Michael T. Compton, MD, MPH

Each decade, the nation, under the direction of the federal government’s Office of Disease Prevention and Health Promotion, sets public health goals and objectives to strive for with regard to the promotion of health and prevention of disease. The overarching goals of 

Attain high-quality, longer lives, free of preventable disease, disability, injury, and premature death;

Achieve health equity, eliminate disparities, and improve the health of all groups;

Create social and physical environments that promote good health for all; and

Promote quality of life, healthy development, and health behaviors across all life stages.

Although work is already underway to develop a new set of goals for the next decade (

), the federal government recently took stock of the progress made toward achieving the goals for this decade, in the 

. This review is vitally important to determine if our country is on the right track for, or is falling behind in, achieving our national health promotion and prevention goals.

Tracking and measuring the nation’s health is no easy undertaking. 

 consists of 42 topic areas, with more than 1200 objectives, which were closely analyzed to evaluate progress across a variety of measures of health.

As with most midpoint evaluations, there are positives and negatives. In many aspects of our nation’s health, we are exceeding expectations. Great strides are being made in maternal, infant, and child health, with lower rates of preterm births and infant deaths, and lower rates of exposure of children to secondhand smoke. In several topic areas, all measurable objectives that track health improvement have either stayed the same or exceeded their targets, with no worsening of targeted objectives over time, including adolescent health, arthritis, diabetes, HIV, and nutrition and weight status. Unfortunately, in considering the status of mental health in the US, the story is not as positive: none of the main measurable objectives of mental health status have demonstrated statistically significant improvement, and many are, alarmingly, getting worse (

We have seen some gains in the expansion of mental health treatment in recent years. For example, more adults are receiving services for co-occurring disorders (from 3.3% in 2008 to 4.2% in 2013); there was a slight increase in screening for depression in primary care settings as well (from 2.2% in 2007 to 2.4% in 2010). A number of improvements in screening for and treatment of alcohol and substance use disorders have been documented, and fewer young people are binge drinking.1 Despite these small gains, many more people need treatment for substance use disorders, all patients in primary care settings would ideally be screened for depression, and we would eliminate binge drinking among young adults.

Despite some success overall, progress in mental health promotion and mental illness prevention is not just stagnating-it is deteriorating (

). There was a significant increase in the age-adjusted suicide rate (from 11.3 to 12.6 deaths per 100,000 of the population) from 2007 to 2013. Mental health worsened for young people, with increased suicide attempts, higher rates of eating disorders, and higher rates of major depressive episodes among high school students. Also, employment rates for people with serious mental illnesses decreased significantly (from 56.0% in 2008 to 48.5% in 2013).

 Moreover, drug use in adults increased, and the number of alcohol-attributable deaths and cirrhosis also increased during the assessment period.

Important conclusions can be drawn from the Midcourse Review. We must do better. It is imperative that we consider the factors that have contributed to the gains, but also think hard about what is causing us to slip backward in the quest to improve many of our public mental health goals.

The Midcourse Review reconfirmed a long-standing fact about our nation’s public health. Health disparities are persistent and, thus far, resistant to initial attempts to reduce or eliminate them. Significant disparities by race/ethnicity and sex were found across most of the domains. Disparities also exist based on educational attainment, income level, and geographic location. Moreover, there is no specific pattern that consistently and universally links certain demographic groups to better outcomes. For example, while male adolescents are less likely to have depression than female adolescents, male adults are more likely to complete suicide than female adults. Non-Hispanic blacks are less likely to complete suicide in adulthood than whites, but biracial adults are more likely to have had a depressive episode in the past year than people of other races/ethnicities. Native Hawaiian or other Pacific Islanders are least likely to have experienced depression in the past year.

In the rare instances when gains are made, they are not being made equally across disparate population groups. The social determinants of mental health are largely responsible for many of these disparities, and the Great Recession’s impact on income inequality, poverty, and unemployment is intimately tied to the inability to make positive gains in outcomes.

 As a nation, we continue to leave too many people behind in our quest for improved mental health.

Many of the areas that are worsening relate to the mental health status of young people. Because mental illnesses and substance use disorders are chronic illnesses that often start in childhood and adolescence, if we wait to treat symptoms of mental illnesses and substance use disorders until they are most obvious in adulthood, we have waited too long to have significant population-level impact. An approach that focuses more on individual risk and protective factors, as well as “the causes of the causes” (including the social and environmental factors that shape risk and protective factors), could ultimately have greater impact than an attempt to treat symptoms and disorders.

