|Year : 2017 | Volume
| Issue : 2 | Page : 86-90
Preventive strategies for common mental disorders
Jasmin Garg, Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||30-Jun-2017|
Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh - 160 030
Source of Support: None, Conflict of Interest: None
Common Mental Disoders (CMDs) include depressive and anxiety disorders; one in five individuals, worldwide, gets afflicted with CMDs over lifetime. A wide range of preventive strategies have shown promise when implemented across different stages of lifespan. There is a common thread of emerging preventive strategies for CMDs on the lines for those already established for non-communicable diseases. In India, although there is emerging research in this area, the much required prevention is still in its incipient stage. Some critical issues in planning research and implementing preventive strategies are also outlined to provide a more appropriate perspective.
Keywords: Anxiety disorders, common mental disorders, depressive disorders, prevention
|How to cite this article:|
Garg J, Gupta N. Preventive strategies for common mental disorders. Indian J Soc Psychiatry 2017;33:86-90
| Introduction|| |
Prevention is typically mentioned to be of three types: primary, secondary, and tertiary. Primary prevention is further categorized into universal, selective, and indicated. Universal primary intervention targets the whole population which has not been identified on the basis of risk factors, indicated preventive efforts target the persons at significantly increased risk of developing a disorder compared to the general population assessed on the basis of biological, psychological, and social correlates. Selective primary intervention efforts target persons who are at high risk of developing a disorder and have certain minimal signs of a disorder or biological markers predisposing to developing a certain disorder; however, at the same time, they do not meet the full criteria for the diagnosis of a disorder. Secondary prevention targets at decreasing the prevalence of an established disease or disorder by early diagnosis and treatment. Tertiary prevention targets at reducing disability, enhancing rehabilitation and prevention of recurrence, and relapse of disorders.
The cost-effectiveness of prevention of mental disorders cannot be underestimated. It has been shown that with the best of interventions, the burden of mental disorders can be precluded by only 30%. Hence, it makes more sense to prevent the occurrence of mental disorders with evidence-based strategies. Action at the level of research and policy in this area lags behind, as there are preference of the government and research funding agencies for short-term interventions over 3–5 year periods, whereas the benefits of preventive strategies may take many years to manifest. Furthermore, the determinants of poor mental health largely exist outside the health sector making effective initiatives more complex and challenging. Hence, to ensure progress of prevention and mental health promotion, there is a need for government and policy makers to understand impact of poverty and social determinants on mental health of population, i.e., to have a persuasive economic argument.
The term common mental disorders (CMDs) nowadays are used to include anxiety and depressive disorders. A meta-analysis which reviewed data of 174 studies from across the world in the period 1980–2013 reported that approximately one in five persons (17.6%, 95% confidence interval: 16.3%–18.9%) experienced CMDs within 1 year, and the lifetime prevalence was reported to be 29.2% (25.9%–32.6%); indicating a huge prevalence of these disorders. From India, an earlier review (2000) which analyzed data from 15 studies across six regions reported the prevalence of depression as 34/1000 population (range 0.5–53) and anxiety as 16.5/1000 population (range 11–70) from eight studies of six regions. Around the same time, another review of ten studies from seven regions of India reported a prevalence of depression as 31.2/1000 population (range 0.5–53) and anxiety neurosis as 18.5/1000 population with range 11–70. However, a recent report has pointed out various lacunae related to the study of epidemiology of mental disorders, especially CMDs. It pointed out that the incidence, prevalence, and other estimates of mental disorders were under-reported globally. In addition, the available data about epidemiology of mental disorders from across the world were heterogeneous, nonrepresentative, and difficult to generalize, and hence overall, mental disorders are given low precedence over other disorders worldwide.
Worldwide, there is more focus on prevention of noncommunicable diseases (NCDs) than CMDs. There are known universal preventive strategies which have successfully reduced the occurrence and mortality of the big four NCDs, i.e., the cardiovascular diseases, diabetes mellitus type 2, cancer, and chronic respiratory diseases., The well-established lifestyle risk factors of these diseases are smoking, physical inactivity, alcohol abuse, and poor dietary habits. Incidentally, it has been identified that these risk factors also contribute to the onset and trajectory of CMDs. Etiologically as well, CMDs and NCDs are strongly interconnected, with high comorbidity, and they share important pathways to the development of illnesses. However, the research into prevention of CMDs and NCDs lays segregated. In fact, depression is the second leading cause of disability and the big four NCDs make up 54% of NCD-related disability-adjusted life years. Hence, researchers have recommended that CMDs should be merged with NCDs, as prevention of CMDs would prevent NCDs.,
| Overview of Preventive Efforts in Common Mental Disorders|| |
The period of early childhood is crucial in shaping the mental health of an individual's whole life. This depends on the in utero environment and parent-child relationships. There is supportive evidence about the programs which enhance parenting skills during antenatal periods and effectively lead to better mental health outcomes in the offspring. However, there is equivocal evidence about prevention of postnatal depression with these programs.
