Reducing Risks for Mental Disorders Frontiers for Preventive Intervention Research (1994) / Chapter Skim
Currently Skimming:
Pages 485-554
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 487... ...
The type and nature of mental disorders vary with age. At least 12 percent of the nation's 63 million children and adolescents suffer from one or more mental disorders including autism, attention deficit hyperactivity disorder, severe conduct disorder, depression, and alcohol and psychoactive substance abuse and dependence (DHHS, 1991; IOM, 1989; OTA, 1986~.
|
From page 488... ...
In the report summarized herein, the Institute of Medicine's Committee on Prevention of Mental Disorders examines what is currently known about the prevention of mental disorders and promotion of mental health and outlines the prospects for advances in that knowledge and its application over the next decade.
|
From page 489... ...
Appendix A / 489 TABLE 1 Time Line of Events Related to Prevention of Mental Disorders 1909 The Mental Health Association was founded; subsequently it became the National Association for Mental Health and then the National Mental Health Association (NMHA)
|
From page 490... ...
designated an Associate Administrator for Prevention within ADAMHA to promote and coordinate prevention programs, including those run by NIMH, the National Institute on Drug Abuse (NIDA) , and the National Institute on Alcohol Abuse and Alcoholism (NIAAA)
|
From page 491... ...
was established at NIMH. This was a step toward consolidation of preventive intervention research throughout NIMH into one unit.
|
From page 492... ...
To date, progress in prevention has been limited because efforts have been sporadic and often have lacked focus. Problems have included difficulties in identifying, defining, and classifying mental disorders; a perception that the knowledge base- including an understanding of etiologies and risk mechanisms-is too small to support preventive interventions; and confusion regarding the terms prevention and prevention research.
|
From page 493... ...
In Chapter 2 of this report, the committee presents a classification system that is tailored for mental disorders and in which the term prevention is reserved for those interventions that occur before the initial onset of disorder. Treatment (for individuals who meet or are close to meeting diagnostic criteria)
|
From page 494... ...
An intervention provided to every prospective marital couple, although low in cost per couple, would be very expensive overall because of the size of the target group. Selective preventive interventions are targeted to individuals or a subgroup of the population whose risk of developing mental disorders is significantly higher than average.
|
From page 495... ...
Then the effects of these interventions are tested in systematic, empirical, and rigorous ways, most often in preventive intervention trials. If risk factors can be decreased or in some way altered, and/or if protective factors can be enhanced, the likelihood that at-risk individuals would eventually develop the mental disorder would decrease.
|
From page 496... ...
THE KNOWLEDGE BASE In order to formulate effective interventions, prevention researchers harvest methodologies, data, theories, and principles from a bounty of disciplines. The core sciences, including neuroscience, genetics, epidemiology, and developmental psychopathology; research on risk and protective factors for the onset of mental disorders; previous preventive intervention research programs; and research on treatment interventions for mental disorders all contribute to the knowledge base for research on preventive interventions for mental disorders.
|
From page 497... ...
Preventive interventions are directed toward reducing incidence, whereas treatment interventions seek to reduce prevalence. Epidemiological studies have yielded valuable data on the origins, life course, and risk factors for mental disorders.
|
From page 498... ...
Many scientific areas of study with links to prevention research have their origins in the behavioral and social sciences. Contributions from these areas that offer substantial leads for research on the prevention of mental disorders include the impact of psychological stress on health; the role of social support mechanisms in decreasing risk factors and enhancing protective factors; usage of health care delivery systems; the relationship between theoretical concepts such as attachment, selfesteem, and self-efficacy and later social relationships and health behaviors; the importance of social frames of reference, including race, culture, gender, and community context; and the relevance of developmental psychopathology in understanding individual patterns of adaptation over time.
|
From page 499... ...
The choice of these five disorders is by no means meant to imply that these are the only disorders that should be targeted for preventive intervention research programs. Anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, and other adult and childhood mental disorders may also be appropriate targets.
|
From page 500... ...
Risk and Protective Factors for Onset During the past 30 years a growing body of research has elucidated some of the risk factors that predispose children and adults to mental disorder. To qualify as a risk factor, a variable must be associated with an increased probability of disorder and must antedate the onset of disorder.
|
From page 501... ...
Alcohol abuse and dependence are genetically influenced disorders, and quantification of genetic risk has begun. Studies examining psychosocial risk factors for onset have often failed to control for family history of alcoholism or other mental disorders, especially antisocial personality
|
From page 502... ...
Conduct disorder has the earliest average age of onset of the five illustrative disorders. Much remains to be learned about its risk and protective factors, but it is clear that the accumulation of risk factors as the child develops is more important than any specific risk factor.
|
From page 503... ...
