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Reducing Risks for Mental Disorders Frontiers for Preventive Intervention Research Patricia J. Mrazek and Robert J. Haggerty Editors Committee on Prevention of Mental Disorders Division of Biobehavioral Sciences and Mental Disorders INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1994 Vo l i NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, NW • Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils o the National Academy of Sciences, the National Academy of Engineering, and th< Institute of Medicine. The members of the committee responsible for this report wen chosen for their special competences and with regard for the appropriate balance. This report has been reviewed by a group other than the authors according to procedure: approved by a Report Review Committee consisting of members of the National Academy o Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences t( enlist distinguished members of the appropriate professions in the examination of poliq matters pertaining to the health of the public. In this, the Institute acts under both th< Academy's 1863 congressional charter responsibility to be an advisor to the federa government and its own initiative in identifying issues of medical care, research, anc education. Dr. Kenneth I. Shine is the president of the Institute of Medicine. The work on which this project is based was performed pursuant to Contract No NIMH-OD-91-0014 with the National Institute of Mental Health. Library of Congress Cataloging-in-Publication Data Reducing risks for mental disorders: frontiers for preventive intervention research/Committee on Prevention of Mental Disorders, Division of Biobehavorial Sciences and Mental Disorders, Institute of Medicine; Patricia J. Mrazek and Robert J. Haggerty, editors, p. cm. Prepared at the request of the U.S. Congress. Includes bibliographical references and index. ISBN: 0-309-04939-3 1. Mental illness—Prevention—Research—Government policy—United States. 2. Mental health promotion—Research—Government policy— United States. 3. Mental illness—United States—Prevention. 4. Mental health promotion—United States. I. Mrazek, Patricia Beezley. II. Haggerty, Robert J. III. Institute of Medicine (U.S.). Committee on Prevention of Mental Disorders. IV. United States. Congress. [DNLM: 1. Mental Disorders—prevention & control—United States. 2. Risk Factors. 3. Preventive Psychiatry. WM 100 R321 1994] RA790.6.R44 1994 362.2'0425'0973—dc20 DNLM/DLC for Library of Congress 92-4791 CIP Copyright 1994 by the National Academy of Sciences. All rights reserved. The serpent has been a symbol of long life, healing, and knowledge among almost al cultures and religions since the beginning of recorded history. The image adopted as j logotype by the Institute of Medicine is based on a relief carving from ancient Greece, nov held by the Staatlichemuseen in Berlin. Printed in the United States of America. Committee on Prevention of Mental Disorders ROBERT J. HAGGERTY* (Chair), Professor of Pediatrics Emeritus, University of Rochester School of Medicine and Dentistry, Rochester, New York BEATRIX A. HAMBURG* (Vice-Chair), President, William T. Grant Foundation, New York, New York WILLIAM R. BEARDSLEE, Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts ROLAND D. CIARANELLO, Professor of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, California JOSEPH T. COYLE,* Eben S. Draper Professor of Psychiatry and of Neuroscience, Chair of the Consolidated Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts WILLIAM W. EATON, Professor, Department of Mental Hygiene, School of Hygiene and Public Health, The Johns Hopkins University Hospital, Baltimore, Maryland J. DAVID HAWKINS, Professor and Director, Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington FRITZ A. HENN, Professor and Chairman, Department of Psychiatry and Behavioral Medicine, State University of New York at Stony Brook, Stony Brook, New York ROBERT P. LIBERMAN, Professor of Psychiatry, UCLA School of Medicine; Director, Clinical Research Center for Schizophrenia, Los Angeles, California BEVERLY B. LONG, Chair, International Committee on Primary Prevention, and President-Elect, World Federation for Mental Health, Atlanta, Georgia SPERO M. MANSON, Professor and Director, National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, Denver, Colorado DAVID MECHANIC,*+ Director, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey RICARDO F. MUNOZ, Professor of Psychology, University of California, San Francisco, San Francisco General Hospital, San Francisco, California HERBERT W. NICKENS, Vice-President of Minority Health, Education, and Prevention, Association of American Medical Colleges, Washington, D.C. RICHARD H. PRICE, Professor of Psychology and Research Scientist, Institute for Social Research, University of Michigan, Ann Arbor, Michigan NAOMI RAE GRANT, Professor and Head, Division of Child Psychiatry, Department of Psychiatry, The University of Western Ontario, London, Ontario, Canada *IOM Member +NAS Member Hi University Libraries Carnegie (Mellon University Institute of Medicine Staff ROBERT M. COOK-DEEGAN, Director, Division of Biobehavioral Sciences and Mental Disorders CONSTANCE M. PECHURA, Associate Director, Division of Biobehavioral Sciences and Mental Disorders PATRICIA J. MRAZEK, Study Director CAROLYN E. PETERS, Research Assistant CAROL M. HOSPENTHAL, Project Assistant Preface M ental disorders cause an enormous burden on affected individ¬ uals, their families, and society. While impressive advances have been made in the past two decades in defining, diagnos¬ ing, and treating many of the major mental illnesses once they become full blown, many of these disorders are characterized by a chronic or relapsing course that has high personal and economic costs to all concerned. Cures are rare. Therefore, the logic of trying to prevent the occurrence of mental disorders is clear. Yet, in sharp contrast to the situation in the physical diseases, efforts to prevent mental disorders have had low priority. Many voices have been raised to correct this gap, including Congress, who charged the Institute of Medicine to prepare an integrated report of current research with policy-oriented and de¬ tailed long-term recommendations for a prevention research agenda for mental disorders. The committee appointed by the IOM to carry out this task provided the diversity, the wide view, and the expert knowledge that this field demands. It included a range of disciplines, including adult and child psychiatry, psychology, pediatrics, epidemiology, sociology, anthropol¬ ogy, and public advocacy (see Appendix B). The committee's process was a multipronged effort. It involved extensive review of a literature that is large in volume but limited in rigorous evaluation of interventions. Conferences were convened with experts who had conducted large-scale interventions to prevent physical diseases, and with