Number range CHAPTER

**THE PROMOTION OF MENTAL HEALTH AND**

**THE PREVENTION OF MENTAL AND BEHAVIORAL DISORDERS:**

**SURELY THE TIME IS RIGHT**

**International Journal of Emergency Mental Health**

**Nancy J. Davis, Ed.D.**

**Public Health Advisor**

**Center for Mental Health Services**

**Substance Abuse and Mental Health Services Administration**

**Department of Health and Human Services**

Requests for reprints may be sent to Nancy J. Davis, Ed.D., Center for
Mental Health Services, 5600 Fishers Lane, Rockville, MD 20857 or
ndavis1@samhsa.gov.

**THEY SAID IT COULDN'T BE DONE**

> ***Never doubt that a small group of thoughtful, committed citizens
> can change the world. Indeed, it is the only thing that ever has.***

***--Margaret** Mead*, 1958

Human history is replete with accomplishments that conventional wisdom,
at one time or another, declared impossible. In 1156 BC, when Egyptian
pharaoh Ramses V died of smallpox (plus a possible blow to the head by
detractors), the idea that smallpox might someday be driven from the
earth was the stuff of fantasy. Throughout the centuries, as smallpox
killed millions of people, physicians used many techniques to try to
control the disease. It was not until 1776, however, that an English
surgeon, Dr. Edward Jenner, experimenting with the Eastern practice of
inoculation, discovered that giving a person a small dose of the
relatively benign cowpox virus could provide protection against the
dreaded smallpox virus ("Jenner," 2000).

No one knew exactly how the cowpox virus worked to prevent smallpox. It
was clearly so promising, however, that people tinkered with the vaccine
until it was perfected. The use and success of smallpox vaccinations
grew throughout the 19^th^ and 20^th^ centuries, but as late as 1967, an
estimated 2,000,000 people died from the disease. At that point, the
political will and funding came together to eliminate smallpox from the
planet. The World Health Organization launched a massive vaccination
project, and in 1977, smallpox was declared eradicated from the earth
("smallpox," *Encyclopaedia Britannica Online, 2000).* The only
remaining supplies of the virus were to be safeguarded at the Centers
for Disease Control and Prevention (CDC) in Atlanta, Georgia, and at a
laboratory in Russia.

Mental illnesses have probably plagued humankind for at least as long as
did smallpox. As was the case with smallpox, various attempts were made
over the centuries to "control" mental illnesses, but all too often, the
approach was to banish people with mental illnesses from society. It was
not until the 19^th^ century that the movement to promote mental health
and prevent mental illnesses got under way in the United States with the
advent of the mental hygiene movement. A number of organizations have
been formed and reports commissioned over the years, but thus far, no
national agenda to promote mental health and prevent mental and
behavioral disorders has been developed in the United States. In some
other countries, including Australia, New Zealand, and Canada, such an
agenda *has* been developed.

At least three factors account for the relative lack of attention to
promotion and prevention issues in the United States. First, the stigma
attached to mental illnesses has led people to believe, among other
myths, that nothing can be done to prevent mental and behavioral
illnesses. Second, until recently, the hard evidence that something
could indeed be done was scarce. However, current research in the
relatively new field known as *prevention science* has brought the
prevention of at least some mental and behavioral disorders into the
realm of possibility, just as Jenner's breakthrough with cowpox
vaccinations made the eventual elimination of smallpox possible.

A third reason that promotion and prevention activities have not
received more attention is the false dichotomy that currently exists
between the concepts of prevention and treatment. This schism is largely
due to the scarcity of funds available for mental health services of any
sort. Advocates for more and better treatment services for people with
mental illnesses have a good point; considerably more funding *is*
needed for treatment and recovery services for people who already have
mental illnesses. But promotion, prevention, treatment, and recovery are
inextricably linked, and adequate funding for the whole continuum of
services is as essential to the Nation's psychological health as, say,
funding for cancer research and services is to the Nation's physical
health.

The good news about treatment and the growing consumer recovery movement
is that they work. People who once were thought to be on a "chronic,
deteriorating course" are now holding jobs, living in the community,
getting married, and being full participants in society. The good news
about promotion and prevention is that, because this is an international
movement with many scholars contributing to the effort, our knowledge of
what works is increasing exponentially. Given the rapid exchange of
information today, it seems likely that the 200 years from Jenner's
cowpox discovery to the eradication of smallpox will be shortened
considerably for the eradication of many mental and behavioral
illnesses. Even if it should take 200 years to eradicate all mental
illnesses, humankind most likely will benefit along the way as
researchers tinker with interventions and gradually learn what works
well for whom.

While recognizing the enormous importance of treatment and recovery
services, this article focuses mainly on issues related to promotion and
prevention. The need for such services is growing, and many effective
and/or promising programs are well under way. The time is clearly right
for the mental health field to follow the lead of Jenner and others in
the medical community and to invest heavily in the promotion of mental
health and the prevention of mental and behavioral disorders.

**THE NEED FOR SERVICES** **TO PROMOTE MENTAL HEALTH AND**

**PREVENT MENTAL AND BEHAVIORAL DISORDERS**

***Mental Illnesses Worldwide: The Global Burden of Disease***

The 1990s witnessed a virtual explosion of information about the impact
of mental illnesses on the health and functioning of people throughout
the world. In 1996, the World Health Organization (WHO), the World Bank,
and Harvard University issued a landmark publication, *The Global Burden
of Disease*, that quantifies "not merely the number of deaths but also
the impact of *premature death* and *disability* on a population." The
researchers combined these numbers into a single unit of measurement,
which they call the overall *burden of disease* in a given population
(Murray & Lopez, 1996, p. 2).

The burden of disease measure marks a major step forward in assessing
the health of a nation. Traditionally, mortality statistics alone have
been used in such assessments, but disability also "plays a central role
in determining the overall health status of a population," and the
causes of disability are often different from the causes of death
(Murray & Lopez, 1996, p. 21). Using mortality data alone greatly
underestimates the importance of psychiatric conditions in the health --
or lack thereof -- of nations. While these conditions are responsible
for only 1.4 percent of deaths worldwide, they account for *almost 11
percent* *of disease burden,* and psychiatric and neurological
conditions together account for *28 percent of all years lived with a
disability* (Murray & Lopez, 1996, p. 21).

The Global Burden of Disease study further found that, of the ten
leading causes of *disability*, five are psychiatric conditions. (See
Table 1.)

+-------------------------------------+-----------------+--------------+
| **Table 1: The Leading Causes of    |                 |              |
| Disability Worldwide, 1990**        |                 |              |
+-------------------------------------+-----------------+--------------+
|                                     | **Total         | **Percent of |
|                                     | (Millions)**    | Total**      |
+-------------------------------------+-----------------+--------------+
| **All Causes**                      | 472.7           | 100          |
+-------------------------------------+-----------------+--------------+
| 1.  **Unipolar major depression**   | **50.8**        | **10.7**     |
+-------------------------------------+-----------------+--------------+
| 2.  Iron-deficiency anemia          | 22.0            | 4.7          |
+-------------------------------------+-----------------+--------------+
| 3.  Falls                           | 22.0            | 4.6          |
+-------------------------------------+-----------------+--------------+
| 4.  **Alcohol use**                 | **15.8**        | **3.3**      |
+-------------------------------------+-----------------+--------------+
| 5.  Chronic obstructive pulmonary   | 14.7            | 3.1          |
|     disease                         |                 |              |
+-------------------------------------+-----------------+--------------+
| 6.  **Bipolar disorder**            | **14.1**        | **3.0**      |
+-------------------------------------+-----------------+--------------+
| 7.  Congenital anomalies            | 13.5            | 2.9          |
+-------------------------------------+-----------------+--------------+
| 8.  Osteoarthritis                  | 13.3            | 2.8          |
+-------------------------------------+-----------------+--------------+
| **9. Schizophrenia**                | **12.1**        | **2.6**      |
+-------------------------------------+-----------------+--------------+
| 10. **Obsessive-compulsive          | **10.2**        | **2.2**      |
|     disorders**                     |                 |              |
+-------------------------------------+-----------------+--------------+
| *(Murray & Lopez, 1996, p. 21)*     |                 |              |
+-------------------------------------+-----------------+--------------+

The report projects that "psychiatric and neurological conditions could
increase their share of the total global burden by almost half, from
10.5 percent of the total burden to almost 15 percent in 2020. This is a
bigger proportionate increase than that for cardiovascular diseases"
(Murray & Lopez, 1996, p. 37). This startling statistic illustrates one
reason the United States needs to move ahead aggressively with a
promotion and prevention agenda. If it does not do so, the already
strained mental health treatment system and other social services will
be completely overwhelmed in less than 20 years.

***Mental Illness in the United States***

Mental disorders already take an enormous toll on the Nation's resources
in terms of both human suffering and health care dollars. Consider the
following statistics[^1]:

-   An estimated 20 percent of all children and adolescents in the U.S.
    have mental disorders with at least mild functional impairment (U.S.
    Department of Health and Human Services, 1999).

-   During a 1-year period, 22 to 23 percent of the U.S. adult
    population -- or 44 million people -- have diagnosable mental
    disorders. When addictive disorders are added, the rate increases to
    28 to 30 percent (U.S. Department of Health and Human Services,
    1999).

