|Year : 2017 | Volume
| Issue : 2 | Page : 71-75
Preventive psychiatry: Current status in contemporary psychiatry
Rakesh Kumar Chadda
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||30-Jun-2017|
Rakesh Kumar Chadda
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Preventive psychiatry is one of the most ignored subdiscipline of psychiatry, which has got important role to play in the contemporary psychiatry. Mental disorders are very common with lifetime prevalence of about 25%, and tend to be chronic. Due to the stigma associated with mental disorders, lack of awareness, and also lack of adequate mental health resources, nearly 60%–80% of the persons suffering from mental disorders do not access mental health care services. Mental and substance use disorders have been identified as one of the major contributors to the disease-related burden and disability-adjusted life years. In this background, preventive psychiatry has an important role to play in public health sector. Since etiology of most of the mental disorders is not known, it is not possible to follow here the standard model of primary, secondary, and tertiary prevention of public health. A concept of universal, selective, and indicated prevention has been proposed in primary prevention. Preventive approaches in psychiatry focus on evidence-based risk and protective factors, promoting quality of life, reducing stressors, and improving resilience. Such interventions, when planned targeting at specific mental disorders, have a potential to prevent mental disorders. Thus, preventive psychiatry has a crucial role to play in mental health, considering the high prevalence of mental disorders, the associated disability and burden, and a great drain on human resources.
Keywords: Burden, disability, mental disorders, preventive psychiatry
|How to cite this article:|
Chadda RK. Preventive psychiatry: Current status in contemporary psychiatry. Indian J Soc Psychiatry 2017;33:71-5
| Introduction|| |
Whether it is possible to prevent psychiatric disorders, is not formally discussed in medical training or health policy making? Due to lack of exposure during the training period, the subject is not taken even seriously by the mental health professionals. The subject, however, has been formally discussed in international forums such as the World Health Organization (WHO) and the World Psychiatric Association to the extent that both these organizations have taken important initiatives in this area., In the current scenario with increasing recognition of the mental disorders being a major contributor to the global burden of disease (GBD) and limited mental health resources, preventive psychiatry assumes an important role as a subspecialty of psychiatry. The next question which arises is whether it is possible to prevent psychiatric disorders? If yes, then how? This paper discusses the status of preventive psychiatry in the current scenario with a specific focus on low-resource settings like South Asia.
Prevention in psychiatry has often been ignored and not specifically mentioned even in many textbooks. Going into its history, the first paper on preventive psychiatry appeared in the American Journal of Public Hygiene in August 1908. PubMed search on preventive psychiatry revealed 5213 references till February 24, 2017, with 545 in 2014, 729 in 2015, 952 in 2016, and 213 till February 24, 2017. The figures depict the increasing interest of the researchers in preventive psychiatry.
| Burden and Disability Due to Mental Disorders|| |
The GBD study of 1990 showed that mental and neurological disorders accounted for 10.5% of the total disability-adjusted life years (DALYs). WHO reassessed the GBD for 2000 and estimated that the neuropsychiatric disorders (mental, neurological, and substance use disorders) accounted for more than a quarter of all nonfatal burden, measured in years lived with disability (YLD). Depression was the most disabling disorder worldwide measured in YLDs and the fourth leading cause of overall burden measured in DALYs. Depression was associated with the largest amount of disability, accounting for almost 12% of the YLDs. The contribution of mental and neurological disorders to the global burden increased to 12.3% in 2000 and 14% in 2005. In the GBD 2000 study, depression, alcohol use disorders, self-inflicted injuries, schizophrenia, and bipolar disorder were among 10 leading causes of DALYs in the most productive age group of 15–44 years. Six neuropsychiatric conditions figured in the top twenty causes of YLDs in the world, which included unipolar depression, alcohol use disorders, schizophrenia, bipolar affective disorder, Alzheimer's and other dementias, and migraine.
