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In both chapters, the authors briefly review epidemiology and risk factors and discuss various forms of prevention that have been studied. Given the increasing use of complementary and alternative health practices in western cultures, Ashli Owen-Smith and Charles Raison review, in Chapter 5 Complementary and Alternative Medicine in the Prevention of Depression and Anxiety , the potential uses of such practices in the prevention of depression and anxiety.

As in other chapters, the authors discuss key implications for mental health practitioners. Although this area arguably remains in its infancy, promising recent researchespecially research into the prodrome and early psychosissuggests that some prevention applications are now feasible and others may be available in the near future. For example, in addition to early detection and phase-specific intervention, clinicians may be able to play a role in delaying, or even averting the onset of psychosis in particularly high-risk youth and young adults.

Other topics of particular relevance to practicing mental health professionals, such as relapse prevention and integrated substance abuse and mental health treatment for patients with dual diagnoses, are reviewed. The prevention of internally and externally directed aggression and violence are the topics of the next two chapters. Michael Grunebaum and Laili Soleimani present, in Chapter 8 Suicide Prevention , an overview of the epidemiology of suicidal behavior; risk factors for suicide; and primary, secondary, and tertiary suicide prevention strategies.

They offer practical suicide prevention suggestions for clinicians. In their chapter on preventing family violence Chapter 9, Prevention of Family Violence , Kenneth Rogers, Barbara Baumgardner, Kathleen Connors, Patricia Martens, and Laurel Kiser provide the reader with a review of the prevention of child physical abuse and neglect, child sexual abuse, and domestic violence.

They too present a number of principles for the practicing mental health professional pertaining to the prevention of family violence. The next two chapters focus on prevention principles for two particular age groups. In Chapter 10 Prevention Principles for Adolescents in Psychiatric Practice , Kareem Ghalib and Gordon Harper give an overview of preventing conduct disorder and other behavioral problems among adolescents in psychiatric practice.

These two chapters focus on these se-. The final two chapters encourage mental health professionals to consider not only the prevention of mental illnesses but also physical health promotion and the prevention of physical illnesses among psychiatric patients. Rebecca Powers and I then give, in Chapter 13 Prevention of Cigarette Smoking , an overview of the prevention of cigarette smoking, which is of great importance for mental health professionals in light of the astonishingly high rates of smoking among patients with serious mental illnesses.

In selecting these particular areas, we could not cover numerous other topics that may be of great interest and practical relevance to mental health professionals. For example, the manual does not review, or even mention, the prevention of many types of psychiatric illnesses, including adjustment disorders, personality disorders, sexual disorders, sleep disorders, somatoform disorders, and others.

Additionally, a large array of topics that have broad social implications could not be covered. This absence of coverage is not due to a lack of importance or relevance to the mental health field, but to space and scope limitations. For example, the other authors and I have not discussed a number of critical complications that arise in applying prevention principles to mental health settings, in terms of politics, access to resources, resource distribution, and financing of prevention services.

Numerous topics of great significance for social justice and population-based mental healthincluding the problem of poverty and other social determinants of disease; adverse health consequences of sexism, racism, and other forms of discrimination; the problem of violence, ranging from urban gang violence to war, torture, and genocide; and the interface between trade, commerce, economic structure and mental healthare not discussed.

The integration of psychiatry and primary care is mentioned in some chapters, though this topic deserves a more comprehensive discussion given that prevention is likely to be advanced through such collaborations and integration. The manual also does not directly address the importance of infusing medical and residency education with a greater awareness of prevention principles.

Nonetheless, this issue is of particular interest. I would like to point out two other important caveats, by way of introduction to this manual. First, some chapters use the term patient, which historically, typically refers to a person who is seeking care from a doctor. Other terms, like client or consumer, may be more appropriate, especially in light of recent conceptualizations of care such as the recovery paradigm and shared decision making. But for simplicity and ease of writing and reading, the manual often refers to individuals experiencing a psychiatric disorder as patients.