-   60% of visits to physicians for medical symptoms are due to
    psychosocial problems, but the frequency of a mental disorder's
    being diagnosed in general medical practice is only 11 to 36 percent
    (Mrazak & Haggerty, 1994).

-   Only 10 to 30 percent of people in need of mental health services
    receive appropriate treatment (U.S. Department of Health and Human
    Services, 1999).

-   In 1996, the direct cost of mental health treatment and
    rehabilitation services in the United States totaled \$69 billion.
    Another \$17.7 billion was spent on Alzheimer's disease and \$12.6
    billion on substance abuse treatment. In 1990, indirect costs due to
    lost productivity were estimated at \$78.6 billion (Rice & Miller,
    1996, cited in U.S. Department of Health and Human Services, 1999).

In children and adolescents, common mental disorders include *autism,
attention deficit hyperactive disorder, depression and anxiety
disorders,* and/or *alcohol and other drug abuse or dependence.* In
addition, according to Dr. Mark Greenberg and his colleagues at the
Prevention Research Center for the Promotion of Human Development at
Pennsylvania State University, "*disorders of conduct* are among the
most prevalent and stable of child psychiatric disorders. Many of our
most costly and damaging societal problems (e.g., delinquency, substance
use, and adult mental disorders) have their origins in early conduct
problems" (Greenberg et al., 1999a, pp. 2-3). Conduct disorders are
extremely difficult to treat, so their prevention becomes all the more
important.

Among adults, *depression* is one of the most common mental disorder.
The statistics are compelling:

-   Major depression affects nearly one in six adults in the United
    States sometime in their lives, and one in 10 in any one year
    (Munoz, 1997).

-   Fifteen to twenty percent of older adults in nursing homes suffer
    from *untreated* clinical depression (NIH Consensus Development
    Panel on Depression in Late Life, 1992).

-   Unipolar depression alone is responsible for more than one in every
    ten years of life lived with a disability worldwide (Murray & Lopez,
    1996).

-   In a major U.S. corporation, employees treated for depression
    incurred annual per capita health and disability costs of \$5,415,
    significantly higher than the cost for hypertension and comparable
    to the cost for heart disease, diabetes, and back problems (Druss et
    al., 2000).

In terms of the *severity of disability* a condition may cause, the
Global Burden of Disease study ranks unipolar major depression in
Disability Class 6 out of a possible seven classes, along with blindness
and paraplegia (Murray & Lopez, 1996, p. 11). (See Table 2.)

  -------------- ----------------- --------------------------------------
  **Table 2:                       
  Gauging the                      
  Severity of                      
  Disability:                      
  Disability                       
  Classes and                      
  Weights Set by                   
  the Global                       
  Burden of                        
  Disease                          
  Protocol for                     
  22 Indicator                     
  Conditions**                     

  **Disability   **Severity        **Indicator Conditions**
  Class**        Weights**         

  1              0.00-0.02         Vitiligo on face, weight-for-height
                                   less than 2 standard deviations

  2              0.02-0.12         Watery diarrhoea, severe sore throat,
                                   severe anaemia

  3              0.12-0.24         Radius fracture in a still cast,
                                   infertility, erectile dysfunction,
                                   rheumatoid arthritis, angina

  4              0.24-0.36         Below-the knee amputation, deafness

  5              0.36-0.50         Rectovaginal fistula, mild mental
                                   retardation, Down syndrome

  6              0.50-0.70         **Unipolar major depression**,
                                   blindness, paraplegia

  7              0.70-1.00         **Active psychosis, dementia**, severe
                                   migraine, quadriplegia
  -------------- ----------------- --------------------------------------

Note: These weights were established using the person trade-off method
with an international group of health workers who met at WHO in Geneva
in August 1995. Each condition is actually a detailed case. For example,
angina in this exercise is defined as reproducible chest pain, when
walking 50 meters or more, that the individual would rate as a 5 on a
subjective pain scale from 0 to 10 (Murray & Lopez, 1996, p. 11).

In his keynote address delivered to the Seventh Annual European
Conference on the Promotion of Mental Health, Dr. Ricardo Munoz stressed
that depression is "a major public health problem that goes far beyond
unipolar major depressive disorder and beyond suicide in terms of its
effect on the health of our societies" (Munoz, 1997, p. 2). He noted
that seven of the nine causes of death (that account for half of deaths
in the United States) may well be influenced by depression. (See Table
3.)

  ---------------- ---------------------------------- -------------------
  **Table 3: Major                                    
  Causes of Death                                     
  Per Year in the                                     
  United States**                                     

  **Rank**         **Cause**                          **Deaths Per Year**

                                                      

  **1**            **Tobacco**                        **400,000**

  **2**            **Diet/Inactivity**                **300,000**

  **3**            **Alcohol**                        **100,000**

  **4**            Microbial agents                   90,000

  **5**            Toxic agents                       60,000

  **6**            **Firearms**                       **35,000**

  **7**            **Sexual behavior**                **30,000**

  **8**            **Motor vehicle accidents**        **25,000**

  **9**            **Illicit drugs**                  **20,000**

  *McGinnis &                                         
  Foege, 1993,                                        
  reported by                                         
  Munoz, 1997*                                        
  ---------------- ---------------------------------- -------------------

He cites other researchers who elaborate on the possible link between
depression and these causes of death as follows:

-   Many people use tobacco, alcohol, or other drugs to manage their
    mood, and mood states influence people's activity levels and eating
    patterns.

-   Teenage girls with depression are more likely to engage in sexual
    intercourse with multiple partners and to become teenage mothers
    than are teenage girls who do not have depression.

-   Suicide accounts for over half of the deaths due to firearms in the
    United States.

***The Role of Treatment***

Clinicians are making valiant attempts to treat people suffering from
depression and other mental illnesses, and these must be continued and
supported. However, according to Dr. Munoz, treatment has many
limitations:

-   It reaches very few of those in need. In the U.S., *78 percent of
    people with major depression do not receive treatment.* In minority
    communities the statistics are even worse. In 1987 in Los Angeles,
    for example, *89 percent* of Mexican-Americans with major depression
    did not receive treatment (Hough et al., 1987, reported in Munoz,
    1997).

-   *Only two-thirds of those who receive treatment for major depression
    improve.*

-   Even if someone improves, the chances of a subsequent episode of
    major depression are *50 percent after one episode, 70 percent after
    two episodes,* and *90 percent after three* *episodes* (Munoz,
    1997).

In the past decade, the prospects for more effective treatment have
gotten better, in part because of significant new knowledge about how
the brain works, in part because of improved systems of care, and in
part because of the mental health consumer movement, a de facto mental
health promotion and relapse prevention program for people with mental
illnesses. However good our news about treatment and recovery, it would
still be an enormous benefit to humankind if even a small percentage of
cases of mental illnesses could be prevented now, with prospects of many
more cases being prevented as research progresses.

**CONTROVERSIES SURROUNDING PROMOTION AND PREVENTION CONSTRUCTS**

As a result of the worldwide interest in promoting mental health and
preventing mental disorders, a number of critical issues have been
raised, though by no means resolved, by researchers, clinicians, public
health officials, program users, and policy makers. Major controversies
arise when people try to define key constructs such as *mental health,
mental illness, mental disorder, mental health problems, promotion,
prevention, treatment*, and *recovery.*

***Defining Mental Health***

Most people would agree that promoting mental health is a worthy
endeavor. However, not all would agree on just what that means. No
universally accepted definitions of *mental health* and *mental illness*
exist. The late Dr. Emory Cowen cautioned us to attend to the issue of
values in any definition of *mental health* and/or *wellness:*

> Built into any definition of wellness . . . are overt and covert
> expressions of values. Because values differ across cultures as well
> as among subgroups (and indeed individuals) within a culture, the
> ideal of a uniformly acceptable definition of the constructs is
> illusory (Cowen, 1994, quoted in U.S. Department of Health and Human
> Services, 1999, p. 5).

Variation in the definition of, and perhaps values underlying, mental
health may be seen when the 1999 U.S. report, *Mental Health: A Report
of the Surgeon General*, is compared to documents written by mental
health agencies in two states in Australia. The Surgeon General's report
defines *mental health* as

> a state of successful performance of mental function, resulting in
> productive activities, fulfilling relationships with other people, and
> the ability to adapt to change and cope with adversity (U.S.
> Department of Health and Human Services, 1999, p. 4).

The document that was written by and for the state of New South Wales
(NSW) in Australia defines *mental health* as

> the capacity of individuals within groups and the environment to
> interact with one another in ways that promote subjective well-being,
> optimal development, and use of mental abilities (cognitive,
> affective, and relational) and achievement of individual and
> collective goals consistent with justice (Scanlon et al., 1997, p. 5).

It is striking that, while the U.S. definition does acknowledge the
importance of relationships with other people, it focuses mainly on the
individual's *doing* something -- performing, adapting, and coping. The
definition set forth by NSW, however, focuses more on relationships with
other people and with society as a whole. Moreover, it takes note of the
individual's inner world and of the importance of a just society.
Interestingly, the Australian state of Victoria adds a spiritual
dimension to its definition that was crafted "to ensure wide community
understanding of the importance of mental health and its relevance to
all people":

> Mental health is the embodiment of social, emotional, and spiritual
> wellbeing. Mental health provides individuals with the vitality
> necessary for active living, to achieve goals and to interact with one
> another in ways that are respectful and just (VicHealth, 1999, p. 4).