Markers can be used to identify high-risk populations, but the interventions will be aimed at those causal and malleable risk factors that appear to have a role in the expression of several mental disorders. Identification of relative and attributable risks associated with various clusters could greatly facilitate preventive intervention research.
|
From page 504... ...
As yet, there is no evidence that preventive interventions reduce the incidence of mental disorders. However, although their numbers are relatively small, some excellent illustrations are available of preventive interventions that can reduce risk factors associated with the onset of mental disorders.
|
From page 506... ...
506 ._ cn ·d ~4 .5 v' ·.p .= A in Em In O u, ~>5 : ·- u: O O O ,~ in ~ ~ O of a, In u, o cat .m I 5 ~ 5 ~ ~4 pa ON =0 ~ ~ ~ ~ ~ , ~ ~ D ~ I } ~ ~ e ~ I ~ ~ r ~ `, is, ~ } ~1, ~ } ~ ~ ~ y ' = ~ C° !
|
From page 508... ...
508 a_ in o U)
|
From page 509... ...
509 oo oo ~ o ~ i x x 1 ~ 1 ~_' ~ o E E ~ C =e but igiE~ a: ~ - o o ~ C,~ ~ 'A a; ~ ~ o ~ o o o U
|
From page 512... ...
Even though biological risk factors have a significant role in the onset of mental disorders, few prevention programs other than prenatal care and childhood immunizations address these factors. As knowledge grows in this area over the next decade, growth in the number of programs addressing these factors is expected.
|
From page 513... ...
In addition to lessons on risk and protective factors and causal chains, Chapter 8 lists a number of other possible applications to prevention from treatment. All are presented with cautious optimism and the realization that only a growing body of empirical trials of preventive interventions can validate their applicability.
|
From page 514... ...
Over the next decade, progress is expected in the development of mutual respect, equal opportunity, and pragmatic collaboration among the scientists and advocates in the prevention and treatment fields. MENTAL HEALTH PROMOTION Chapter 9 shifts the focus from mental disorder and the attendant risk-oriented approaches for preventive intervention to mental health and the research and intervention specific to its promotion.
|
From page 515... ...
DESIGNING, CONDUCTING, AND ANALYZING PROGRAMS WITHIN THE PREVENTIVE INTERVENTION RESEARCH CYCLE Successful science benefits from cumulative progress, and the field of prevention of mental disorders is no exception. The task over the next decade will be to enlarge the body of work represented in Chapter 7 into a prevention science by instituting rigorous standards for designing, conducting, and analyzing future preventive intervention research programs, as described in Chapter 10.
|
From page 516... ...
The model building and hypothesis testing inherent in prevention research can elucidate pathways taken by individuals as they move toward or away from the onset of a mental disorder, as well as intervening mechanisms and brain-behaviorenvironment interactions that result in mental disorders or avert their occurrence, even in individuals at very high risk. In addition, empirical validation of preventive interventions can usefully inform and broaden clinical practice.
|
From page 517... ...
The ultimate goal of preventing or delaying the development of a full-blown mental disorders should be ex~licitlv stated even though at this stage that may not be the goal of the preventive intervention itself. These goals will influence the choice of research methodology.
|
From page 519... ...
519 ~ ,~, ~ ~ t~ ~ ~ ~ ~ u ~ ~ ~ ~ e D E He e co e = ~ E c ~ He, ° ° E E ~ ~ ~E he A.-!
|
From page 520... ...
The choice of the sample from the targeted population also has methodological repercussions. The major problem in using selective and indicated preventive interventions is the identification of the high-risk group.
|
From page 521... ...
It is particularly desirable for prevention research programs to include measures of the incidence of mental disorders. Measures of process-which reflect certain characteristics of the participants, program, activities, change technologies, and so on, and of the interaction of these, that might help to generate hypotheses as to why and how the program might work are also appropriate, as are measures of compliance.
|
From page 522... ...
Analyses of changes in risk over time may be particularly sensitive indicators of a programs efficacy and effectiveness. The hope is that the intervention program might begin to exert an effect at its inception and gradually build to its full effect as it is fully implemented with desired impacts on the participants' risk and protective factors.
|
From page 523... ...
Issues of Culture, Ethnicity, and Race Given the cultural diversity that characterizes this country, no discussion of the current and future status of preventive intervention research could possibly be complete without systematic attention to issues of culture, ethnicity, and race. Throughout the preventive intervention research cycle, investigators must be sensitive to the attitudes, values, beliefs, and practices of the cultural groups with whom they are working, as matters of good science and therapeutic leverage, as well as professional ethics (Kavanagh and Kennedy, 1992; Locke, 1992; Vega, 1992; Galanti, 1991~.
|
From page 524... ...