Second, some chapters make reference to a very important publication, the Institute of Medicines report called Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. However, I wish to wholeheartedly acknowledge the fact that a new Institute of Medicine report on prevention in mental health was eagerly awaited as we compiled these chapters and as this manual was in production. Although the authors of this book did not have the good fortune of reading the report prior to writing their chapters, I recommend it, along with other related Institute of Medicine reports, to the readers of this manual.

My primary goal in the development of this book has been to encourage mental health professionals to adopt prevention-mindedness into their everyday practice with patients and in their collaborations with community organizations and agencies that may have a role to play in prevention efforts. I hope that Clinical Manual of Prevention in Mental Health will accomplish this goal and perhaps stimulate a much needed discussion within psychiatry and the other mental health professions of how we can consider prevention, in addition to treatment, in each and every patient we see.

The development and writing of this book were truly collaborative efforts, which seems particularly appropriate given that mental health promotion and the prevention of mental illnesses requires collaboration among numerous professionals.

Mental health publications

The 30 authors that I have worked with to develop the 13 chapters included here were exceptionally receptive, responsive, and giving of their time and tremendous expertise. Each of them played an important role in making this manual an informative and practical text for mental health professionals.

It has also been a true pleasure to work with the experienced editorial staff at American Psychiatric Publishing, Inc. Hales, M. I feel privileged to have developed this book with inspiration, and ongoing guidance and support, from my fellow members of the Prevention Committee of the Group for the Advancement of Psychiatry GAP.

I consider this entire book, beyond Chapter 1, their product, rather than mine. Although not directly involved in the development of this book, Erica Frank, my residency training director during my second residency, in preventive medicine, deserves my special acknowledgment. During that critical training period, and since, she has been an advocate and mentor, pushing me to aim high and think big in my endeavor to bring together my two medical discixxxi.

I also deeply appreciate the support and encouragement given by my partner, Kendrick Hogan, while I dedicated many extra hours to this project.

I appreciate Dr. David Satchers willingness to provide a thoughtful foreword to the manual, and Ruth Shims assistance with that process. I admire Dr. Satchers past work e. Finally, I am very grateful to Beth Broussard, my close colleague and research team member, who generously gave of her time to provide unfaltering, highly professional, and thorough assistance in compiling and finalizing the various chapters. Her thoughtful advice, as well as practical help, while developing this manual has been especially meaningful to me, given that such work came at a very busy time when she and I were putting the finishing touches on our own book.

Mental Health Promotion and Illness Prevention: A Challenge for Psychiatrists

I could not have met the deadlines or accomplished a satisfactory level of thoroughness without her. An Introduction to Prevention In recent decades, psychiatrists, psychologists, preventionists, and allied professionals have learned a great deal about risk and protective factors related to mental illnesses, as well as the development of evidence-based interventions 1.

These developments in the prevention of behavioral disorders, which parallel the medical professions increased knowledge about preventing infectious diseases and chronic illnesses, were reviewed in detail in the Institute of Medicine IOM report titled Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research Institute of Medicine These three resources are essential reviews of the expanding knowledge base on mental illness prevention and mental health promotion.

In the past, prevention has been the mainstay of the field of public health; however, this population-based approach is now being embraced by the general health sector and is becoming more widely accepted in the mental health field.

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Both general medicine and psychiatry are primarily involved in individual-level treatment, but with the widespread prevalence of chronic medical and psychiatric illnesses, and an aging population, there has been increased recognition of the importance of a population-based prevention approach.

We have previously described what is meant by prevention psychiatry and discussed its historical context, recent epidemiological studies, evidence-based prevention practices, and the paradigm shift toward prevention Koplan et al. We then give eight principles for mental health professionals to consider in their endeavor to become prevention-minded clinicians. It is our hope that this description of the two classifications, which are referred to throughout this book, and our eight principles, will provide a foundation for the reader to then delve more deeply into specific content areas addressed in the other chapters.