In 2007, a new GBD study was launched, and the results for the GBD, Injuries, and Risk Factors Study 2010 (GBD 2010) were reported in December 2010. In the GBD 2010, mental and substance use disorders accounted for 183.9 million DALYs (95% UI 153.5 million–216.7 million), constituting 7.4% (6.2–8.6) of total disease burden in 2010. Global burden caused by the mental disorders was higher than that due to individual groups of HIV/AIDS and tuberculosis, and diabetes, urogenital, blood and endocrine diseases. Although the burden of mental and substance use disorders increased by 37.6% between 1990 and 2010, the change for mental disorders was almost entirely attributable to population growth and aging. The group was the leading global cause of all nonfatal burden of disease as measured in YLDs and the fifth leading disorder category of global DALYs, accounting for 175.3 million (95% UI 144.5 million–207.8 million) YLDs or 22.9% (18.6–27.2) of all nonfatal burden. The burden of mental and substance use disorders spanned all age groups. Cumulative global effect of mental disorders in terms of lost economic output is estimated at US $16 trillion in the next 20 years, equivalent to 25% of the global GDP in 2010.
| Mental Health Resources|| |
Most of the low- and middle-income countries (LAMIC) have a gross deficiency of mental health-care workers. A total number of mental health care workers in 58 countries from the LAMIC group were estimated at 362,000 in 2005, representing 22.3 workers per 100,000 in low-income countries and 26.7/100,000 in the middle-income countries, comprising 6% psychiatrists, 54% nurses, and 41% psychosocial care providers. The figure adds up to a shortage of 1.18 million mental health workers in the 144 LAMIC countries. As per the WHO Mental Health Atlas of 2014, mental health resources in India consist of 2.1 psychiatric beds, 0.3 psychiatrists, 0.07 clinical psychologists, 0.12 psychiatric nurses, and 0.07 social workers per 100,000 of the population. Average national deficit of psychiatrists in India has been estimated at 77%. More than one-third population has >90% deficit of psychiatrists. Only the states/union territories of Chandigarh, Delhi, Goa, and Puducherry have a surfeit of psychiatrists. Kerala and Maharashtra have <50% deficit, while all the other states have more than 50% deficit of psychiatrists.
| Prevention in Psychiatry: How?|| |
The public health concept of disease prevention views prevention as primary, secondary, and tertiary with primary prevention focused at preventing the disease itself, secondary prevention targeted at reducing the severity of disease, and the tertiary prevention aiming at disability reduction and involving rehabilitation. This system works well for various medical illnesses with a known etiology. However, we do not know the exact etiology of most of the mental disorders, and hence, the public health model of prevention becomes difficult to apply.
Primary prevention is aimed at reducing the incidence of the illness. It would be a difficult task considering that we are not aware of etiology of most of the mental disorders. Primary prevention in psychiatry has been conceptualized as universal prevention, selective prevention, and indicated prevention. Universal preventions are targeted at general public or to a whole population group that has not been identified on the basis of increased risk. Examples may include encouraging healthy lifestyle, regular physical exercise, stay away from drugs, etc. Selective prevention targets individuals or subgroups of population who are at a higher risk of developing a mental disorder than the general population due to certain biological, psychological, or social risk factors like family members of a person with schizophrenia or bipolar disorder. Indicated prevention targets high-risk people, who have minimal but detectable signs or symptoms indicating a mental disorder or biological markers indicating predisposition for mental disorder but do not meet diagnostic criteria for disorder at that time.
Secondary prevention focuses on early recognition and treatment of mental disorders. As pointed out earlier, there exist a number of barriers to secondary prevention including limited mental health resources, enormity of population with mental health problems, and stigma, lack of awareness and misconceptions about mental disorders interfering in access to services for treatment. Solutions could include enhancing mental health resources in the community, creating community awareness especially about the early signs of mental disorders and their treatment, strategies at reducing stigma, and facilitating contact with mental health services. This would help in early recognition of mental disorders. Non adherence to treatment in patients with mental disorders is also an important problem which needs to be tackled since treatment of most of the mental disorders often continues for a long period. The treating psychiatrists need to take special care at ensuring adherence to treatment so as to promote recovery and prevent relapses.
Tertiary prevention, as in public health, focuses on rehabilitation of the patients following treatment. It is also a long-drawn process, considering frequent chronicity of mental disorders. Patients especially those with severe mental disorders such as schizophrenia, bipolar disorder, other psychotic disorders, and severe depression tend to run a chronic or relapsing course, many times with associated disability and deficits. Developing a rehabilitation program for patients with severe mental disorders and preventing disabilities is a major challenge in psychiatry in the background of meager resources. Families are a major support here, but it is very important to mobilize the community and the policy makers in developing such programs. The psychiatrists need to use their negotiating and leadership skills to develop tertiary prevention strategies in mental health, focusing on the above-mentioned targets.