***Defining Mental Illness, Mental Disorders, and Mental Problems***

Even more value-laden is the construct of *mental illness*.
Interestingly, however, the U.S. and Australian definitions of *mental
illness* and/or *mental disorder* have more in common than do their
definitions of *mental health*. The definition of *mental illness* from
the Surgeon General's Report is

> all diagnosable mental disorders, health conditions characterized by
> alterations in thinking, mood, or behavior (or some combination
> thereof) associated with distress and/ or impaired functioning (U.S.
> Department of Health and Human Services, 1999, p. 5).

The NSW document does not use the term "illness," but its definition of
*mental disorder* is virtually the same as the U.S. definition of
*mental illness*:

> a recognized, medically diagnosable illness that results in the
> significant impairment of an individual's cognitive, affective, or
> relational abilities (Scanlon et al., 1997, p.5).

The Surgeon General's Report further distinguishes between *mental
illness* and *mental health problems.* It defines the latter as

> signs and symptoms of insufficient intensity or duration to meet the
> criteria for any mental disorder. Mental health problems may warrant
> active efforts in health promotion, prevention, and treatment. An
> example is prolonged bereavement which, if not treated, may evolve
> into a major depressive episode (U.S. Department of Health and Human
> Services, 1999, p. 5).

Similarly, the NSW document defines *mental health problems* as:

> a disruption in the interactions between the individual, group, and
> the environment, producing a diminished state of positive mental
> health (Scanlon et al., 1997, p. 5).

These definitions reflect a view that *mental health and mental illness
are not mutually exclusive categories*. Rather, they are *points on a
continuum* ranging from *positive mental health* through *mental health
problems* to *serious mental illnesses*. All of us move back and forth
along this continuum, depending on a multitude of biological,
psychological, and social factors that change over time. A person's need
for mental health services and the type of services he or she needs will
vary according to where he or she is on the continuum at any given time.
The NSW conceptualization of the relationship between the Mental Health
Status Continuum and the Mental Health Care Continuum can be seen in
Figure 1.

**Figure 1 Interactions of the Mental Health Status Continuum and the
Mental Health Care Continuum**

  ----------------------- ----------------------- -----------------------
  *Positive mental        *Mental health          *Mental disorder*:
  health* high-level      problem:* disruption in medically diagnosable
  capacity of the         interactions between    illness that results in
  individual, group, and  individual, group, and  significant impairment
  environment to interact environment, producing  of cognitive,
  to promote well-being,  a diminished state of   affective, or
  and optimal development positive mental health  relational abilities.
  and use of mental       abilities.              
  abilities.                                      

  ----------------------- ----------------------- -----------------------

**MENTAL HEALTH STATUS CONTINUUM**

**MENTAL HEALTH CARE CONTINUUM**

  ----------------- ----------------- ----------------- ------------------
  *Enhancing        *Primary          *Early            *Treatment and
  health:*          prevention:*      recognition and   rehabilitation:*
  promoting optimum addressing risk   intervention:*    intervening to
  mental health,    factors in        detecting a       reduce the
  e.g., job         vulnerable        problem or        symptoms of an
  satisfaction,     groups, e.g.,     illness at an     illness, diminish
  promoting         coping skills for earlier stage and disability, and
  resilience,       people who are    increasing access improve quality of
  self-esteem, and  unemployed, home  to effective      life, e.g.,
  social skills,    visits for        treatment, e.g.,  effective and
  and improving     families at risk  earlier detection compassionate
  access to income  coping skills for and treatment of  treatment,
  and workplace     people who are    depression or     involvement of
  certainty.        unemployed, home  psychosis.        consumers and
                    visits for                          careers,
                    families at risk,                   information about
                    coping skills for                   patient rights,
                    families                            and full
                    experiencing                        participation in
                    separation and                      rehabilitation
                    divorce.                            programs

  ----------------- ----------------- ----------------- ------------------

Source: Scanlon, K., Williams, M., & Raphael, B. (1997). Mental health
promotion in NSW: Conceptual framework for developing initiatives. NSW
Health Department, Sydney, Australia, p. 9.

In the early 1990s, the U.S. Congress appropriated funds for the
Institute of Medicine (IOM) to evaluate the status of research on the
prevention of mental disorders, make recommendations for Federal policy,
and set forth a prevention research agenda. The result was a highly
influential publication, *Reducing Risks for Mental Disorders: Frontiers
for Preventive Intervention Research* (Mrazek & Haggerty, 1994). The IOM
committee developed a Mental Health Intervention Spectrum for Mental
Disorders, which is similar to the NSW continuum. This spectrum
graphically illustrates a range of interventions for mental disorders,
from prevention through treatment to maintenance and rehabilitation.
This model is presented in Figure 2.

**Figure 2**

**The IOM Committee's Mental Health Intervention Spectrum for Mental
Disorders**

![](media/image1.png){width="6.485416666666667in" height="2.65in"}

Source: Mrazek, P.J., & Haggerty, R.J., Eds. (1994). *Reducing Risks for
Mental Disorders: Frontiers for Preventive Intervention Research.*
Washington, DC: National Academy Press

***Defining Promotion and Prevention***

When the IOM committee wrote its report, it decided not to include
*mental health promotion* in its spectrum of interventions focused on
preventing mental disorders. It acknowledged that mental health
promotion activities are "important and widespread," but went on to say
this:

> The reason for not including it in the above spectrum is that health
> promotion is not driven by an emphasis on illness, but rather by a
> focus on the enhancement of well-being. It is provided to individuals,
> groups, or large populations to enhance competence, self-esteem, and a
> sense of well-being rather than to intervene to prevent psychological
> or social problems or mental disorders (Mrazek & Haggerty, 1994, p.
> 27).

Despite differences conceptually and philosophically, the goals of
promotion and prevention are not mutually exclusive, and considerable
overlap exists in techniques used to achieve these goals. Moreover, the
same program is sometimes cited as an example of both a promotion and a
prevention program. (For a detailed discussion of this issue, see Mrazek
& Haggerty, 1994, Chapter 9.)

The Australian/NSW definition of *mental health promotion* also focuses
on the positive end of the spectrum:

> enabling people, communities and populations to increase control over
> and improve and/or maintain their subjective well-being, optimal
> development, and use of mental abilities (cognitive, affective, and
> relational), and the achievement of goals consistent with social
> justice (Scanlon et al., 1997, p. 7).

However, in its discussion of the principles underlying its mental
health promotion campaign, it stresses that *prevention is included in
its definition of mental health promotion*. The first principle states
that

> Mental health promotion needs to be seen in two contexts: promoting
> positive mental health and preventing the development of mental health
> problems and disorders. These two contexts are inextricably linked
> \... to the extent that initiatives aiming to promote positive mental
> health will also impact upon the prevention of mental health problems
> and disorders. Similarly, initiatives aiming to prevent mental health
> problems and disorders will also impact upon promoting positive mental
> health (Scanlon et al., 1997, p. 7).

A great deal of controversy still surrounds the use of the term
*prevention*. Historically, the term *primary prevention* has been used
to refer to prevention before the onset of a disorder, *secondary
prevention* has referred to prevention of disability from a disorder,
and *tertiary prevention* has referred to prevention of relapse of a
disorder. As can be seen in Figure 2, for the IOM Report, the committee
used a rather restrictive definition of prevention:

> For purposes of monitoring federal research and demonstration efforts,
> prevention research \[shall\] be limited to processes that occur
> before there is a diagnosable mental illness (Mrazek & Haggerty, 1994,
> p. v).

That is, the term refers only to those interventions that occur before
the initial onset of a disorder. One reason for defining prevention in
this manner was purely pragmatic. Prior definitions had included the
prevention of comorbidity, relapse, and disability -- all conditions
that occur *after* the onset of a disorder. Because funds were scarce
and the needs of people with mental illnesses were great, very little
money got channeled into "primary" prevention -- i.e., that which takes
place before the initial onset of a disorder and, one hopes, prevents
the disorder from ever occurring. The IOM committee wanted to be sure
that "primary" prevention was seen as a legitimate endeavor worthy of
sound funding sources.

In 1998, the National Institute of Mental Health (NIMH) Ad Hoc Committee
on Prevention issued *Priorities for Prevention Research at NIMH*. This
committee reconsidered prior definitions and decided to define
prevention in broader terms. Under the NIMH definition,

> prevention refers not only to interventions that occur before the
> initial onset of a disorder, but also to interventions that prevent
> comorbidity*,* relapse, disability*,* and the consequences of severe
> mental illness for families.

NIMH also revised the Mental Health Interventions Spectrum to
accommodate this broader definition. (See Figure 3). At present, no
general consensus has emerged regarding the use of the term, though the
prevention science field appears to be moving toward the IOM definition.

**Figure 3: The NIMH Committee's Mental Health Interventions Spectrum**

![](media/image2.png){width="6.5in" height="3.254861111111111in"}

> Source: NIMH (1998). *Priorities for Prevention Research at NIMH: A
> Report by the National Advisory Mental Health Council Workgroup on
> Mental Disorders Prevention Research.* NIH Publication No. 98-4321.