 This approach would mean a shift in focus to emphasize prevention of adverse childhood experiences, for example, and diverse other harmful social determinants of mental health that affect young people.

Similarly, a small shift in focus from treatment of serious mental illnesses and substance use disorders to advancing mental health promotion on a population level could lead to great progress in achieving 

 Important mental health promotion priorities include supporting and encouraging strong social ties, educating diverse populations about healthy behaviors, and developing cross-sector collaborations to strengthen protective factors and reduce risk factors within communities.

Many of the significant gains in the treatment expansion category can be attributed to policies and laws that have improved access to care. The passage and implementation of the Affordable Care Act (ACA) and, specifically, the advances in mental health parity that came before, as part of, and after the ACA track very closely with the timing of rare gains that were seen in treatment expansion from a mental health perspective. The slight increase in depression screening in primary care settings was also a focus of the ACA, which allotted specific funding to expand collaborative and integrated care models for depression care. Similarly, more individuals received treatment for co-occurring disorders in 2013 than in 2008, which might be associated with a rise in health insurance coverage for Americans during that time.

 goals in mental health and substance use disorders are especially concerning, considering that many physical health outcome goals are being achieved. Lagging mental health and substance use disorders outcomes may be particularly sensitive to public policy interventions. Additional policies-focused on improving educational attainment, education quality, and education equality; decreasing income inequality, poverty, and neighborhood-level poverty; increasing employment and reducing job insecurity; improving housing quality and housing equality; and eliminating food insecurity-could have lasting benefits on mental health for the US population.

The decrease in alcohol and substance use among young people is not by chance. For a multitude of complex reasons, adolescents and young adults hold differing beliefs regarding alcohol and illicit drug use than previous generations. However, the changing social norms surrounding the health benefits of marijuana use, coupled with legislation to legalize recreational marijuana use, have had consequences, one of which may be an increase in marijuana use among young people, even in the face of a decline in the use of other illicit drugs and alcohol. This change in social norms has also driven policy change, as more states are passing laws that legalize recreational marijuana use. The findings from the Midcourse Review shed light on how social norms can influence health outcomes.

 Midcourse Review serves a number of important purposes for psychiatrists and other mental health professionals. We must be as committed to the promotion of mental health and the prevention of mental illnesses and substance use disorders as we are to treatment. We must also embrace the nation’s health goals, as set forth in 

, and work across sectors to tackle some of the greatest challenges to improving the population’s mental health. The numbers indicate that we must redouble our efforts in response to these challenges. Doing so will require work outside of clinical settings as we collaborate with other groups in implementing evidence-based practices and programs that are known to promote mental health and prevent mental illnesses and substance use disorders. It also means improving local, state, and federal policies and legislation across far-ranging areas (eg, education, employment, housing) so that their downstream effects will reduce rather than increase risk, while at the same time working to shift social norms in a way that ultimately accomplishes the same goal.

Dr. Shim is Associate Professor of Clinical Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA; Dr. Compton is Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY.

The authors report no conflicts of interest concerning the subject matter of this article.

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Tracking and measuring the nation’s health is no easy undertaking. How are we doing?

Measuring Up on Mental Health?

The doctor of the future will give no medication, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.

In considering Edison’s adage, we note an increasing interest in prevention in the field of psychiatry. Medical specialists in, for example, cardiology, oncology, and neurology, detect and evaluate conditions such as hypertension, ductal carcinoma in situ, transient ischemic attacks, and elevated cholesterol, not to treat a symptomatic or disabling medical condition, but to prevent disabling conditions by addressing the earliest manifestations. In psychiatry, we monitor and treat symptoms once a disorder manifests-but is that enough? Is there a way to intervene earlier-to halt or prevent illness progression?

In this article, we discuss the need for further advancement of prevention science and practice. We also present 2 classifications of preventive interventions; emphasize the importance of risk factors, protective factors, and risk prediction models; analyze the growing evidence base for preventive interventions across the life span; and describe the concept of mental health promotion. Finally, we present some of the tasks and challenges ahead as psychiatry re-envisions its scope, with prevention taking a more prominent role.

Antonio is 17 years old, with a long history of ADHD. Recently, his functioning declined and he began displaying odd behaviors. Specifically, over the past 6 months, Antonio has gradually isolated himself from friends, and he stopped going to school one month ago. His father reports that Antonio is “doing weird things with his hands,” which seem to be occasional repetitive stereotypies and finger snapping.

Although always interested in indigenous cultures, Antonio has recently become obsessed with reading about the Mayan culture online. Antonio’s mother died at age 24, soon after a 3-month hospitalization for newly diagnosed disorganized type schizophrenia when Antonio was 7 years old. Her death was either an accident or suicide.