| Focus on Evidence-Based Risk and Protective Factors|| |
Risk factors include characteristics which are associated with an increased probability of onset, greater severity, and longer duration of major health problems. Protective factors refer to conditions that improve a person's resistance to risk factors and disorders. Individual protective factors are similar to positive mental health, and include self-esteem, emotional resilience, positive thinking, problem-solving, and stress management skills. Preventive psychiatry focuses on counteracting the risk factors and reinforcing protective factors. Certain protective and risk factors are of generic kind, common to several mental health problems, and acting at them would have a broad preventive effect. For example, poverty and child abuse increase risk of depression, anxiety disorders, and substance use. Some factors may be disease specific, while others carry a generalized risk to a variety of mental disorders, for example, negative thinking is specifically related to depression, and depression is related to suicide risk, whereas war and other disaster situations can cause posttraumatic stress disorder, anxiety, depression, and alcohol use disorders. Poverty, social inequity, and war act at a macro level increasing risk of adverse mental health and increase risk of a range of mental disorders in wide strata of population.,
Some general macro-level strategies acting at risk factors could include restricting access to alcohol and drugs, and policies aimed at improving education and nutrition, poverty alleviation, acting at social discrimination and stigma, reducing violence in society, enhancing social cohesion, and improving employment opportunities. Preschool and early education interventions, school-based mental health promotion programs, promoting healthy lifestyle and healthy workplaces are some of the methods in this direction. Actions are also required at enhancing the protective factors such as good parenting, early cognitive stimulation, regular physical exercise, improving literacy, positive parent–child interactions, prosocial behaviors, socioeconomic growth, stress management, and improving social support.
Individual risk factors for mental disorders include academic problems and failure, attention deficits, caregiver stress, child or elder abuse, chronic insomnia, chronic pain, chronic physical illness, early pregnancy, low birthweight, substance use in self or parents, low social class, parental loss, and many others. Strategies at prevention also need to be focused on early identification of the individual risk factors and ameliorating them.
| Strategies Focused at Specific Mental Disorders|| |
This section briefly discusses specific primary preventive interventions for conduct disorders, depression, anxiety disorders, eating disorders, psychotic disorders, and suicide. Successive papers in this volume have devoted exclusively to preventive strategies for the individual group of disorders.
A number of interventions have been described for prevention of aggressive and violent behavior and conduct disorders in children. Universal interventions include behavior management, social skills intervention, promoting alternative thinking strategies, and bullying prevention programs. Selective interventions include prenatal and early childhood programs and school- or community-based programs. Multimodal school-based programs for children at risk are examples of indicated prevention.,
A number of risk and protective factors have been identified for depression, which could be grouped as psychological, biological, familial, and social ones. Universal interventions can include school-based programs targeting cognitive, problem solving and social skills of children and adolescents, and exercise programs for the adult group. Selective interventions have been used for parents of children with conduct problems aimed at improving psychosocial well-being by information provision and training in childrearing and have shown reduction in severity of depressive symptoms by about 30%. Similarly, interventions targeted at coping with major life events, for those exposed to unemployment and persons with chronic debilitating physical illnesses, and children following parental death or divorce, have a potential of reducing depressive symptoms. Indicated interventions can be used for individuals having depressive symptoms not amounting to a depressive disorder. Such programs mainly use a group format to educate people at risk about positive thinking, challenge negative thinking styles, and improve problem-solving skills. Written self-help materials, mass media, and internet have also been used for such interventions. Such programs have a potential of reducing severity of the depressive symptoms and preventing onset of clinical depressive episodes.