***Types of Preventive Interventions: Universal, Selective, and
Indicated***

The IOM committee developed a new system, classifying preventive
interventions as *universal, selective,* or *indicated*, according to
the target population of the intervention:

1.  *Universal interventions* are conducted with an entire population,
    regardless of risk. The best example \-- infant immunization
    programs \-- comes from medicine. An example of a potential
    universal mental health intervention would be primary care
    physicians' screening all of their patients for depression,
    regardless of whether a patient was at risk for, or showing symptoms
    of, the illness.

2.  *Selective interventions* are those offered to a subset of a
    population which is deemed to be at risk. For example, one might
    provide an evidence-based nurse home visitation program to pregnant
    adolescents regardless of a given adolescent's mental status
    because, as a group, adolescent mothers are known to be at high risk
    for depression and other mental and behavioral disorders.

3.  *Indicated interventions* are provided to individuals who are at
    elevated risk for developing a negative outcome and who may or may
    not show symptoms. Interventions with children who are showing signs
    of disruptive behavior at school and whose parents have major
    affective disorders are examples of indicated interventions.

***The Links Among Promotion, Prevention, Treatment, and Recovery***

As the NSW document makes clear, the concepts of promotion and
prevention are "inextricably linked" (Scanlon et al., 1997, p. 7). We
would argue that these concepts also are -- or should be -- inextricably
linked to the concepts of treatment and recovery. For example, in the
course of conducting a preventive intervention such as screening
children of parents with depression, a clinician or researcher is likely
to identify one or more children who may already have the full-blown
illness and are in need of treatment. Similarly, in the course of
treating a mother with depression, the clinician is likely to identify
her children as in need of prevention services.

In addition, many clinicians have begun speaking about
"prevention-oriented treatment." By this they mean that, in the course
of treating someone, the clinician must be knowledgeable about how to
prevent comorbidity, disability, and relapse. For example, in the case
of a person with depression, a common warning sign of relapse is early
morning awakening (EMA). People with depression may try to "treat" EMA
with alcohol, but doing so increases their risk of developing
comorbidity of depression and alcohol abuse. A clinician who practices
"prevention-oriented treatment" will help the patient monitor warning
signs of relapse and understand the circumstances that place him at risk
for comorbidity and/or relapse.

The IOM Mental Health Intervention Spectrum includes rehabilitation
under maintenance. The NIMH spectrum includes prevention of comorbidity,
disability, and relapse under both treatment and prevention, and it
lists maintenance as a separate category. Perhaps it is time that the
spectrum be revised yet again to include *recovery*, and that *promotion
and prevention* be both a *segment* of the spectrum plus the *foundation
of the spectrum* since promotion and prevention activities may, and
indeed should, occur at any point in the spectrum.

It should be noted that many techniques used by consumers in the
recovery movement are similar to those common in mental health promotion
programs: wellness action plans, self-advocacy, psychoeducational
classes and seminars, strengths model case management, and spiritual
practices (Ridgway, 2000, p. 8). As research with and by consumers
becomes more available, we will likely know better which of these
practices are more effective not only in preventing disability and
relapse of mental illnesses but also, perhaps, in preventing the onset
of some mental illnesses in the first place. (For information regarding
research involving consumers, see
[[http://www.mhselfhelp.org/research.html.)]{.underline}](http://www.mhselfhelp.org/research.html.)

***Resilience***

Considerable health promotion is done today in programs whose aim is to
"foster resilience." While this is a very popular concept, it has come
under criticism from many in the scientific community because of the
lack of consensus regarding the definition of the construct. Indeed, it
is currently used as if it were a trait, an outcome, and/or a process.

In the popular press and in many programs, "resilience" is frequently
used as if it were a character trait, as in "John is very resilient."
However, using the term this way has had an untended but serious
negative consequence in that it has paved the way for perceptions that
some individuals will "pull themselves up by their bootstraps" no matter
what their circumstances, while others simply do not \"have what it
takes\" to overcome adversity. Such perceptions let policy makers off
the hook by allowing them to believe that their actions do not matter
when it comes to programs and policies that support healthy human
development. In the words of noted resilience researcher, Dr. Ann
Masten,

> *The great danger I see in the idea of resilience is in expecting
> children to overcome deprivation and danger on their own\....There is
> no magic here; resilient children have been protected by the actions
> of adults, by good nurturing, by their assets, and by opportunities to
> succeed. We cannot stand by as the infrastructure for child
> development collapses in this nation, expecting miracles (Masten,
> 1998*).

It is extremely important to stress that resilience does not represent a
discrete trait of an individual (Luthar, Cicchetti, & Becker, 2000;
Masten, 1999; Rutter, 1999; 2000). Besides being misinformed,
unwarranted, and potentially harmful, such a perspective does little to
illuminate processes underlying resilience or to guide the design of
appropriate interventions (Luthar, Cicchetti, & Becker, 2000). We
recommend avoiding using the term resilient as an adjective for
individuals and apply it, instead, to profiles or trajectories of
adaptation (Luthar, 2000; Luthar & Cicchetti, 2000). The positive
adjustment of an at-risk child may reflect in part his or her own
sturdiness of character, but it may equally derive from the effects of
an exceptionally well-functioning family or community. In situations
that necessitate reference to individuals or groups, somewhat qualified
descriptors might be used such as \"apparently, or manifestly
resilient\" youth, or still more simply, \"behaviorally competent\" or
\"emotionally healthy\" youngsters.

It is further important to note that resilience is not absolute --
neither across domains, nor over time. At-risk individuals can show
remarkable success in many important domains of functioning, such as job
or academic performance, while still experiencing difficulties in
domains such as family and social functioning. Moreover, a person's
behavioral functioning might be quite good in any or all of these areas,
but he or she might still experience high depression or anxiety (Luthar
Cicchetti, & Becker, 2000), what has been called "the price of
resilience." Similarly, successful adaptation at one point in
development by no means guarantees subsequent immunity from dysfunction.
Rather, depending on the matrix of biological, psychological, and
environmental forces, manifestly resilient individuals (like all others)
will show some fluctuations over time and within discrete domains of
adjustment.

We propose that the term *resilience* be used to refer to a *dynamic
process encompassing positive adaptation within the context of
significant adversity* (Luthar, Cicchetti, & Becker, 2000). For a
thorough discussion of the implications of resilience for interventions
and social policy, see Luthar & Cicchetti, 2000.

**WHY A PUBLIC HEALTH APPROACH IS NEEDED**

It is a truism in the public health arena that no major epidemic has
ever been eradicated by treating individual cases. The public health
model virtually mandates that one take a broad perspective in developing
promotion and prevention initiatives. The Surgeon General's report on
mental health describes this model as follows:

> In the United States, mental health programs, like general health
> programs, are rooted in a population-based public health model.
> Broader in focus than medical models that concentrate on diagnosis and
> treatment, public health attends, in addition, to the health of a
> population in its entirety. A public health approach encompasses a
> focus on epidemiologic surveillance, *health promotion, disease
> prevention*, and access to service. Although much more is known
> through research about mental illness than about mental health, *the
> report attaches high importance to public health practices that seek
> to identify risk factors for mental problems; to mount preventive
> interventions that may block the emergence of severe illnesses; and to
> actively promote good mental health* (U.S. Department of Health and
> Human Services, 1999, p. viii).

The public health approach has had an extremely positive impact on the
health status of Americans during the past century. For example, the
campaign against cigarette smoking has led to the elimination of
millions of cases of lung cancer, and the campaign encouraging the
wearing of seat belts has greatly reduced the number of deaths from
automobile accidents. It seems reasonable, therefore, to use the public
health approach to promote mental health and prevent mental and
behavioral disorders.

The core elements of the public health approach include

-   Community-based methods for *identifying the sources of the problem*
    \-- taking a population-based perspective, in contrast to the
    individual intervention approach of the physician's office;

-   Epidemiological data and analyses for identifying and *delineating
    patterns of risk and protective factors* associated with the
    problem;

-   Ongoing surveillance and tracking of the problem and the identified
    risk and/or protective factors to establish trends in their
    prevalence and incidence \-- telling who suffers from specific
    problems and why;

-   Designing community-based interventions based on a scientific
    analysis of the problem to *reduce or eliminate risk factors and
    enhance or introduce protective factors;*

-   Evaluating and monitoring interventions to establish and improve
    their effectiveness; and

-   Public education to share information about the problem and
    effective and ineffective interventions (Elliott et al., 1998, pp.
    20-42).

The public health approach is an optimistic approach that provides tools
for individuals and communities to proceed in a positive,
problem-solving manner.

***The Issue of Risk and Protection***

Central to the public health approach is the issue of risk and
protection. This issue is set forth in the first key principle of
preventive interventions in the IOM Report:

> Prevention of the initial onset of mental disorders can be
> accomplished through intervention programs aimed at risk reduction,
> which can include both reduction of causal risk factors and
> enhancement of protective factors. The goal is to *address malleable,
> or modifiable, risk and protective factors related to the onset of
> disorders*, including precursor symptoms, to reduce the incidence of
> mental disorders or at least to delay their onset (Mrazek & Haggerty,
> 1994, p. 215).