experts in the fields of ethics and cultural diversity; and there were spirited committee meetings, in which the form and vi / Preface substance of the report were debated with an eye towards forgii consensus in the final report. The committee examined some agen budget figures, but it was difficult to get firm data. In addition, sevei background papers were commissioned (see Appendix D). Committ members themselves contributed to many of the technical sections of tl report. The conclusions and recommendations the committee makes this report are based on its best judgment of the information and da that were available for review. The committee concludes that the federal government should tal several actions. For some mental disorders there have now be< sufficient advances in knowledge to warrant the prompt mounting intensive interventions designed to prevent mental disorders, so long these programs are rigorously evaluated. For other conditions there still the need for development of an adequate knowledge base befo sound theoretically-based interventions are warranted. For the field general there needs to be support for training of a cadre of investigate and for coordination of the currently fragmented efforts in prevention mental disorders across the many departments of government and tl private sector. The committee recognized early that disparate definitions of the fie of prevention were causing confusion in preventing mental disordei The committee, therefore, developed a set of definitions to provic common terminology and to help achieve a common understanding what is being done in the field. To date, the definitions have been i broad and flexible that almost everything has been labeled prevention one time or another. The committee's more restrictive definition e eludes interventions aimed at reducing recurrences among patients wi diagnosed illnesses. Instead, we have labeled such programs as a part good treatment. While there are honorable differences of opinion as whether this should be called prevention, the committee recommem that for purposes of monitoring federal research and demonstratic efforts, prevention research be limited to processes that occur befo there is a diagnosable mental illness. When the new definition prevention is used, we will be able to understand better what is beii done in prevention per se. Our estimate is that the field of research c true prevention of mental illness, by our definition, is very small. The committee recognizes the considerable barriers to progress in tl prevention field. Currently there is little evidence from research that ai specific mental disorder can be prevented. There is, however, consi erable evidence that certain risk factors (some of which are causal of ar some only markers of mental disorders) have been clearly identifie TTnino- fhp mriHpl fminH pffprfix/p in thp nrp’upn+irm rif nlivniral <"1icr» Hpt Preface / vii it seems quite appropriate to initiate interventions designed to reduce these identified risk factors (and also to enhance known protective factors) with rigorous evaluations of outcomes. One advantage of targeting interventions on risk factors is that certain clusters of them are common to several disorders, and the potential for reducing more than one disorder by comprehensive intervention is appealing and is likely to be more cost effective. For other disorders the knowledge base is yet too small and must be further developed before theoretically sound interventions can be tested. Promising areas of research are delineated. For many mental disorders, there is now convincing evidence for a genetic predisposition, but in practically all disorders there is also evidence that the genetic factors do not act alone, and that environmental factors can precipitate, or delay, onset. Therefore, research on understanding the causes of mental disorders must integrate biologic and behavioral sciences. In addition, there is considerable evidence that many mental disorders are brought on by physical diseases and that behavioral factors initiate or delay onset of physical disease. The committee urges more research in the interactions between physical and mental disorders. The quality of the Institute of Medicine staff was crucial to the development of this report. Dr. Patricia J. Mrazek, the study director, brought a background in both service experience and research expertise, together with her organizational skills and uncompromising attention to scientific evidence, to all aspects of the committee's work. She did most of the writing of the report, ably assisted by Carolyn Peters and Carol Hospenthal. We are very grateful for their skills and dedication. We believe that the U.S. Congress was wise to initiate this timely review of the field of prevention of mental disorders. The field is so important that the nation must invest the relatively small amounts recommended in this report to capitalize on the advances already made and to develop the knowledge base necessary for future advances. The one-third of our nation who today face the threat of mental disorder during their lifetime will be immediate beneficiaries when effective prevention programs are implemented, and the nation as a whole will ultimately benefit from the lifting of the burden mental disorders placed upon it. The time is right to move ahead with a national agenda to prevent mental disorders. Robert J. Haggerty, M.D., Chair Beatrix A. Hamburg, M.D., Vice-Chair Acknowledgments T he Committee on Prevention of Mental Disorders expresses its appreciation to the agencies within the Department of Health and Human Services that co-funded this 24-month study: the National Institute of Mental Health (NIMH); the Administration on Children, Youth, and Families; the Maternal and Child Health Bureau; the Center for Substance Abuse Prevention; the Office of the Assistant Secretary for Planning and Evaluation; the Office of the Assistant Secretary for Health; and the Office of Disease Prevention and Health Promotion. Many people outside of the committee contributed to this study in various ways. The committee gratefully acknowledges the enthusiastic support of Dr. Juan Ramos, Deputy Director of Prevention at NIMH and project officer for this study; the excellent assistance of Roseanne Price, who collaborated in the editing and writing of the report; and all of those who contributed by writing commissioned background papers, provid¬ ing technical reviews of drafts of chapters, and making presentations to the committee. Many others contributed by providing preventive inter¬ vention research or service program materials, technical and funding information, and moral support. To all of you, the committee offers its sincere gratitude. The names and affiliations of contributors are listed in Appendix B; additionally, authors of commissioned papers are acknowl¬ edged in the relevant chapters. To anyone who was overlooked, please accept the committee's apologies and appreciation.