Anxiety disorders are another common group of psychiatric disorders with a potential of preventive interventions. Most anxiety disorders first appear during childhood and adolescence and tend to continue in adulthood. Persons at risk to develop anxiety disorders include children of anxious parents, and victims of child abuse, accidents, violence, wars, or disasters. Evidence-based preventive strategies would vary according to the type of targeted population, targeted anxiety disorder, risk or protective factors, and the timing. Strengthening the emotional resilience and cognitive skills remains an important step in this direction. Such programs can be introduced in schools, clinics, and hospitals, and can be used as universal, selective, or indicated prevention strategy, depending on the population targeted.,
Schizophrenia and related psychotic disorders are responsible for considerable disability and global burden both due to the potential severity of illness as well as chronicity. Etiology is multifactorial with genetic as well as environmental contributions. Risk factors include obstetric complications, childhood trauma, migration, socioeconomic disadvantage, and urban birth. It may not be possible to employ a universal prevention approach except in form of general improvement in living conditions, health facilities, and obstetric care. Improving mental health literacy, early intervention, ensuring adherence to treatment, and rehabilitation remain important components of a prevention programme, as discussed in other sections.,
Substance use disorders
Common psychoactive substances of abuse include tobacco products, alcohol, opioids, and cannabinoids. Tobacco and alcohol are major public health problems. Both alcohol and tobacco are leading causes of disease-related burden due to the multiple serious physical complications associated with their use. Effective universal preventive interventions which can be introduced at various levels include taxation, restrictions on availability, and total ban on all forms of direct and indirect advertising. School-based interventions at raising awareness about their ill effects remain an important component of a prevention program. Brief advice from a general practitioner routinely given to all patients who smoke has been found to lead to about 40% individuals attempting to stop and about 5% stopping smoking for at least 6 months. Nicotine gums and plants remain important alternative option for the individuals who are unable to stop use of tobacco on their own.,
Suicide is an important public health problem. The National Crime Report Bureau statistics suggest a suicide rate of 11 per 100,000 per year in India, indicating that about 1,34,799 people in this country forfeit their lives by suicide every year. The Million Death Study has estimated the rate as almost double of this figure. The most important evidence-based risk factors for suicide are psychiatric disorders (depression, schizophrenia), past or recent social stressors such as sexual or physical abuse, childhood adversities, unemployment, social isolation, or serious economic problems. Crisis helplines may be of some help but the results have not been consistent. Suicide education in school settings has also failed to show any impact on suicide behavior. Rather, there have been some indications of such programs increasing the number of students considering suicide as an option. Systematic direct screening of the adolescents has been found to show positive results. Reducing access to the means to commit suicide such as restricting the availability of insecticides and pesticides in our country, safety measures on high-rise buildings and bridges, and restricting access to firearm are some proven preventive strategies. Early diagnosis of depression and its effective treatment remains an important preventive strategy.
Eating disorders such as anorexia nervosa and bulimia, and subsyndromal eating problems are common in adolescent population with an increasing prevalence observed in the last 2–3 decades with changing food habits and increasing use of junk and fast foods. The disorders are also common in female athletes, fashion models, and culinary students, and are quite disabling. Risk factors include unhealthy dieting, excessive concerns about weight or shape, and body dissatisfaction. Family and social influences such as modeling behavior of friends and glamorizing of thinness through mass media further increase the risk. Generic risk factors have also been identified which include insecure attachment, physical and sexual abuse, bullying, low self-esteem, and difficulties in coping with stress and conflict. Universal prevention can be targeted at school populations and may include educative interventions such as diet counseling and sensitizing to the risk of eating disorder. Selective interventions on the same line can be targeted at athletes, fashion models, and cookery students. Indicated interventions are generally focused at young female adults presenting with subclinical unhealthy dieting behavior. Efficacy of these programs is, however, not proven and the results are generally conflicting.,,
Mental Health Promotion and Prevention
It is important to differentiate between mental health promotion and prevention, which have an important difference in their targeted outcomes. Mental health promotion has a secondary outcome of decreasing incidence of mental disorders while improving mental health, whereas prevention program uses promotion strategies as one of means to achieve target of reduction of symptoms and ultimately of mental disorders. Prevention and promotion elements have often many common strategies and recommend similar activities, one aimed at promoting mental health and other preventing the development of illness. The two approaches are conceptually distinct but interrelated. Here, it is important to mention the positive psychiatry movement, which is another approach toward prevention of mental disorders and mental health promotion. Positive psychiatry focuses on understanding and promoting well-being through assessment and introducing positive psychosocial interventions involving positive characteristics in persons who suffer from or are at high risk of developing mental or physical illnesses. The approach includes basic principles of mental health promotion and lifestyle modification.
| Conclusion|| |
Preventive psychiatry is an important component of the discipline of psychiatry, which has not been given due recognition by the mental and public health professionals. Its significance cannot be ignored considering mental health being an essential component of health and increasing recognition of the burden and disability due to mental disorders. It is high time that the mental health professionals and health planners recognize the need of preventive approaches in mental disorders. It is not difficult to introduce preventive approaches in psychiatry in routine clinical practice. Mental health professionals need to be aware of the basic principles of preventive psychiatry and need to introduce these in their day-to-day clinical practice as well as should raise awareness about mental disorders and mental health promotion in the general public.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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