The need to bring community, policy makers and researchers to the table in prevention programs
Authors: Margarita Alegria
Journal: World Psychiatry (2024)

Kirkbride et al's outstanding paper1 updates recommendations from the perspective of social determinants of health to mitigate the onset of mental disorders and lay out a roadmap for an effective prevention plan. They explain that the maldistribution of essential social determinants is not random, is shaped by policy and by those in power, and could reproduce intergenerational inequities in people's opportunities. They refer to the saliency of "a threshold moment" to actualize our response, given societal demands to tackle the global burden of psychiatric morbidity. They underline the shift of focus from the internal individual-level factors to the environmental conditions that impact mental health and well-being, particularly in children, adolescents and younger ages. The authors' analysis leads to several new significant insights. Their preventive framework to enhance children's mental health and prevent psychopathology offers a rich array of primary and secondary interventions with proven evidence for rapid implementation. They identify gaps and inconsistencies in intervention results that require further evaluation, and studies that lack scientific rigor. With a strong anchor on equity, their seven recommendations make a compelling claim for investing in primary prevention. This important contribution offers a blueprint for preventive actions. However, the authors acknowledge the limitations of prevention strategies to significantly reduce the incidence and prevalence of mental disorders, since there is a shortage of population coverage and it is highly challenging to implement interventions to alter social or physical environments. Preventive interventions may fail to solve the structural problems that generate them in the first place. Some studies may not stratify the diverse groups to examine if the average effect differs by population subgroups of age, sex, region and ethnicity. Partly missing from the review is an adequate attention to the possible unintended harmful effects of prevention interventions, some of which may have consequences that are the opposite of those desired2. These unintended consequences – such as stigmatization of children or frustration of teachers who participate in a school mental health promotion program – are hard to anticipate, identify and observe3. Recent work suggests the need to consider possible physical, psychosocial, economic, cultural and environmental harms of prevention interventions, especially when they do not align with the target community's norms, values and preferences4. For example, work using mediation analysis5 found that boys in families receiving a housing voucher in the Moving to Opportunities intervention showed an elevated risk of mood and externalizing disorders. Similarly, other research points to how primary prevention interventions can aggravate disparities and social inequities, particularly when they lack cultural humility in their approaches for minoritized populations6. Having the perspective of those involved in the program can be critical to optimize the impacts of the prevention interventions and minimize their unintended consequences. Specific framing is one of the tricky features of this contribution. Certain review areas may sound like putting the onus on individuals, replicating a narrative that the problems are theirs rather than at the institutional or societal levels. Subtly, this message may convey disempowerment, implying that we researchers can tell these groups how to solve their problems rather than co-create with them the solutions. Considering racial or minoritized groups as the inheritors of the problems, and framing appropriately the preventive interventions (i.e., acknowledging the role that society as a whole has had in generating the problems) can revert the liability. Sometimes we phrase race questions as biological or behavioral flaws or equate race with racism in our interpretation of findings7. A more extensive review of the system- and institution-level preventive interventions would call attention to policies and regulations to prevent the onset of mental illness and psychological distress. Addressing structural determinants, as in income support provided by the Earned Income Tax Credit, and changing legislation which promotes unpredictable and precarious work schedules for parents in low-paying jobs, are examples of the broad potential impact of policy levers in reducing the adverse mental health harms to young children and decreasing the psychological distress to families. Public policies play a role in onset of and recovery from mental illness. An example is the analysis of the impact of health insurance expansions in Oregon, which demonstrated a decrease in the depression rate8, although physical health outcomes did not improve in the first two years. Kirkbride et al focus on positive and enrichment approaches to the neighborhood, such as neighborhood regeneration programs. This section is one of their review's most thoughtful and provocative components. It lends itself to collaborating with the community and policy makers to co-create a program of how, given the context and resources, mental health prevention should best be prioritized. In deciding which alternatives should be selected, the community voice must be central to the discussions. This can help researchers to anticipate unintended consequences and align with what matters most to that community. On the other hand, it can avoid that policy makers view the feasibility and sustainability of such prevention programs as challenging to sell to their electorate. The authors are practical in recommending that we give precedence to interventions that might influence multiple domains, such as intervening in the prenatal period or in childhood in order to orient mental, physical and cognitive trajectories. However, policy makers must also play a significant role, since their ranking of what needs to be prioritized and invested in might differ from our theoretical models of causation and reparation. Community-research-policy partnerships9 might be the best avenue to build and implement the preventive agenda. Because not all social determinants equally affect or impact onset, progression or recovery of mental health problems, which might depend on the population and its characteristics, some preliminary work and convening might be needed to bring the different partners to agree on a plan of action and on the desired outcomes.