Although Antonio has a history of occasional marijuana use with his friends, the evaluating psychiatrist is mainly concerned that Antonio might be in a prodromal state, at imminent risk for schizophrenia. As the psychiatrist gathers additional history and plans for further evaluation and close monitoring, she realizes that the optimal treatment regimen remains unknown or undeveloped. What she really needs are tools for prediction and prevention, at least if her worry about an emerging psychotic disorder is indeed the most reasonable explanation for Antonio’s recent behavioral changes.


The emerging field of prevention psychiatry (ie, preventive psychiatry, mental illness prevention) combines the principles of public health and population-based mental health with evidence-based interventions that focus on the prevention of mental illnesses and the promotion of mental health. Although there was great hope for prevention during the early days of the community mental health centers movement some 50 years ago, evidence for effective prevention has grown relatively slowly.

Even so, increased interest and advances in prevention science are occurring. A MEDLINE search for “psychiatry or mental health” and “prevention” resulted in an average of only 71 citations per year in 1992 through 1996. By 2012, there was a 9-fold increase in such articles (

). Yet, there are many uncharted frontiers with regard to preventing the vast array of psychiatric disorders.

As defined by the Commission on Chronic Illness in the late 1950s, primary prevention refers to those interventions that avert the incidence, or initial occurrence, of a disease; secondary prevention refers to interventions that detect disease in the early stages, and thus reduce prevalence.

Tertiary prevention, which is typically conceived of as treatment with the goal to reduce disability, aims to reverse or slow the damage or progression of disease and is often the main activity of most psychiatrists in day-to-day practice.

In 1994, these concepts were expanded to classify mental illness prevention in terms of the population to which the preventive intervention is targeted. Universal preventive interventions target the general public or an entire population regardless of individuals’ level of risk. Selective interventions are preventive measures specifically targeted to groups with an elevated risk for an illness. Indicated preventive interventions focus on extremely high-risk groups-those with evidence of early symptoms of an illness but not yet meeting criteria for the disease per se.

 Universal, selective, and indicated preventive interventions are all delivered before the onset of frank illness. Mental health examples of primary, secondary, and tertiary prevention, as well as universal, selective, and indicated preventive interventions are presented in the 

Understanding prevention in the context of mental illnesses also requires consideration of risk and protective factors. Risk factors precede a disorder and are significantly associated with that disorder. They can be modifiable (or malleable)-able to be changed through preventive interventions-or they can be nonmodifiable (eg, age, race, sex, family history). Risk factors can also be causal or noncausal. Some noncausal risk factors can simply be markers for a causal risk factor (proxy risk factors).

Similarly, protective factors also precede the disorder and are associated with a reduced risk of that disorder. Like risk factors, the extent to which protective factors can be changed is highly variable. Within the social/cultural environment, those events that precede and drive some risk and protective factors are considered underlying determinants of health and poor health, which are modifiable through environmental and policy measures. Preventive interventions can aim to reduce risk factors; enhance protective factors; or target the underlying root causes-the social determinants of diseases.

Identifying risk factors, protective factors, and the underlying determinants of disease is just one step toward a preventive approach. Risk factors vary substantially in how strongly they are associated with an outcome and also in how common they are within a population. As such, risk factors vary in their population attributable risk, or the extent of reduction in incidence that would be expected if the population were entirely unexposed to the risk factor, as compared with the actual level of exposure. Thus, some risk factors are more predictive than others, and addressing some modifiable risk factors can exert a more powerful effect in terms of prevention.

Individual risk factors are never as useful as profiles of risk factors. For example, data from the Framingham Heart Study have been used to combine a number of easy-to-assess risk factors to predict the 10-year risk of having a heart attack.

 Similarly, the Gail model estimates 5-year or lifetime risk of invasive breast cancer in women without a history of carcinoma in situ using a combination of risk factors.

 While risk prediction models are being studied in psychiatry, further advances are necessary before risk stratification (and thus selective and indicated preventive interventions) can be embraced in routine practice.

Prevention efforts take place across the life span. However, because half of all mental disorders manifest by age 14 and three-fourths by age 24, special emphasis must be placed on prevention in childhood and adolescence (and especially early childhood) if true primary prevention is to be accomplished.

 Effective, high-quality prenatal care and screening of new mothers can have a robust impact on the risk and detection not only of postpartum depression but also of behavioral and emotional problems for the child as he or she grows up.

