World Psychiatry | 2021
Prevention in the mental health field should be implemented synergically at different levels
Abstract
Fusar-Poli et al present a comprehensive preventive framework for improving mental health in young people. Prevention in psychiatry is not a high funding priority, which is also reflected in the relatively low number of publications in the field. The responsibility for primary prevention and mental health promotion is placed in the social and educational sectors and, most often, the evidence base for initiatives is lacking. In spite of research showing that risk of mental illness is associated with adversities during pregnancy and birth, low socioeconomic status, poor parenting skills, lack of stimulation and support during childhood, bullying, trauma, and early exposure to alcohol and drugs, initiatives to reduce these risk factors have attracted little scientific attention. Much can be done to improve the evidence base for early and broad preventive efforts. Prevention of psychiatric disorders requires a coherent and multifaceted strategy, including at least five levels. The first is universal primary prevention to improve well-being (e.g., initiatives at the population level focusing on a healthy childhood, such as efforts to improve mental health literacy and parenting in early childhood). The second is universal primary prevention to prevent development of mental illness (e.g., interventions such as prevention of preterm birth and perinatal depression as well as initiatives to prevent bullying and traumatic childhood experiences and to reduce risk of adolescents engaging in substance abuse). The third is selective primary prevention to reduce risk of mental illness in risk groups (e.g., children born to parents with mental illness). The fourth is indicated primary prevention for young people showing signs or symptoms foreshadowing emerging disorder (e.g., clinical high-risk groups for psychosis or children with common mental health problems). The fifth is secondary prevention in early stages of psychiatric disorders (e.g., early intervention services in psychosis or early treatment of attention-deficit/hyperactivity disorder and autism spectrum disorders in child and adolescent services). Here we focus briefly on selective interventions for families with parental mental illness and on indicated primary prevention initiatives, on the basis of the experience in Denmark. Children born to parents with mental illnesses constitute an important risk group with a large prevention potential. Danish register-based figures indicate that every sixth child has a parent who has been diagnosed and treated in the secondary mental health sector. The true number at risk is likely to be even higher, since this does not include treatment in primary health care, nor those who, due to lack of accessible treatment offers, fail to be helped by health services. So, this is a very large number of children, who have been shown repeatedly to have a markedly increased risk of being diagnosed with a mental disorder before age 18, are more likely to live with a single parent, are at higher risk of having poor school performance, and have more neurocognitive, social and motor problems than controls. Due to the parental mental illness, they are also more likely to experience insufficient support and stimulation in the home environment and to be exposed to traumatic life events – all factors that hamper their healthy developmental course. Parental mental illness is often silenced in the family, passing on stigmatization across generations. Programmes directed towards the whole family should be developed and tested in order to change this trajectory that has been known for decades. Parental training and support as part of the recovery approach, collaboration of adult and child psychiatry with the primary sector, systematic family-based psychoeducation, and social, financial and practical support may be some elements potentially improving the functioning of the entire family and building resilience in the children at risk. Concerning indicated prevention, implementation of transdiagnostic interventions are suggested to meet the needs of youths with common and multiple mental health problems. A Danish effectiveness study documented the superiority of a new scalable transdiagnostic cognitive behavioral therapy (CBT), called “Mind My Mind” (MMM), compared to management as usual (MAU), for youths aged 6-16 years with emotional and/or behavegies. Implementing interventions to ameliorate cognitive impairments early in life may be a means for psychiatric prevention with substantial societal benefits beyond prevention of psychiatric outcomes (e.g., increasing the cognitive reserve in midlife may be a strategy to reduce dementia). So, there are multiple challenges to implementing preventive strategies in psychiatry. There is, however, a clear need, and the time is ripe to make the leap towards primary and secondary prevention pathways in the critical period of early life and via cognition.