Two Classifications of Prevention There are at least two ways of classifying prevention, and both are advantageous in framing the complex goals of prevention in mental health. The first. The traditional public health classification encompasses a broad range of interventions that include routinely used treatments i. In fact, the IOM report specifically states that the term prevention is reserved for those interventions that occur before the onset of the disorder, whereas treatment refers to interventions for individuals who meet or are close to meeting diagnostic criteria.

The Traditional Public Health Classification of Prevention Primary prevention refers to keeping a disease or adverse outcome from occurring or becoming established by eliminating causes of disease or increasing resistance to disease Katz As such, primary prevention seeks to decrease the number of new cases incidence of a disease, disorder, or adverse outcome Institute of Medicine Thus, primary prevention refers to interventions occurring during the predisease stage and focusing on health promotion and specific protection Katz Primary prevention protects health through personal and communal efforts and is generally the task of the field of public health Last An example of primary prevention pertaining to infectious diseases is the prevention of influenza and other acute infections using vaccination.

In mental health, examples of primary prevention are less numerous, partly because of the lack of understanding of discrete etiological factors. Thus, primary prevention in mental health tends to focus on the reduction of risk factors, such as adverse childhood experiences; such risk reduction is presumed to have primary prevention effects and, in some cases, to be strongly associated with decreased incidence. The success of primary prevention efforts in reducing mental disorders or adverse psychiatric outcomes is exemplified by the fact that many infectious diseases with psychiatric manifestations e.

Mental hospitals once housed many people with the psychiatric sequelae of these and other disorders in addition to primary psychiatric illnesses. Secondary prevention refers to interrupting the disease process before it becomes symptomatic Katz As such, secondary prevention ultimately lowers the number of established cases prevalence of the disease, disorder, or adverse outcome in the population Institute of Medicine Thus, secondary prevention refers to interventions occurring during the latent stage of disease and focusing on presymptomatic diagnosis and treatment early detection.

Secondary prevention may control disease and minimize disability through the use of screening programs Last , and is generally the task of prevention-related as opposed to treatment-related aspects of the medical profession.


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If a disease is detected early it can be treated promptly and, ideally, resolved. Early detection and intervention decrease the time a person has a disease, thus reducing the number of individuals having the disease at any given time. From the medical field, examples of secondary prevention include mammography, Papanicolaou smears, colonoscopy, and other screening measures to detect the earliest stages of cancer, before overt symptoms develop. In psychiatry, an example of secondary prevention is screening for symptoms of depression or suicidal thinking to prevent the onset of full-syndrome depression and to prevent suicide attempts or completed suicides.

Tertiary prevention refers to limiting physical and social consequences or disability associated with an existing, symptomatic disease, disorder, or adverse outcome Institute of Medicine ; Katz Thus, tertiary prevention refers to interventions that occur during the symptomatic stage of disease and focus on the limitation of disability and on rehabilitation Katz Tertiary prevention softens the impact of long-term disease and disability by eliminating or reducing impairment or handicaps, minimizing suffering, and maximizing potential years of useful life Last , and is generally the task of the treatment- and rehabilitation-related aspects of the medical community.

Clinical Manual of Prevention in Mental Health

Of note, the traditional definition of tertiary prevention may be thought of as treatment, whereas the newer IOM classification presented in Table 12 limits the term prevention to refer to interventions occurring before the onset of disease. Nonetheless, tertiary prevention is an important consideration, especially given that most practicing mental health professionals mainly see patients with established disorders for whom tertiary.


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In medicine, tertiary prevention is exemplified by rehabilitation after a cerebrovascular accident to minimize functional impairment. In psychiatry, tertiary prevention involves preventing relapse, reducing the likelihood of developing comorbidities, and providing treatments to enhance psychosocial functioning. For example, a number of evidence-based interventions have been studied in the context of severe and persistent mental illnessessuch as assertive community treatment, social skills training, and supported employmentto prevent relapse and rehospitalization, improve social interactions, and assist in obtaining competitive employment.