A gold-standard intervention in preventing adverse behavioral outcomes is the Nurse-Family Partnership, which has been replicated many times and has followed infants and their families for almost 20 years. Findings show that mothers have improved prenatal health and greater economic self-sufficiency, and children experience fewer episodes of abuse and neglect, fewer injuries, and fewer juvenile and adult incarcerations.

 Other interventions include Head Start and the HighScope Perry Preschool Program, school-based bullying prevention programs, and group-based interventions for the prevention of depression in at-risk high school students.

 Such programs, whether delivering universal, selective, or indicated preventive interventions, aim to reduce the risk and incidence of mental illness or other adverse outcomes.

With a life span approach, preventive interventions can be provided not only in childhood and adolescence but also in early and later adulthood. For example, screening, brief intervention, and referral to treatment (SBIRT) is an effective, well-studied secondary prevention approach to problem drinking or drug use.

 Similarly, screening for depression in primary care settings has a secondary prevention, or early detection and intervention, goal. Among older adults, preventive interventions also often involve screening and other secondary prevention measures, including building connections and social contacts among isolated older adults with early depressive symptoms.

In addition to preventing mental illnesses, another goal of preventive psychiatry is mental health promotion, which is defined as “any action taken to maximize mental health and well-being among populations and individuals.”

 Health promotion activities target both physical health and mental health-promotion of mental health is promotion of physical health, and vice versa.

Physical health promotion is crucial, considering that the leading causes of death among individuals with serious mental illness are chronic diseases (eg, cardiovascular disease, cancer, pulmonary disease, diabetes) that lead to a dramatically reduced life expectancy. Health promotion decreases morbidity and mortality associated with poor mental health.

It is also noteworthy that risk factors for mental illnesses and physical illnesses are often the same, as are the social determinants of mental illnesses and physical health conditions. Poverty, unemployment, food insecurity, housing instability, social isolation, and adverse early childhood experiences, just to name a few, are all factors that affect physical and mental health.

Preventive interventions can be used in everyday clinical practice. Acute episodes need to be addressed quickly and effectively, but psychiatrists can also consider the burden of risk factors for various adverse health outcomes, the availability of protective factors, and how the social determinants of mental health affect patients and communities. While psychiatrists cannot provide effective interventions for all risk factors, they can address modifiable risk factors and underlying determinants. They can also embrace clinical preventive interventions as well as policy approaches to address risks.

We do not deny that the primary duty of contemporary psychiatry is to evaluate for and treat mental illnesses, with a goal of reducing disability (tertiary prevention) and promoting recovery. However, we are cautiously confident that our field is also advancing in the direction of prevention of mental illnesses and the promotion of mental health more broadly. Some of the tasks ahead for this journey toward a re-envisioned and re-engineered psychiatry include:

• Identifying additional risk factors (ie, social, environmental, biological, and genetic), especially those with substantial population attributable risk

• Identifying additional protective factors, particularly those that can be easily modified

• Merging risk factors into risk prediction models

• Discovering and testing effective preventive interventions, both biological and psychosocial, to reduce risk among high-risk populations (selective preventive interventions) or markedly elevated risk or prodromal manifestations (indicated preventive interventions)

• Determining the ideal means of integrating psychiatric preventive activities into general physical preventive activities (aligning with the recent focus on treatment integration)

• Clearly staking out our role in mental health promotion in the broader population, outside of the clinic

Antonio’s psychiatrist might not need a treatment for his unusual mannerisms or a means of focusing him away from ancient Mayan culture; rather, she needs an effective way to predict risk and then provide or prescribe evidence-based preventive interventions tailored to his level of risk. She needs an approach to interest Antonio “in the care of the human frame,” to use Edison’s words, and in the care of the human mind from a preventive perspective.

Edison’s wise prediction from more than 100 years ago was prescient for medicine, but also for psychiatry, since issues related to the causes and prevention of mental illnesses will surely be increasingly relevant to a modernized psychiatry. While unexplored frontiers in treatment undoubtedly remain, we believe that the real next frontier is studying, testing, proving, and applying preventive measures.

Dr Compton is Chairman of Psychiatry at Lenox Hill Hospital in New York. Dr Shim is Associate Professor in the department of psychiatry and behavioral sciences at Morehouse School of Medicine in Atlanta. They report no conflicts of interest concerning the subject matter of this article.

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The authors emphasize the importance of risk and protective factors and risk prediction models; analyze the growing evidence base for preventive interventions; and describe the concept of mental health promotion.

Author | Michael T. Compton, MD, MPH

Articles

Measuring Up on Mental Health?

Considering Edison’s Predictions: Prevention as the Next Frontier for Psychiatry