As the number of people who struggle with clinical levels of mental health problems continues to rise, many experts and policy makers are calling not only for more availability of mental health treatment but also preventative efforts that might reduce the burden of these conditions in the first place.
The recommendation certainly makes a lot of sense on many levels, from motivations to reduce human suffering to saving money. The call also is based on an assumption that prevention work is substantively different than treatment. But is it? Or is the difference based less on what interventions are being done and more on when interventions are being done (that is, earlier in life and before the onset of symptoms)?
In other areas of medicine, the distinction is much clearer: You wear sunscreen to prevent the onset of skin cancer. You wear a seatbelt to prevent injuries in case of a car crash. Here, not only is the timing important but the intervention is vastly different than the treatment of those things you are trying to prevent; sunscreen doesn’t do much to treat melanoma.
But in the mental health world, things seem much murkier. Prevention efforts can look an awful lot like what occurs in treatment, and these efforts are frequently being performed with folks who already have developed some level of distress when it comes to their mental health.
Take, for example, an important study published in the respected journal JAMA Psychiatry: “Effect of a cognitive-behavioral prevention program on depression 6 years after implementation among at-risk adolescents.” While this is a strong and well-constructed study, it highlights many of the complexities of the prevention/treatment conundrum. It is billed as a prevention study for “at risk” youth who receive a “cognitive behavioral prevention program.” Looking more closely, however, most of the participants had already suffered a depressive episode and many at baseline had elevated depressive symptoms. Further, the prevention intervention was modified from a depression treatment program. Finally, the outcomes being measured included not only the onset of a future diagnosable depressive episode but also quantitative measures such as reductions in depressive symptoms and numbers of “depression free” days. Many other purported prevention studies don’t even look at rate of diagnosable psychiatric disorders at all as an outcome and assess solely a quantitative reduction in symptoms.
Acknowledging these blurry boundaries between treatment and prevention in both practice and research, a logical next question might be, Does it matter? If something helps reduce the burden of emotional-behavioral problems maybe what we call it is just semantics.
But, in my view, the answer to the does-it-atter question is maybe. Indeed, there may be important distinctions to understand between interventions that can truly prevent the onset of full-fledged mental health conditions among those who don’t meet criteria at baseline versus interventions that can statistically reduce the level of problems in folks who are already showing signs of distress. These may be differences related both to the amount or “dose” of the intervention required or actually qualitative differences in what the intervention actually looks like.
A group of us at the American Academy of Child and Adolescent Psychiatry have been tasked to review what is now known about the prevention of psychiatric disorders in youth. In doing so, we are applying this more narrow definition of prevention to see if the answer we get is different than what we have been hearing previously.
Preventing mental health problems before they start, rather than waiting for people to struggle, is a critical line of research and intervention that needs much more attention and resources if we are ever going to be able to stem the tide of our growing epidemic. Understanding what exactly prevention means is an important part of this equation.