Institute of Medicine Classification of Prevention The IOM report elaborated on the definition of primary prevention by emphasizing the target population addressed by the intervention, rather than by categorizing prevention based on the stage of disease during which an intervention occurs the latter being the traditional public health classification; Institute of Medicine On the basis of the newer classification, primary prevention can be subdivided into universal, selective, and indicated preventive interventions depending on the target population receiving the intervention Table Universal preventive interventions target a whole population or the general public.

Such interventions are desirable for everyone in the eligible population Institute of Medicine , regardless of ones level of risk for the disease, disorder, or adverse outcome. In general medicine, universal preventive interventions include fluoridation of drinking water, fortification of food products, seat belt legislation, and routine childhood vaccinations. In the mental health field, such interventions may include public service announcements or media campaigns to prevent substance abuse or cigarette smoking, as well as legislation to increase the legal drinking age.

Selective preventive interventions target individuals or a subgroup of the population whose risk of developing a disease, disorder, or adverse outcome is significantly higher than average Institute of Medicine A risk group may be identified based on psychological, biological, or social risk factors. In the field of medicine, an example of a selective preventive intervention is lifestyle modification and pharmacological management of hyperlipidemia to prevent cardiovascular disease. An example of a selective intervention in mental.

Universal preventive Targets a whole population or the general public; Fluoridation of drinking water, fortification of such measures are desirable for everybody in the intervention food products, seat belt eligible population regardless of ones level of risk laws for the disease, disorder, or adverse outcome Selective preventive intervention. Targets individuals or a subgroup of the population Lifestyle modification and Group-based psychological treatments for children of pharmacological managewhose risk of developing a disease, disorder, or depressed parents ment of hyperlipidemia adverse outcome is significantly higher than average; a risk group may be identified based on psychological, biological, or social risk factors Prevention in Mental Health.

Identification and treatment Detection and targeted Indicated preventive Targets particularly high-risk individuals treatment of the metabolic of individuals with sympintervention individuals who, on examination, are found to toms consistent with the syndrome have a risk factor, condition, or abnormality that prodrome of schizophrenia identifies them as being at high risk for the future development of the disease, disorder, or adverse outcome ; such high-risk individuals may be identified as having minimal but detectable signs or symptoms foreshadowing a disease or disorderor a biological marker indicating a predisposition to a disorderalthough diagnostic criteria for the illness are not yet met Source.

Indicated preventive interventions target particularly high-risk individuals those who, on examination, are found to have a risk factor, condition, or abnormality that identifies them as being at high risk for the future development of a disease, disorder, or adverse outcome Institute of Medicine Such high-risk individuals may be identified as having minimal, but detectable, signs or symptoms foreshadowing a disease or disorderor a biological marker indicating a predisposition to a disorderalthough diagnostic criteria for the illness are not yet met.


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  8. An indicated preventive intervention relevant to both general medicine and psychiatry is the detection and targeted treatment of people with the metabolic syndrome, which is associated with an especially high risk of cardiovascular disease and diabetes. Another example in psychiatry that is currently being studied is the identification and treatment of individuals at ultra-high risk for schizophrenia i.

    Such prospective identification efforts are an important first step in developing targeted interventions to delay or avert the onset of the disorder. Thomas Insel, Director of the National Institute of Mental Health, recently presented the notion of preemption, noting that preemptive interventions in psychiatry, which target individuals at greatest risk of a mental illness and those with subthreshold signs and symptoms, provide what has previously been labeled as selective or indicated prevention Insel He notes that preemptive interventions can be directed best once an understanding of individual patterns of risk that predict a disorder are better elucidated.

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    As the field advances, risk prediction is likely to rely on a combination of factors rather than a single biomarker. Such combinations are used in the prediction of risk for cardiovascular disease e. The prevention of specific mental disorders or behavioral problems may be attainable using a variety of interventions. For example, in a meta-analysis of randomized, controlled trials of psychological interventions designed to reduce the incidence of depressive disorders, Cuijpers and colleagues examined data from 21 interventions, including 2 universal preventive interven-.

    These studies involved 5, participants, and follow-up periods ranged from 3 to 36 months.