Dr. David Olds and his colleagues echo the words of the IOM Report. "The
most useful investigations," they say, "have focused on risk and
protective factors that, *at a group level*, can be traced
developmentally to predict adaptive and maladaptive functioning" (Olds,
et al., 1999, p. 4). Similarly, Greenberg and his colleagues state:

> Preventive interventions are best directed at risk and protective
> factors rather than at categorical problem behaviors. With this
> perspective, it is both feasible and cost-effective to target multiple
> negative outcomes in the context of a coordinated set of programs
> (Greenberg, et al, 1999a)**.**

A problem does exist, however, if we assume that decreasing risk factors
and/or increasing protective factors will *inevitably* lead to improved
mental health *for a given individual*. In talking about risk and
protective factors that are *associated with* a given condition, we must
keep in mind that these factors are only *correlated with mental
health*, and *correlation does not imply causality.* According to Olds
and his colleagues,

> risks, by themselves, explain *only a small part of variance* in the
> incidence of mental disturbance\.... The outcomes for children may be
> predicted in probabilistic terms, but *efforts at predicting later
> outcomes for any individual child from conditions very early in life
> will almost always be less than satisfactory*. This is because current
> research methods are limited (e.g., by the numbers of participants who
> exhibit particular conditions, limits of measurement, etc.), and
> because *the list of biological strengths and vulnerabilities found in
> any single child and the environmental circumstances that the child
> will encounter over his or her life time will be enormous* (Olds et
> al., 1999, p. 5).

Given these complexities, many developmental theorists now subscribe to
*transactional theories of development* that maintain that "the child's
adaptation is continuously transformed by the child's biological
characteristics and transactions with the external environment (e.g.,
parents, family members, peers, larger milieu)" (Olds et al., 1999, p.
5). Unfortunately, adequate research methods to study development in
transactional models do not yet exist. Rather, researchers must try to
identify as accurately as possible those risk and protective factors
implicated in particular disorders, reduce the risk factors and enhance
the protective factors, then document any changes in mental health
status of the target population. Finally, they must make a judgment
about *whether correlative or causal processes are occurring*. While
this method of research is not ideal, many very useful investigations
have been based on this approach (Olds et al., 1999).

*What are those malleable risk factors for mental illness that can be
decreased and those significant protective factors that are amenable to
enhancement and that, one hopes, will lead to improvements in a
population's mental health?*

Some researchers have focused on identifying risk factors that are
unique for specific illnesses. The IOM Report summarizes some of these
findings regarding risk factors for schizophrenia, depression, and
conduct disorders. The report notes, however, that "even though some
risk factors may be specific to a particular disorder, *other risk
factors are common to many disorders,"* and they see great "value in
clarifying the role of these risk factors that appear to be common to
many mental disorders, especially in view of the frequent comorbidity of
these disorders" (Mrazek & Haggerty, 1994, p. 182). (See Table 4 for
risk factors common to many disorders and Table 5 for protective factors
common to many disorders.)

+---+--------------------------------------------------------------------+
|   | **Table 4: Risk Factors Common in Many Mental Disorders**          |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Individual Risk Factors**                                        |
|   |                                                                    |
|   | Individual risk factors during childhood can lead to a state of    |
|   | vulnerability in which other risk factors may have more effect.    |
|   | For instance,                                                      |
+---+--------------------------------------------------------------------+
|   | -   A *prematurely born, low-birthweight* baby may be more         |
|   |     vulnerable than a full-term, healthy sibling in a suboptimal   |
|   |     family environment.                                            |
|   |                                                                    |
|   | -   A child may be vulnerable to parent-child interaction          |
|   |     difficulties by reason of a *difficult temperament*, a         |
|   |     *chronic physical illness, neurophysiological deficits*, or    |
|   |     *below-average intelligence*.                                  |
|   |                                                                    |
|   | -   *Low I Q* is associated with several mental disorders.         |
|   |                                                                    |
|   | -   *Language disabilities* have been linked to the development of |
|   |     later severe behavior disorders.                               |
|   |                                                                    |
|   | -   *Gender*: From before birth through the first 10 years of      |
|   |     life, boys are more vulnerable to both physical and            |
|   |     psychosocial stressors. Between 10 and 20 years, girls are     |
|   |     more vulnerable. In early adulthood, men appear to be more     |
|   |     vulnerable.                                                    |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Family Risk Factors**                                            |
|   |                                                                    |
|   | Family factors that constitute significant risk factors for        |
|   | increased childhood psychopathology:                               |
+---+--------------------------------------------------------------------+
|   | -   *Severe marital discord*                                       |
|   |                                                                    |
|   | -   *Social disadvantage*                                          |
|   |                                                                    |
|   | -   *Overcrowding or large family size*                            |
|   |                                                                    |
|   | -   *Paternal criminality*                                         |
|   |                                                                    |
|   | -   *Maternal mental disorder*                                     |
|   |                                                                    |
|   | -   *Admission into the care of child welfare services*            |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Community** **Risk Factors**                                     |
|   |                                                                    |
|   | Community factors that impinge on children:                        |
+---+--------------------------------------------------------------------+
|   | -   *Social disadvantage*, particularly the experience of being    |
|   |     part of a welfare family. This is not simply due to income     |
|   |     levels; with income controlled, rates of impairment have been  |
|   |     found to be significantly higher for children from low-income  |
|   |     welfare families than for children from low-income non-welfare |
|   |     families.                                                      |
|   |                                                                    |
|   | -   Living in *subsidized housing*.                                |
|   |                                                                    |
|   | -   Living in a community that has a high rate of *community       |
|   |     disorganization*.                                              |
+---+--------------------------------------------------------------------+
|   | (Mrazek & Haggerty, 1994, pp.182-185)                              |
+---+--------------------------------------------------------------------+
|   | **Table 5: Factors That Are Protective Against Many Mental         |
|   | Disorders**                                                        |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Individual Protective Factors**                                  |
+---+--------------------------------------------------------------------+
|   | -   *Positive temperament*: Children who are easygoing and         |
|   |     responsive *call forth the best* from their parents and from   |
|   |     peers, teachers, and other adults.                             |
|   |                                                                    |
|   | -   *Above-average intelligence*, which allows a child to do well  |
|   |     in school and also to develop *problem-solving skills,* a      |
|   |     sense of *perspective*, and *psychological differentiation*    |
|   |     from family or community, fostering the growth of the          |
|   |     *autonomy* and *independence* necessary for optimal adult      |
|   |     functioning.                                                   |
|   |                                                                    |
|   | -   *Social competence*, which includes the ability to get along   |
|   |     with others.                                                   |
|   |                                                                    |
|   | -   *A sense of coherence.*                                        |
|   |                                                                    |
|   | -   An *internal locus of control* orientation.                    |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Family Protective Factors**                                      |
+---+--------------------------------------------------------------------+
|   | -   *Smaller family structure*, i.e., not more than four children  |
|   |     in the family, and spacing of more than two years between      |
|   |     siblings.                                                      |
|   |                                                                    |
|   | -   In early childhood, having a *close relationship with a parent |
|   |     who is responsive and accepting*.                              |
|   |                                                                    |
|   | -   For older children, *supportive parents, good sibling          |
|   |     relationships*, and *adequate rule setting by parents*.        |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | **Community Protective Factors**                                   |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | -   *Relationships* with peers, significant other adults, church,  |
|   |     youth groups, school, and recreational activities, all of      |
|   |     which build *competence* and provide children with *success.*  |
|   |                                                                    |
|   | -   *Good schools* positively affect *academic achievement* and,   |
|   |     subsequently, vocational outcome, and they reduce the rates of |
|   |     truancy, school dropout, and juvenile court appearances for    |
|   |     children in disadvantaged areas.                               |
|   |                                                                    |
|   | -   The IOM report further cites Dr. Emmy Werner's and Dr. Ruth    |
|   |     Smith's 1992 Kauai Longitudinal Study, in which they report    |
|   |     that three clusters of protective factors distinguished their  |
|   |     resilient subjects from those who did not do well over the 30  |
|   |     years they have studied this group:                            |
|   |                                                                    |
|   |     -   *At least* *average intelligence* and *temperamental       |
|   |         attributes that elicit positive responses* from family     |
|   |         members and strangers.                                     |
|   |                                                                    |
|   |     -   *Good relationships* with parents or parent substitutes,   |
|   |         which encourage *trust, autonomy*, and *initiative.*       |
|   |                                                                    |
|   |     -   An *external support system that rewards competence* and   |
|   |         *provides a sense of coherence*.                           |
+---+--------------------------------------------------------------------+
|   | (Mrazek & Haggerty, 1994, pp. 182-185)                             |
+---+--------------------------------------------------------------------+

Olds and his colleagues identify a "set of factors within the child and
his environment that, with some consistency, increase the likelihood
that the child will exhibit emotional, cognitive, and/or behavioral
disturbance later in life" (1999, p. 4). When these risks are combined
and interact with each other, Olds says, the likelihood of poor
adjustment increases. He and his colleagues conceptualize these risk
factors as "putative mediating conditions that an intervention may seek
to alter, with the long term goal of preventing mental health problems
for the child" (1999, pp. 9-10). These risk factors are detailed in
Table 6.