The development of a specific ethical code for prevention research is premature and perhaps not even desirable. What is needed is not only a sensitivity on the part of the individual investigator, and within the research community in general, regarding the importance of ethical issues throughout the preventive intervention research cycle, but also the ability to recognize these issues in changing circumstances and respond responsibly with appropriate questions, skills, and decisions to them.
|
From page 525... ...
Briefly, these are do no harm, practice with competence, do not exploit, treat participants with respect and dignity, protect confidentiality, obtain informed consent, and promote equity and justice. Although there is consensus about the importance of ethics in prevention research on mental disorders, ethical accountability in this area has not yet received the emphasis it deserves.
|
From page 526... ...
THE KNOWLEDGE EXCHANGE PROCESS: PROM RESEARCH INTO PRACTICE The success of the preventive intervention research cycle for a given research program lies only partly in how well it works to expand the knowledge base for prevention. The cycle's ultimate merit and the justification for the expenditure of large amounts of research monieslies in how effectively that knowledge can be exchanged among researchers, community practitioners, and policymakers to successfully implement the program in real-life settings and ultimately, with widespread societal application, to reduce the incidence of mental disorders.
|
From page 527... ...
It is recognized that many preventive interventions require a long follow-up period to assess the effects of the programs and investigators are reluctant to publish
|
From page 528... ...
Improving Community Access to Research Knowledge Many research findings relevant to the prevention of mental disorders never have a chance to make an impact because they are never made known to the practitioners, educators, administrators, and policymakers who would use them. Any national research agenda for prevention of mental disorders will have to include the development of mechanisms for promoting the proper application of prevention technologies that have been validated in confirmatory, replication, and large-scale field trials.
|
From page 529... ...
INFRASTRUCTURE FOR PREVENTION: MUNG, PEEL, ~ COO~ATION Preventive intervention research cannot thrive without providing for its infrastructure. What levels of funding and personnel are necessary to implement the prevention research activities outlined in this report?
|
From page 530... ...
. many federal agencies are involved in prevention research and services related to mental disorders- though to varying degrees and perhaps not recognized or acknowledged by the agencies themselves (see Table 3~.
|
From page 531... ...
are derived from this estimate and the committee's analysis of the investment needed to enable the field of preventive intervention research on mental disorders to proceed.
|
From page 532... ...
Although it is difficult to be precise, the steady-state national requirement of trained personnel, from various disciplines, is certainly at least 1,000 people. Few, if any, of the current researchers in preventive intervention research have completed a formal training program to produce researchers in the prevention of mental disorders.
|
From page 533... ...
No agency has both the expertise in mental disorder preventive intervention research and an established track record in working collaboratively with other agencies and departments on prevention. To coordinate these diverse participants in prevention, a lead agency would require several attributes.
|
From page 534... ...
Therefore the committee strongly recommends that an enhanced research agenda to prevent mental disorders be initiated and supported across all relevant federal agencies, including, but not limited to, the Departments of Health and Human Services, Education, Justice, Labor, Defense, and Housing and Urban Development, as well as state governments, universities, and private foundations. This agenda should facilitate development in three major areas: ~ Building the infrastructure to coordinate research and service programs and to train and support new investigators.
|
From page 535... ...
As previously stated, the committee's recommendations for funding of rigorous preventive intervention research are based on its best estimates of current efforts and its judgment of needed resources to create a robust federal research agenda. The committee finds the need for prevention of mental disorders so great and the current opportunities for success so abundant that it recommends an increased investment across all federal agencies over the next five years (1995 through 1999)
|
From page 536... ...
agencies conduct research or provide interventions for mental disorders (including addictions) , educational disabilities, criminal behavior, and physical disorders as though these were separate conditions, whereas, more often than not, coexisting disorders or problems occur; and (4)
|
From page 537... ...
This office could be charged with forming a subcommittee or task group to focus specifically on the coordination of research aimed at preventing mental disorders and substance abuse. These preventive efforts share many features with other disorders already subject to coordination within this office, but the involvement of the criminal justice system, the education system, child and spousal protective services, civilian and military family support services, and other nonmedical services necessarily encompasses activities in an even broader array of federal agencies.
|
From page 538... ...
Mental disorders contribute to these problems and vice versa; therefore, ultimate solutions must be broad in scope. Adequate staffing and resources are essential to successful coordination of prevention research regardless of where it is located in the federal government.
|
From page 539... ...