Childhood and adolescence
Most of the mental disorders begin in adolescence due to which it is important to promote mental health of this age group. A large number of school-based mental health promotion and prevention programs have been found to be consistently effective, especially with regard to universal and targeted interventions in the short term (small to moderate) and among high-risk children. Researchers have suggested better effect of complex, multicomponent approach within whole school rather than piecemeal.
Many a times, CMDs begin in adulthood in response to traumas, loss of loved ones, or chronic stress. In adulthood, the main focus of interventions is at the workplace where adults are easily approachable. Furthermore, poor working conditions predispose to development of CMDs. There is strong evidence of health benefits reported for interventions targeting job stress, especially using the “systems approach”. This approach incorporates changes in working conditions and the individual's skills and behaviors. There is also evidence of meditation as an effective and economical approach to decrease work stress.
Poor social circle in old age predisposes to CMDs. According to some meta-analysis, there is evidence of social support interventions in reducing depression and improving quality of life, but overall the quality of studies is very poor.
| Other Emerging Preventive Strategies|| |
Diet and health behaviors
Several population-based studies and prospective studies have found that poor dietary habits, i.e., consumption of takeaway foods, red meat, confectionery, etc., are associated with depression. Maternal poor dietary intake and also maternal smoking are associated with poor mental outcomes in offspring. There is also association of alcohol consumption and depression, and it is a well-known precursor for suicide. Although there is a lack of availability of RCTs in this area, there is strong evidence of association of poor lifestyle behaviors, CMDs, and NCDs.,
New pharmacological approaches
There is emerging evidence that inflammatory and oxidative stress may lead onto development of depression and NCDs. Research is still required for assessing the role of cardiovascular risk-lowering drugs such as statins and aspirin for prevention of depression which work by the same mechanism. There are preliminary data that deficiency of some nutrients is associated with development of depression; hence, supplementation of diet with certain nutrients can also be a preventive approach.
Internet and associated technologies
Internet- and mobile-based technologies provide a medium equivalent to face-to-face interview and psychotherapy. It is an emerging approach and has more acceptability and potentially less associated stigma. There is evidence in support of indicated and selective prevention of CMDs with this technique in decreasing the incidence and improving outcome as well.,
| Indian Scenario|| |
The CMDs are highly prevalent yet are not recognized by primary care physicians. The recognition is challenging to physicians because of many factors such as very high patient loads, poor undergraduate training of physicians in psychiatry, stigma associated with mental illness, and frequent somatic presentation of CMDs. Hence, very low rates are reported from routine clinical practice of physicians, whereas very high rates of CMDs are found when screening questionnaire are administered on the same population.
One of the major risk factor for development of CMDs in developing countries is poverty. Poverty is associated with low education levels, experience of insecurity, risk of ill-health, and violence which increases vulnerability to CMDs. Development of mental disorders further worsens the financial condition thereby creating a vicious cycle. In the past decade, there are approximately 20 published studies on CMDs from India; majority of which are cross-sectional assessments of prevalence and risk factors with fewer interventional studies.,,,,,,,,,,,,,,,,,,,
One of these is the landmark MANAS trial conducted in Goa. This trial evaluated the effectiveness of lay health counselors in primary care in improving the outcomes of CMDs as there is shortage of skilled workforce in India. This was a cluster randomized trial involving 24 primary care facilities (12 public and 12 private). All patients coming to these facilities were screened for the presence of CMDs on general health questionnaire, and those above cutoff scores were included in the trial (n = 2796). They were allocated to the either the intervention group in which a trained lay health counselor-delivered interpersonal therapy and psychosocial intervention along with pharmacotherapy advised by the general practitioner or the control group in which comprised pharmacotherapy by the general practitioner. The general practitioners were guided by visiting psychiatrists periodically for pharmacotherapy and were given information booklets about identification and management of CMDs. The results demonstrated that identification and management of CMDs were significantly enhanced at primary care facilities with these interventions of low resource settings. The intervention by lay health counselors was, especially, effective in public health care settings compared to private settings. The training of lay counselors also reduced suicidal behavior and disability days at 12 months. This was the largest trial demonstrating integration of evidence-based interventions of CMDs to routine primary care in India.