The Australian/NSW plan acknowledges that a multitude of factors
contribute to one's mental health \-- or lack thereof. It therefore
lists a number of risk factors as possible targets for promotion and
prevention interventions throughout the life span. The issues it targets
for children and young people are presented in Table 7, and those for
adults are presented in Table 8.

**WHY A BIOPSYCHOSOCIAL, DEVELOPMENTAL,**

**LIFE SPAN APPROACH IS NEEDED**

The development and/or prevention of a mental illness is an extremely
complex matter. Neither a single cause nor a single cure exists. The IOM
Report stresses the fact that mental illnesses are *biopsychosocial*
conditions that *may occur at any point in the life cycle*.
Interventions must be appropriate to one's age and developmental stage,
and they must be culturally competent.

Most mental illness prevention activities thus far have targeted
children and adolescents. However, research and life experience remind
us that neither development nor adversity ends with adolescence. *Young
adults* must find their way in the adult world and deal with the
developmental tasks of intimacy and career choice. In the most
vulnerable, biochemistry mingles with life events to precipitate a first
psychotic episode. *Middle-aged adults* caring for both the young and
the old are the "sandwich generation," and without good adaptive skills,
they may fall prey to significant anxiety and depression. Their mental
health and emotional resilience are essential for the health and
well-being of the many who depend on them. *Elderly adults* encounter
multiple losses as spouses and friends die and as their own health
begins to decline. In short, vulnerability to mental illness may change
at different points in the life cycle; at each stage, the
biopsychosocial issues must be understood and addressed with appropriate
interventions.

According to the IOM Report, the academic discipline that best
accommodates the complexity necessary for preventive intervention
research is developmental psychopathology. This field is concerned with
the concepts of "risk and protective factors, precursors, sequelae,
competence/ incompetence, developmental antecedents of disorders,
age-defined adaptation, resilience, and predictability" (Mrazek &
Haggerty, 1994, p. 65). Because it is an *interdisciplinary* field of
study, developmental psychopathology is likely to acknowledge the
multiplicity of risk and protective factors -- and their interaction --
that might account for health or illness at any given time. Moreover,
developmental psychpathology stresses that effective programs must deal
with the *complexity* of the problems they are addressing, and that the
preventive interventions must be *developmentally appropriate* to the
target audience's age and life stage issues.

Finally, developmental psychopathology provides examples of how *one
element of the biopsychosocial paradigm may inform other elements*. For
example, findings from the field of genetics \-- the "bio" element \--
"identify the potential importance of environmental preventive
interventions for individuals who are known to be at genetic risk
through mechanisms involving vulnerability to environmental factors"
(Mrazek & Haggerty, 1994, p. 68). Thus, if we know that someone is at
risk for, say, schizophrenia, by virtue of his genetic makeup, we can
design programs aimed at decreasing those environmental risk factors --
high negative emotional expressiveness in a family, for example -- that
are known to interact with genetics in the etiology and/or exacerbation
of schizophrenia.

**MENTAL DISORDERS MOST LIKELY TO BE TARGETED FOR PREVENTION
INTERVENTIONS AT THIS TIME**

The mental conditions for which the most evidence-based interventions
are currently available are the most frequently occurring disorders --
conduct and oppositional defiant disorders among children and
adolescents (Greenberg et al., 1999b), and dysthymia and major
depressive disorders among adults (Munoz et al., 1987). In the case of
manic-depressive illness and schizophrenia, work is under way to
intervene during the prodromal phase of these conditions to prevent the
development of full-blown psychotic episodes. As is noted in the IOM
Report:

> The best hope now for prevention of schizophrenia lies with indicated
> preventive interventions targeted at individuals manifesting precursor
> signs and symptoms who have not yet met full criteria for diagnosis.
> The identification of individuals at this early stage, coupled with
> the introduction of pharmacological and psychosocial interventions,
> may prevent the development of the full-blown disorder (Mrazek &
> Haggerty, 1994, p. 154).

Several organizations around the world are actively engaged in research
regarding prodromal intervention. The Early Psychosis Prevention and
Intervention Center (EPPIC) in Melbourne, Australia, convened
international experts to develop an Early Psychosis Training Pack for
use by clinicians and other caregivers. A journal, *Interventions in
Early Psychosis*, has been established. And conferences are being held
that speak of "schizophrenia as a process and a stage in a process" with
different treatment foci for different stages. No one is claiming that
he or she can prevent schizophrenia, but many are increasingly confident
that, with sound, early psychosocial and psychopharmacological
interventions, they can delay the onset and/or lessen the impact of the
illness.

Ethical concerns must be addressed when one is considering the optimum
time for any intervention, especially in the use of medicine. For
example, does the risk involved in giving a psychotropic medication to a
person presumed to have a serious mental disorder before irrefutable
signs of psychosis are apparent outweigh the potential benefits of
staving off a possible psychotic episode? What constitutes "informed
consent" in such a situation? These and many other ethical questions
must be thoroughly discussed among clinicians, consumers, and
researchers before prodromal interventions become a widespread, accepted
practice.

**TRANSLATING RESEARCH INTO PRACTICE**

The process of developing and pilot testing an intervention, doing
efficacy and effectiveness studies and replications of it, and ensuring
that it is appropriate for the age, developmental level, gender, and
ethnicity of the target audience is both long and complicated. But these
steps are necessary to ensure that, once the intervention is taken into
the "real world" on a large scale, it will actually decrease the risk
factors and increase the protective factors being targeted in order to
promote mental health and/or prevent the specified mental disorder. Once
all these tasks are accomplished, an intervention is said to be ready to
"take to scale."

For a number of years, researchers have been working on various
interventions to prevent mental and behavioral disorders, and some
guiding principles for effective programs have been developed. In a
review of programs for children ages 0 to 5, Olds and his colleagues set
forth the following principles:

1.  ***Epidemiologic foundation*:** An intervention must be grounded in
    "an understanding of the *specific modifiable risks and protective
    factors* associated with (and possibly contributing to) the adverse
    outcomes the investigator wishes to prevent."

2.  ***Theoretical foundation*:** It is crucial that an intervention
    have a theory of behavioral change, such as self-efficacy theory or
    reasoned action. These theories, then, must be translated into
    programmatic activities for reducing risks (such as parents'
    attributions of hostile intent on the part of their babies) and
    increasing protective factors (such as consistently supportive
    relationships between the mother and others close to her).

3.  ***Relevant and perceived as needed by the population to be
    served*.** Using "client focus groups and pilot studies to shape new
    interventions prior to testing them in larger trials \... is
    necessary to ensure that the content, methods, and service providers
    who deliver the program are perceived as sufficiently needed and
    helpful to engage the family or child in the intervention."

4.  ***Manualized*:** The program will have a greater chance of being
    delivered reliably if its contents, methods, and timing of
    activities are written and spelled out in sufficient detail to make
    it easy for service providers to follow. Manualization also makes it
    easier to replicate the program outside of research contexts (Olds
    et al., 1999, p. 52).

In their review of programs for children, ages 6 to 18, Goldberg and his
colleagues enumerated these principles:

5.  ***Adequate duration*:** A program must run long enough to secure
    its desired benefits. Short-term promotion and prevention
    interventions produce time-limited benefits, at best, with at-risk
    groups, where as multiyear programs are more likely to foster
    enduring benefits. Preventive interventions may operate throughout
    childhood when developmentally appropriate risk and protective
    factors are targeted. However, given the resistance to treatment of
    serious conduct problems, ongoing interventions starting in the
    preschool and early elementary years may be necessary to reduce
    morbidity.

6.  ***Multiple domains*:** Promotion and prevention programs that focus
    independently on the child are not as effective as those that
    simultaneously "educate" the child and instill positive changes
    across both the school and home environments. The success of such
    programs is enhanced by focusing not only on the child's behavior,
    but also on the teacher's and family's behavior, the relationship
    between the home and school, and the needs of schools and
    neighborhoods to support healthy norms and competent behavior.

7.  ***Necessity of collaborative strategies*:** There is no single
    program component that can prevent multiple high-risk behaviors; a
    package of coordinated, collaborative strategies and programs is
    required in each community. For school-age children, the school
    ecology should be a central focus of intervention.

8.  ***Systems of care*:** In order to link to other community care
    systems and create sustainability for mental health promotion and
    the prevention of mental and behavioral disorders, programs will
    need to be integrated with systems of treatment. In this way,
    communities can develop common conceptual models, common language,
    and procedures that maximize the effectiveness of programs at each
    level of need. Schools, in coordination with community providers,
    are a potential setting for the creation of such fully integrated
    models (Greenberg et al., 1999a, p. 3)**.**

Once these first eight guiding principles have been adhered to, the
ninth is absolutely crucial.

9.  ***Sound Research Designs:*** The soundness of a program's research
    design tells others the strength of the level of evidence of the
    program's efficacy and/or effectiveness. The higher the level of
    evidence, the more likely the program is to work in other settings.
    In 1998, the U.S. Preventive Services Task Force articulated the
    following ***levels of evidence***:

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2.  Evidence obtained from at least one properly designed randomized
    controlled trial;

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2.  Evidence obtained from well-designed controlled trials without
    randomization;

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2.  Evidence obtained from well-designed cohort or case-control analytic
    studies, preferably from more than one center or research group.

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2.  Evidence obtained from multiple time series with or without the
    intervention, or dramatic results in uncontrolled experiments.