States that do establish such offices should, as a group, elect representatives to the national scientific council. · Agencies must be required to identify their funded programs for the prevention of mental disorders, separately accounting for universal, selective, and indicated preventive interventions, using the definitions developed in this report.
|
From page 540... ...
Congress and federal agencies should immediately take steps to develop and support the training of additional researchers who can develop new preventive intervention research trials as well as evaluate the effectiveness of current service projects. This training effort should include consortiums, seminars, fellowships, and research grants to attract existing researchers into prevention research, training programs for new investigators, and expansion of the training component of the specialized prevention research centers.
|
From page 541... ...
An emphasis on postdoctoral training should be consistently high throughout the decade. Funding Coordination and training are the two most immediate and important needs in preventive intervention research on mental disorders (see Table 4~.
|
From page 542... ...
1995 1996 1997 1998 1999 Infrastructure Council/office/dissem~nation 2.0 2.0 2.0 2.0 2.0 Training 12.0 12.0 12.0 12.0 12.0 Knowledge Base Research Risk and protective factor research 6.5 6.5 6.5 6.5 6.5 (biolo~cal/psychosoaal interactions Child epidem~olog~cal study 2.5 2.5 2.5 2.5 2.5 Population studies 5.0 5.0 5.0 5.0 5.0 Mental health promotion study 0.5 0.5 0 0 0 Prevention Research Preventive intervention research projects 20.0 20.0 20.0 25.0 25.0 Preventive intervention research centers 2.0 2.0 5.0 8.0 8.0 Total Budget 50.5 50.5 53.0 61.0 61.0 NOTE: Figures are based on 1993 dollar amounts and are not adjusted for inflation. These recommendations for support are based on the com~ruttee's best estimates of current efforts and its judgment of needed resources to create a robust preventive intervention research agenda for mental disorders across the federal government.
|
From page 543... ...
These epidemiological investigations should be oriented toward diagnosis but also should record a range of symptomatology, so that future changes in the diagnostic system, or developmental changes in individuals, do not preclude understanding of the development of psychopathology throughout this age range and into adult life. These prospective studies also should be oriented toward identification of modifiable risk factors in this age group with the explicit goal of recommending modifiable targets for preventive interventions in the future.
|
From page 544... ...
Specialty areas in treatment research that are likely to yield payoffs for preventive intervention research include clinical psychopharmacology, cognitivebehavior therapy, and applied behavior analysis. ~ Research should continue to be supported to determine which risk and protective factors are similar and which ones are different for treatment and prevention of a variety of mental disorders.
|
From page 545... ...
Funding The committee recommends that $6.5 million be budgeted each year for the next five years for risk research on the complex interaction between biological and psychosocial risk and protective factors. This would augment the research base for those mental disorders furthest along the continuum in the understanding of etiology, emphasizing the identification of malleable risk factors that would augur well for further preventive intervention research.
|
From page 546... ...
Research on selective and indicated interventions targeting high-risk groups and individuals should be given high priority. Many of the programs described in this report are selective preventive intervention research programs, targeting multiple risk factors including poverty, job loss, caregiver burden, bereavement, medical problems, divorce, peer rejection, academic failure, and family conflict.
|
From page 547... ...
Many rigorously designed preventive intervention programs document impacts on risk and protective factors that are likely to reduce incidence rates of mental disorders. Addressing clusters of risk and protective factors increases the chances of preventing multiple disorders, especially major depressive disorder and conduct disorder.
|
From page 548... ...
Priority should be given to research that addresses multiple risk factors for young children with early onset of aggressiveness, including parental psychopathology, poverty, and neurodevelopmental deficits in the child. · Research should be supported on alternative forms of intervention for the caregivers and family members of individuals with mental disorders, especially AZzheimer's disease and schizophrenia, to prevent the onset of stress-induced disorders among these caregivers.
|
From page 549... ...
Community groups that hope for the best long-term outcomes need to express an increased willingness to have service projects more rigorously evaluated and to bring promising prevention programs into the research cycle for a more complete analysis of efficacy and effectiveness. Funding Preventive intervention research (excluding the specialized prevention research centers)
|
From page 550... ...
There will be no "magic bullet." No single prevention strategy or method of changing people's life-style, behavior, or environment will work across the broad range of risk factors and mental disorders that will be encountered. A program designed to prevent one public health problem will not exactly fit the needs and goals of another.
|
From page 551... ...
(1990) Prevention in Child and Adolescent Psychiatry: The Reduction of Risk for Mental Disorders.
|
From page 552... ...
(1989) Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders.
|
From page 553... ...
(1979) Protective factors in children's responses to stress and disadvantage.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.