Among others, there are five studies on the prevalence and correlates of CMDs in women from India.,,,, These studies have indicated high rates of incidence (1.8% per year) and prevalence (23%) of CMDs particularly more in those who were married and had associated poverty, chronic physical illness, or tobacco use.,,, For specifically postpartum women, the prevalence of CMDs has been reported to be 11.5%, which also was associated more with poverty and health problems. More often, the women present with somatic symptoms such as weakness and vaginal discharge as manifestations of CMDs. Research has also been carried out for assessing correlated of CMDs in those who volunteer for HIV testing, and social and economic reasons were reported to be associated with CMDs. Another study estimated the prevalence of CMDs in disaster survivors which came out to be 64% (339 of 532), and they found that the CMDs were more common in females, old age, and in those who had lost their primary family member.
There are studies on beliefs of community about CMDs which showed a lack of awareness, false beliefs, and negative attitudes in the people of community. Similarly, a study evaluated the beliefs of alternative medicine practitioners about mental disorders as they are often preferred over allopathic doctors for seeking treatment by the community, and it reported that 40% (20 out of 50) of them felt difficulty in identifying mental disorders, and 60% (30 out of 50) of them held negative attitudes for mental disorders.
A multi-country study assessed the prevalence of risk factors for NCDs in which India was also a part. Although it did not assess risk factors for CMDs or its prevalence, yet it reported 47% (n = 6560) of persons above 50 years used tobacco and among all countries; India was one of the countries where the recruited persons had multiple risk factors together. A study also evaluated prevalence and correlates of alcohol use in slums and found CMDs as also one of the risk factor for alcohol use with odds ratio 1.5.
There is emerging interest in telepsychiatry in India. Results of a pilot study demonstrated assessment and diagnosing using telepsychiatry to be a reliable approach. There is an ongoing research on intervention using telepsychiatry in which online cognitive behavior therapy is being administered to college students with generalized anxiety disorders. Interventional studies have been published in which yoga therapy was successfully used for CMDs, somatoform disorders, and menstrual disorders., Recently, the Ministry of Health and Family Welfare has also published a manual for management of CMDs.
Despite the highly prevalent proportions of mental disorders, there is scanty infrastructure available for their management in India. There are meager 4000 psychiatric outpatient facilities (0.329/100,000 population), 10,000 beds in general hospital psychiatric units (0.823/100,000 population), and 43 mental hospitals (0.004/100,000 population) with an admission rate of 14.52/100,000. The number of available psychiatrists are barely 0.301/100,000 population, with number of psychiatric nurses 0.166/100,000 population, psychologists 0.047/100,000 population, and psychiatric social workers 0.33/100,000 population. There are no reported data about persons with mental disorders treated in primary health care, any psychosocial or psychopharmacological intervention in primary health care, and number of admissions in general hospital psychiatric units and day care centers from India.
| Issues for Future Research|| |
There are some critical issues with available literature, and much more research is still required in the area of prevention of CMDs. Some of the following issues should be kept in perspective while planning such research.
There is a wide scope of research in this area, and while planning there should be proper matching of interventions as per phase or need, for which, there should be proper quantification of a particular need. Studies are most appropriate for situations where we know what to do, but less about how to do it. There should be a balance between “Single-target” interventions and “Multi-level, multi-component” interventions. There is also a need to plan for large-scale community interventions with consideration of psychosocial factors for making it pressing on the government to take action. The “communities that care” and the “European alliance against depression” models are good examples for planning a multicomponent systematic preventive intervention at community level.,
Although there is multitude of studies available in this area majority of these are of poor quality, which makes it difficult for reviewers to draw conclusions and generalize the findings. Hence, while planning research, one should ensure the presence of appropriate comparison/control groups with adequate sample size. One should also ensure validity of measures used, presence of fidelity, and avoidance of duplication. Furthermore, the interventions should be tested over longer periods (both in terms of duration and follow-up).
While there are some very effective preventive strategies identified, not many have been modeled for cost-effectiveness. Hence, the planned intervention should be cost-effective, both within and beyond the health system for integration at the population level.
Systematic reviews have reported that the translation of research findings to population level is lacking. The policy makers are unaware of the cost-effectiveness of prevention. Hence, there should be better communication with policy makers and the wider community about the imperative need of prevention. There should also be focus on enhancing mental health literacy of general public and practitioners. The WHO manual “Diagnosis and Management of CMDs in primary care” has been developed for guidance of primary health providers as they are in a key position for identification and treatment of CMDs. Enhancing knowledge helps in building reciprocal and meaningful relationships with key agencies.
| Conclusion|| |
Efforts are being made in different countries for promotion and prevention to decrease the burden of mental disorders in community settings. This can be done step-wise by first of all quantification of burden due to CMDs, identification of specific risk factors, setting priorities and criteria for interventions, developing intervention strategies, testing the intervention strategies for effectiveness, cost-effectiveness, fidelity and replicability, and then incorporating the interventions into mental health sector while involving various agencies/organizations and by including mental health outcome measures into planned large scale/whole of community interventions with finally (re) formulation of government policies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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