A Vision for Preventative Mental Healthcare

Barnabas J Gilbert^1*, Anne Stevenson², William R Beardslee³

¹Kennedy Scholar, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA

²Program Director, Massachusetts General Hospital, The Chester M. Pierce, MD Division of Global Psychiatry, 25 Staniford St,2nd Fl, Boston, MA 02114, USA

³Director, Baer Prevention Initiatives; Chairman Emeritus, Gardner/Monks Professor of Child Psychiatry, Boston Children's Hospital, 21 Autumn St, Boston, MA 02215, USA

*Corresponding Author:

E-mail: bgilbert@g.harvard.edu

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Abstract

The importance of preventative medicine has been firmly established for decades, most notably in addressing risk factors for cardiovascular disease. However, in the field of mental healthcare, the prevention agenda has received insufficient attention. One of the principal reasons for this, besides the global funding deficit for mental health (WHO, 2011), is that mental disorders have complex etiology. Within this biopsychosocial framework, understanding of both the molecular biology of neuropsychiatric disorders and deep-rooted economic and social risk factors (e.g. poverty, unemployment, and abuse) remains limited. Presently, few evidence-based interventions are scalable at the population level

The importance of preventative medicine has been firmly established for decades, most notably in addressing risk factors for cardiovascular disease. However, in the field of mental healthcare, the prevention agenda has received insufficient attention.

One of the principal reasons for this, besides the global funding deficit for mental health (WHO, 2011), is that mental disorders have complex etiology. Within this biopsychosocial framework, understanding of both the molecular biology of neuropsychiatric disorders and deep-rooted economic and social risk factors (e.g. poverty, unemployment, and abuse) remains limited. Presently, few evidence-based interventions are scalable at the population level.

Here, we define preventative mental healthcare as the medical, social, and economic ecosystem which functions to maximize individual and societal wellbeing and minimize the risk of individuals developing common mental disorders, such as major depression and anxiety disorders. Because most mental disorders develop in youth (half of all lifetime cases begin by age 14), (McLaughlin, 2012) an effective preventative mental health agenda should target children and adolescents.

Within the biopsychosocial framework, prospective biological interventions might include measures to reduce substance abuse and to promote regular exercise. By addressing clusters of risk factors, such approaches could be effectively integrated into primary care. At the same time, research efforts to identify targeted molecular pathways should be prioritized. Here, progress is being made: the National Institute of Mental Health’s Research Domain Criteria project has made this a funding priority (Insel, 2010). However, there are currently no magic bullets. We must hope that major investments in neuroscience and epidemiology result in targets being identified soon.

Simultaneously, health systems must invest in effective preventative psychological interventions. In Garber and colleagues’ 2009 multi-center randomized control trial, for example, rates of depressive episodes fell markedly in a group of adolescents who had had at least one previous depressive episode or current depressive symptoms, following a group cognitive behavioral intervention (Garber, 2009). Additionally, several studies have found that learning mindfulness techniques can promote resilience (Zenner, Herrnieben- Kurz & Walach, 2014). Such approaches could be transformative in reducing deaths due to suicide, a key goal of the World Health Organization’s Mental Health Action Plan, and currently the second leading cause of death in 15-29 year-olds (WHO, 2014).

Addressing the societal risk factors connected with mental illness requires new thinking around deep-seated political issues, such as the impact of immigration and >divorce on the wellbeing of families and children. Policymakers should evaluate interventions using metrics that prioritize gains in wellbeing (e.g. quality-adjusted life years) and less on morbidity (e.g. disability-adjusted life years). By providing detailed cost-savings analyses, mental health experts could advocate for channelling resources from social services into preventative mental health programs and integrating public budgets. Ultimately, such an approach may both shift the mental health paradigm from a deficit- to a resilience-based model and save health systems money.

References

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2. Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., et al. (2010). Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 16(7): 748-751
3. McLaughlin, K.A., Greif Green, J., Gruber, M.J., Sampson, N.A., Zaslavsky, A.M., Kessler, R.C. (2012). Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents. Archives of General Psychiatry, 69(11), 1151-1180
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5. World Health Organization (2014). Preventing Suicide: A global imperative. Geneva: WHO. Available from: http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/ . Accessed July 24th  2015. Zenner, C., Herrnieben-Kurz, S., Walach, H. (2014). Mindfulness-based interventions in schools - a systematic review and meta-analysis. Frontiers in Psychology, 5, 603.