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2.  Opinions of respected authorities, based on clinical experience,
    descriptive studies, or reports of expert committees.

> (U.S. Department of Health and Human Services, 1998)

The tenth guiding principle was recommended by the National Mental
Health Association (NMHA):

2.  ***The program must be accessible, understandable, and affordable
    for communities to replicate with fidelity.*** These concepts should
    be considered at the program design stage, long before they are
    "going to scale," for without these characteristics, programs "are
    not worth the dollars invested in them" (NMHA, 2000, personal
    communication).

**Identifying Evidence-Based Programs**

Various organizations have enlisted scholars to identify and evaluate
many programs which, according to one set of criteria or another, they
have labeled "evidence-based**."** Sometimes words such as "exemplary"
or "model" are assigned to these programs. However, "promising" is
probably a more accurate term for most, as most have not been subjected
to extensive replication and effectiveness testing to know just how well
they perform in the "real world," in different settings, and with
different racial and ethnic groups. Reviews of several promotion and
prevention programs may be found in the following documents:

1.  Mrazek, P.J., & Haggerty, R.J., Eds. (1994). *Reducing Risks for
    Mental Disorders: Frontiers for Preventive Intervention Research.*
    Washington, DC: National Academy Press.

2.  Olds, D., Robinson, J., Song, N., Little, C., & Hill, P. (August
    1999). *Reducing Risks for Mental Disorders During the First Five
    Years of Life: A Review of Preventive Interventions.* A report
    prepared for the Center for Mental Health Services, Rockville, MD.

3.  Greenberg, M.T., Domitrovich, C., & Bumbarger, B. (July 1999b).
    *Preventing Mental Disorders in School-Age Children: A Review of the
    Effectiveness of Prevention Programs.* A report prepared for the
    Center for Mental Health Services, Rockville, MD.

4.  Stuart, B.J., & Stuart, R.B. (2000). *Hardiness and the Prevention
    of Mental Illness in Midlife Adults: Theoretical Perspectives,
    Review of Empirically Substantiated Programs, and Recommendations
    for Action.* A White Paper prepared for the Center for Mental Health
    Services, Rockville, MD.

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1.  Mrazek, P.J. (1998). *Preventing Mental Health and Substance Abuse
    Problems in Managed Health Care Settings.* Alexandria, VA: National
    Mental Health Association.

2.  Dorfman, S.L. (October 1999). *Preventive Interventions for Mental
    Health and Substance Abuse Under Managed Care.* A report prepared
    for the Offices of Managed Care of the Center for Mental Health
    Services and the Center for Substance Abuse Prevention, Substance
    Abuse and Mental Health Services Administration, Rockville, MD.

A review of specific programs is beyond the scope of this paper.
However, it should be noted that one nurse home visitation program for
low-income, unmarried mothers decreased child abuse, a major risk factor
for a wide range of mental and behavioral disorders, by 80 percent. At
15 year follow-up, the children showed less drug and alcohol use, ran
away from home less frequently, and were arrested less frequently,
compared to the control group. An evaluation done by the Rand
Corporation found that investments in the preventive services were
recovered with dividends by the fourth year of the child's life. For
every dollar invested, \$4.00 were saved.

(Olds et al., 1997).

In addition, conduct disorders are precursors to many of our most costly
and damaging societal problems -- delinquency, substance use, and adult
criminality, for example. Not only do anti- bullying programs prevent
the aggressiveness and disciplinary referrals associated with conduct
disorders, but they also show marked increases in students' social
relationships and in their satisfaction with school (Olweus, 1994). A
more general program to promote social and emotional competence through
cognitive skill-building not only improved social problem-solving skills
and understanding of emotions in elementary school students, but also
decreased conduct problems, depression, and somatic complaints
(Greenberg & Kusche, 1997, 1998a; Greenberg, Kusche, Cook, & Quamma,
1995). Similarly, a group intervention for high school students at high
risk for depression prevented the development of a full-blown depressive
disorder. Since depression is a risk factor for substance abuse
disorders, this program has considerable preventive potential (Clarke et
al., 1995).

Existing prevention programs are not for children only. Unemployment is
a major risk factor for depression in adults. One effective intervention
decreases depressive symptoms and increases coping skills of people who
have recently lost their jobs (Price et al., 1992; Vinokur et al.,
1992). This protocol has been so successful in the United States that it
is now also being used in China and Finland. An evaluation of the
program found that the net total benefit per person 32 months after
completing the program was \$6, 420, and this increased to \$12,619 by
the time five years elapsed (Price, 2000). Recent bereavement is a
high-risk time for the elderly. One program for widows that provides
one-to-one support, practical help, and small group meetings has been
found to decrease social withdrawal and depressive symptoms (Vachon et
al., 1980, 1982).

Finally, an intervention targeting low-income Hispanic American women in
primary care settings significantly decreased depressive symptoms
(Munoz, et al., 1995).

**Measuring the Outcomes of Evidence-Based Programs**

At this time, almost no programs present outcomes in terms of DSM or ICD
diagnoses. However, several do report decreases in *symptoms* of several
mental and behavioral disorders, among which conduct disorder,
oppositional defiant disorder, attention-deficit hyperactivity disorder,
some forms of depression and anxiety disorders, and post traumatic
stress disorder are key.

Many programs demonstrate that it is quite possible to *reduce a number
of risk factors* and *increase a number of protective factors* for the
above-mentioned disorders. Common malleable risk factors include low
birthweight, poor parenting and family management, child abuse and
neglect, violence, school failure, and alcohol and other drug use.
Common malleable protective factors include parent-child attachment,
self-efficacy, problem solving skills, realistically high confidence and
self-esteem, self understanding, stress management skills, and social
supports. And a number of programs report behavioral outcomes that
*correlate* with good mental health -- better school attendance, less
school dropout, less arrests, less need for special school services, and
more employment, for example.

Relatively few promotion and prevention programs have done cost-benefit
and other financial analyses. Among those that have done these analyses,
however, the results have been quite promising. In addition to those
programs mentioned above, one program for preschoolers has been credited
with reducing the cost of delinquency and crime by approximately \$2,400
per child (Barnett & Escobar, 1990). And a major longitudinal study in a
large midwestern city found that every dollar invested in preschool
programs for at-risk children returned \$7.10 in reduced costs of crime
and remedial programs and increased earnings capacity from higher levels
of education (Reynolds et al., 2001). This is extremely significant
because the annual cost to society of school dropout and crime is
approximately \$350 billion (National Science and Technology Council,
1997).

The prevention science field would be strengthened if researchers could
come to some agreement on standard outcome measures so that findings
among different programs could be readily compared. In addition, from
early on, attention must be paid to modifications that may be required
to ensure that the practice is useful and appropriate in varied cultural
contexts. Furthermore, in keeping with the trend of consumerism
throughout health care services and increasingly in the mental health
arena, the field would be strengthened if researchers worked more
closely with mental health consumers and consumer researchers to provide
consumer satisfaction analyses and evaluations. An enormous need also
exists for the replication of programs by independent investigators and
for long-term follow-up evaluations to examine stability of program
efforts. Finally, due in part to the categorical nature of funding,
programs now often assess quite narrow outcomes (e.g., only substance
abuse, psychological symptoms, positive adaptation). As programs begin
to focus the intervention on modifying common risk factors for multiple
problem behaviors as well as on promoting competence, measures of
multiple dimensions of outcome are necessary (Greenberg et al., 1999b).

**A WORLDWIDE RESPONSE** **TO THE NEED**

**FOR PROMOTION AND PREVENTION SERVICES**

Just as the 1990s witnessed an explosion of information regarding the
impact of mental illnesses on the world's health, the decade also
witnessed efforts by governmental and nongovernmental organizations
(NGOs) throughout the world to institute promotion and prevention
policies and programs. The governments of Australia, New Zealand,
Finland, Canada, and other countries have developed comprehensive
agendas for the promotion of mental health and the prevention of mental
disorders in their countries. Interestingly, many developing countries
are enthusiastic about and active in promotion and prevention
initiatives for they readily acknowledge that they will never have
adequate resources to create sufficiently large treatment systems to
attend to the needs of their rapidly growing populations. Among the
organizations actively working in the field are the following:

***World Federation for Mental Health (WFMH)***

[[www.wfmh.org]{.underline}](http://www.wfmh.org/)

When Margaret Mead uttered the famous statement quoted in the
introduction to this paper, she was speaking as president of the WFMH,
the world's oldest, international, nongovernmental, multidisciplinary
mental health advocacy and education organization. Founded in London in
1948, WFMH's membership includes mental health professionals of all
disciplines, consumers and their friends and family, and other concerned
citizens in more than 100 countries on six continents. Its mission is
"to promote, among all people and nations, the highest possible level of
mental health in its broadest biological, medical, educational, and
social aspects" (WFMH, 1998, p. 3).

WFMH, in collaboration with the Clifford Beers Foundation and with the
cosponsorship of the World Health Organization, the Carter Center,
Federal agencies including the Center for Mental Health Services, the
National Institute of Mental Health, the Centers for Disease Control and
Prevention, and other organizations, held the *Inaugural World
Conference on the Promotion of Mental Health and Prevention of Mental
and Behavioral Disorders* in Atlanta, Georgia, in December 2000. Leading
scientists, policymakers, program developers, consumers, and advocates
met "to develop a common vision, shared strategies, and a course of
action for the development of science-based mental health promotion and
prevention of mental and behavioral disorders worldwide" (Inaugural
World Conference, 2000). Proceedings of the conference will be available
early in 2002. In September 2002, a second such conference will be held
in London, England.

