waldo, and McKusick, 1992). Three federal agencies have recently recognized the increasing importance of prevention. The U.S. Department of Health and Human Services issued national objectives for health promotion and disease prevention, including mental and physical health, in its report Healthy People 2000 (DHHS, 1991). The U.S. Centers for Disease Control, one of the primary federal health agencies, officially changed its name in late 1992 to the Centers for Disease Control and Prevention, and the National Institute of Mental Health recently issued a report on a national research agenda for the prevention of mental disorders (NIMH, 1993). In this type of cultural climate, efforts to prevent mental disorders may well find fertile soil. ORGANIZATION OF THIS REPORT The committee began its work with a review of the definitions of prevention and prevention research. With a clearer definition of what constitutes preventive intervention, the committee undertook a review of

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH the current state of research in and relevant to the prevention of mental disorders and the promotion of mental health throughout the life span. The committee selected five illustrative disorders to outline what is currently known about opportunities for preventive intervention research: Alzheimer's disease, schizophrenia, depression, alcohol abuse and dependence, and conduct disorder. The disorders were selected to demonstrate a range of potential etiologies—from largely psychosocial (conduct disorder) to largely biological (Alzheimer's disease)—and a range of age of onset of disorder—from childhood to late adulthood. There are, of course, many other disorders that could be used as illustrations, but space precludes their inclusion in this report. In its review of the field, the committee noticed a common inclination to view prevention research as implementation and evaluation of randomized controlled trials to assess the impact of a preventive intervention. In fact, however, these trials are only part of a multistage research cycle in which each of the steps is linked sequentially and logically to other steps. Ideally in this process, the results of earlier steps inform subsequent research steps in important ways. A brief explication of the preventive intervention research cycle is critical both to gain perspective on the knowledge base that provides the foundation for any preventive trial and to evaluate the actual contributions of subsequent research activities to the knowledge base. Figure 1.1 provides a schematized version of the various steps in this cycle and is explained more fully in a later chapter. The committee found the framework of the preventive intervention research cycle useful as a loose guide to the structure of its review of the field. And with this framework in mind, the reader may be similarly guided through this report and experience conceptually the stages he or she would go through in designing a prevention program. Following the introduction and description of definitions in Chapter 1 and Chapter 2, the committee presents a series of chapters on lessons learned from prevention of physical illness (Chapter 3); from the core sciences that provide part of the knowledge base for preventive interventions (Chapter 4); from a description of illustrative mental disorders (Chapter 5); from research on risk and protective factors associated with the onset of mental disorders (Chapter 6); from a review of illustrative preventive interventions for mental disorders that serve as promising models for future interventions (Chapter 7); from treatment research (Chapter 8); and from a review of the field of mental health promotion (Chapter 9). Throughout this report, as throughout the preventive intervention research cycle itself, the critical issues of ethics, cultural diversity, and economics unfold and require our attention.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH FIGURE 1.1 The preventive intervention research cycle. Preventive intervention research is represented in boxes three and four. Note that although information from many different fields in health research, represented in the first and second boxes, is necessary to the cycle depicted here, it is the review of this information, rather than the original studies, that is considered to be part of the preventive intervention research cycle. Likewise, for the fifth box, it is the facilitation by the investigator of the shift from research project to community service program with ongoing evaluation, rather than the service program itself, that is part of the preventive intervention research cycle. Although only one feedback loop is represented here, the exchange of knowledge among researchers and between researchers and community practitioners occurs throughout the cycle.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH In the final section of the report the committee builds the agenda for the future: how to design, conduct, and analyze preventive interventions within the preventive intervention research cycle (Chapter 10) and how to exchange knowledge about preventive interventions and mental health promotion among researchers, practitioners, and communities (Chapter 11). The committee then assesses the infrastructure of the field, focusing on coordination, funding, and personnel (Chapter 12). In its major conclusions and recommendations (Chapter 13), the committee describes its vision for fulfilling the promise of the field of mental disorder prevention. REFERENCES American Academy of Child and Adolescent Psychiatry. ( 1990) Prevention in Child and Adolescent Psychiatry: The Reduction of Risk for Mental Disorders. Washington, DC: American Academy of Child and Adolescent Psychiatry. American Psychiatric Association. ( 1987) Diagnostic and Statistical Manual of Mental Disorders (Third Edition —Revised). Washington, DC: American Psychiatric Association. American Psychiatric Association. ( 1980) Diagnostic and Statistical Manual of Mental Disorders (Third Edition) . Washington, DC: American Psychiatric Association. Barrett, J. E.; Barrett, J. A.; Oxman, T. E.; Gerber, P. D. ( 1988) The prevalence of psychiatric disorders in a primary care practice . Archives of General Psychiatry; 45: 1100–1106. Breslow, L. ( 1990) A health promotion primer for the 1990's. Health Affairs; 9: 6–21. Burner, S. T.; Waldo, D. R.; McKusick, D. R. ( 1992) National health expenditures projections through 2030. Health Care Financing Review; 14(1): 14. DHHS (Department of Health and Human Services). ( 1991) Healthy People 2000. Washington, DC: Government Printing Office; DHHS Pub. No. (PHS) 91–50212. Eisenberg, L. ( 1992) Treating depression and anxiety in primary care: Closing the gap between knowledge and practice. The New England Journal of Medicine; 326(16): 1080–1084. Evans, D. A.; Scherr, P. A.; Cook, N. R.; Albert, M. S.; Funkenstein, H. H.; Smith, L. A.; Hebert, L. E.; Wetle, T. T.; Branch, L. G.; Chown, M.; Hennekens, C. H.; Taylor, J. O. ( 1990) Estimated prevalence of Alzheimer's disease in the United States. Milbank Quarterly; 68: 267–289. Garmezy, N. ( 1983) Stressors of childhood. In: N. Garmezy and M. Rutter, Eds. Stress, Coping and Development in Children. New York, NY: McGraw-Hill; 43–84. ICD (The International Classification of Diseases [10th Revision]) . ( 1992) Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization. IOM (Institute of Medicine). ( 1989) Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders. Washington, DC: National Academy Press. IOM (Institute of Medicine). ( 1982) Health and Behavior: Frontiers of Research in the Biobehavioral Sciences . Washington, DC: National Academy Press; Pub. No. 82–010. Kennedy, J. F. ( 1963) Message from The President of the United States Relative to Mental

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