***National Mental Health Association***

[www.nmha.org](http://www.nmha.org/)

Since its establishment in 1909, the organization now known as NMHA has
been a strong advocate for the promotion of mental health and the
prevention of mental illnesses. To NMHA, prevention is "about equalizing
chances and leveling the playing field for *all* people" ( NMHA, 2000,
p. 1).

***The Society for Prevention Research (SPR)***

[www.oslc.org/spr](http://www.oslc.org/spr)

SPR is a professional organization focused upon the advancement of
science-based prevention programs and policies through empirical
research. A primary goal of SPR is "to create a scientific,
multidisciplinary forum for prevention science" (SPR, 2000, p. 2).

**The U.S. Federal Government**

***Substance Abuse and Mental Health Services Administration (SAMHSA)***

***Center for Mental Health Services (CMHS)***

[www.samhsa.gov/centers/cmhs/cmhs.html](http://www.samhsa.gov/centers/cmhs/cmhs.html)

When the U.S. Congress created the Substance Abuse and Mental Health
Services Administration (SAMHSA) in 1992, it instructed the Secretary of
the Department of Health and Human Services, acting through the
Administrator of SAMHSA, not only "to improve the provision of treatment
and related services to individuals with respect to substance abuse and
mental illness," but also "to improve prevention services,\[and\]
promote mental health" (United States Statutes at Large, 1992). In
enumerating the 12 duties of the Director of the Center for Mental
Health Services (CMHS), Congress placed promotion and prevention at the
top of the list as it instructed him or her to "design national goals
and establish national priorities for the prevention of mental illness
and the promotion of mental health."

CMHS has pursued its promotion and prevention mission in many ways. For
example, it commissioned three of the above-mentioned reviews of
preventive practices, developed a curriculum to train mental health
professionals to deliver prevention services, developed and field tested
a monograph on hiring mental health consultants for day care centers,
and commissioned *A Resource Guide on Preventive Mental Health Services
for Children in the District of Columbia*. CMHS has provided support for
prevention conferences including the Inaugural and Second World
Conferences on the Promotion of Mental Health and the Prevention of
Mental Disorders and the New York State Office of Mental Health's
*Mental Health Prevention: Research in Practice Working Conference.*
CMHS is striving to strengthen the evidence base of preventive
interventions via the development of *A Consensus Report on the
Conceptual and Practical Issues in Measuring the Effectiveness of
School-Based Mental Health Prevention Programs* and *A Review of
Standards of Evidence Used by Key Stakeholders Who Disseminate
Evidenced-based Practices in Mental Health***.** Furthermore, CMHS is
supporting projects to enhance the replicability of a family-focused
preventive intervention for depression in families with parental
psychopathology and to alter other programs to meet the needs of diverse
racial and ethnic minority groups.

***The Resilience Project.*** A key element of the CMHS Promotion and
Prevention Initiative is the Resilience Project, which advocates a
strengths-based approach to child and adult development and to
prevention and treatment services. Tasks undertaken in this project
include *Resilience: Status of Research and Research-Based Programs*
(Davis, 1999), a working paper on resilience for policymakers and the
general public, and projects to identify and promote indigenous models
of resilience among African Americans, American Indians and Alaska
Natives, Asian Americans and Pacific Islanders, and Hispanic Americans.

***U. S. Federal Grant Programs***

A number of Federal agencies sponsor grant programs that relate to the
promotion of mental health and the prevention of mental and behavioral
disorders. An especially innovative program is the *Safe Schools/Healthy
Students Initiative* (SS/HS). Begun in FY-1999 and continued through
FY-2001, this multifaceted school violence prevention program is a
collaborative effort of the U.S. Departments of Education, Justice, and
Health and Human Services (DHHS). The goals of the program are to
promote the healthy development of children and youth, foster their
resilience in the face of adversity, and prevent violence. One provision
of the initiative is that grantees must use evidence-based programs in
their youth violence prevention activities.

As of this writing, 97 SS/HS sites have been awarded \$1,000,000 to
\$3,000,000 per site for three years, for a total of approximately \$445
million. CMHS is the lead DHHS agency in this initiative. In addition to
helping manage the overall grant program, CMHS provides a technical
assistance center for grantees, a communications program, and
interactive violence-prevention technology. CMHS also provides smaller
violence-prevention grant programs to compliment SS/HS.

***Substance Abuse and Mental Health Services Administration (SAMHSA)***

***Center for Substance Abuse Prevention (CSAP)***

[www.samhsa.gov/csap/csap.html](http://www.samhsa.gov/csap/csap.html)

In addition to CMHS, SAMHSA includes two substance abuse components, the
Center for Substance Abuse Treatment (CSAT) and the Center for Substance
Abuse Prevention (CSAP). Over the last 15 years, CSAP (and its
predecessor agency) has played a leadership role in substance abuse
prevention theory, programming, and research. The more general field of
mental health promotion and mental illness prevention encompasses a
larger, more diverse collection of illnesses than those focused upon by
CSAP. However, since substance use disorders are a significant category
of mental and behavioral disorders, many of the principles of substance
abuse prevention developed by CSAP are applicable to the promotion of
mental health and the prevention of other mental and behavioral
disorders. Among these principles are

1.  In the individual domain, build social and personal skills.

2.  In the family domain, target the entire family.

3.  In the peer domain, design intensive programs that include a variety
    of approaches and a substantial time commitment.

4.  In the school domain, avoid relying solely on knowledge-oriented
    interventions.

5.  In the community domain, develop integrated strategies rather than
    one-time community-based events (CSAP, 2001).

**CLEARLY THE TIME IS RIGHT**

As Dr. Jenner learned 200 years ago, discovering a method of preventing
a dreaded illness -- be it physical or mental -- is only half the
battle. Getting that method perfected, widely accepted, and implemented
with fidelity brings human nature with all its foibles into the fray.
The Royal Medical Society rejected Jenner's article on the success of
his vaccine, so in 1798, he published *An Inquiry into the Causes and
Effects of the Variolae Vaccinae, a Disease Known by the Name of Cow
Pox,* on his own. Even after publishing the book, he had trouble
recruiting volunteers. The vaccine was popularized in London by two
other doctors, one of whom tried to steal credit from Jenner, and the
other of whom contaminated the vaccine with the smallpox virus
("Jenner," *2000).*

Fidelity proved to be a major problem for smallpox vaccinations, as
doctors did not always follow the procedures exactly as Jenner
instructed them to do. Other problems arose because pure cowpox vaccine
was difficult to obtain, preserve, and transmit. Moreover, no one
understood the biological factors that produced immunity, and many
mistakes were made in the process of gathering information and
standardizing effective procedures. Over the years, Jenner received many
honors, but he also aroused much opposition. He apparently devoted so
much time to promoting his vaccine that his private practice and
personal affairs fell into disarray ("Jenner," 2000).

In the promotion of mental health and the prevention of mental and
behavioral disorders, scholars now readily acknowledge the need for more
well-controlled research. However, they also generally conclude that
*adequate data are available for the field to proceed, provided that the
research meets rigid standards of design, control, and evaluation*. An
NIMH committee concluded that, as a result of earlier research,

> Scientifically rigorous studies are now yielding promising evidence of
> the efficacy of preventive interventions\.... The field is ready to
> build on prior prevention research accomplishments and integrate these
> with advances in the biomedical, behavioral, and cognitive sciences
> (NIMH, 1998, pp. 14-15).

One researcher sums up her position by saying

> While the documented state of the art is in an early stage of
> development, intervention research has produced solid evidence that
> selected preventive programs and services are associated with positive
> outcomes and that the cost of providing them may be offset by savings
> elsewhere in the health care system (Dorfman, 1999, p. 3).

The story of the eradication of smallpox, though different in many
obvious ways from the prevention of mental and behavioral disorders,
reminds one of a proverb that all people interested in promotion and
prevention must keep in mind: "A journey of a thousand miles begins with
the first step." The journey to prevent smallpox was a long one, but
what if the Chinese had not spread the word about inoculation? What if
Jenner had not noticed the connection between falling ill with cowpox
and *not* falling ill with smallpox?

The first steps have been taken on the journey to promote mental health
and prevent mental and behavioral disorders, but many more steps remain.
We must remember that Jenner persisted despite personal attacks and
human chicanery, and doctors eventually figured out why fidelity is so
important. Surely the time is right to persist on this long journey, and
for community advocates, consumers, researchers, program developers,
clinicians, academicians, and policymakers to launch a major initiative
to promote mental health and to make the eventual prevention of mental
and behavioral disorders a reality.

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[^1]: *(Footnote: For an explanation of how the statistics were derived,
    see U.S. Department of Health and Human Services (1999), Mental
    Health: A Report of the Surgeon General. Rockville, MD: U.S.
    Department of Health and Human Services, Substance Abuse and Mental
    Health Services Administration, Center for Mental Health Services,
    National Institutes of Health, National Institute of Mental
    Health.*)