Progress in the Prevention of Mental Disorders

“It is very important that psychology, as well as other behavioral sciences, become aware of the recent emergence of prevention as an area [of legitimate research],” says Irwin Sandler of Arizona State University. Sandler and Jean Ann Linney (University of South Carolina) were co-chairs of the Fifth National Conference on Prevention Research, hosted this year by the National Institute of Mental Health (NIMH), May 8-11, in McLean, Virginia.

To facilitate this awareness, participants at that meeting received the latest major report on prevention research, A Plan for Prevention Research for the National Institute of Mental Health: A Report to the National Advisory Mental Health Council. The 44-page NIMH report summarizes two earlier reports, one from NIMH (The Prevention of Mental Disorders: A National Research Agenda), and one from the Institute of Medicine (IOM) (Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research).

The Elements of Good Research

The NIMH report is billed as “an integrative summary of the scientific and programmatic steps NIMH should take for advancing the field of prevention science.” Like its predecessors, the new report recommends funding initiatives, and describes some of the desirable characteristics of such research.

Modem prevention science centers around four concepts. The first is risk reduction, which means that although the ultimate goal is to prevent cases of mental disorder, the interventions attempt to decrease specific risk factors and increase specific protective factors in the lives of the study participants; that is, to modify shorter-term (and more easily measurable) aspects of behavior and environment.

The second focus is on developmental processes. The studies are longitudinal and must ask how risk factors conspire to cause mental disorders as well as determine during which critical periods in the life span interventions can have maximum impact.

The third element of modem prevention research is an epidemiological perspective, which is required to identify the essential risk and protective factors that might be important or useful to modify.

The fourth concept in the quartet is that of the cyclical and iterative nature of research, meaning that the outcomes of an intervention must be objectively evaluated, and that assessment must inform the next revision and next trial of the intervention.

Although it might seem unnecessary to spell this out for the researchers who develop preventive interventions, these programs and evaluations must eventually be performed in the communities by teachers, social workers, and others with no previous training in research.

NIMH Prevention Conference

Sandler and Elaine Walker (Emory University) summed up the main and the new ideas reinforced at NIMH’s McLean conference on prevention. Sandler emphasized the need for NIMH to take an active role in coordinating the prevention research activities of the many federal agencies involved, and he pointed to the positive results that have been coming in from many research groups. “The payoff is there,” he says, referring both to the efficacy of these programs and to their benefit/cost analyses. “Quite a few of these programs are demonstrating efficacy comparable to the best work NIH does in terms of new prevention or treatments for other types of disorders.” But, one of the next big issues in the field is dissemination of the results of prevention trials, and “dissemination is as much a scientific research issue as efficacy of the interventions per se,” Sandler said.

Agreeing, Walker said that “one of the major goals of the conference was to present an increasingly integrated framework for the interaction of biological and psychosocial factors in the etiology and prevention of mental disorders.” As an example, she referred to animal research showing that stress can have structural and functional consequences in the central nervous system, and that some of those consequences can be reversed by environmental factors. “There is no real distinction between biological and psychosocial aspects of development,” she says.

And, in reference to the relatively modest costs of prevention as compared with biomedical technology, she says, “it is just as important to know about the malleability of human development, as to know about brain structure and its abnormalities.”

With the recent advances in methodology and the positive research results that have come out, the mood within the prevention research community about prospects for further expansion of the field is guardedly optimistic, despite the federal budget crunch.

“We are hoping that as positive findings are disseminated, the message will get out to the public and to Congress,” says Walker.

Developments in Prevention Research

What has been going on in this field?

“Over the years, there have been a number of prevention movements, but because research methodology was not yet well-developed, these movements were not scientifically based. There were good reasons to shy away from prevention research-the methodology simply was not good enough. But this is a different time,” says Patricia Mrazek, who was the study director for the 1994 10M report Reducing Risks for Mental Disorders (see March 1994 Observer). Beverly Long (now President of the World Federation for Mental Health) was on President Carter’s Commission on Mental Health in 1978, which recommended a specific focus on primary prevention. As she puts it, “From an NIMH research investment of some $4 million in the early 1980s, along with some hope and optimism undergirded by a determined coalition of advocates, prevention has emerged with a science and a constituency to which we can point with pride.” Or, as APS Executive Director Alan Kraut puts it, “In the past, prevention was more in the realm of community action than science, but we think now it is time to take prevention more seriously.”

A quick look into this area of psychological research reveals that the field is indeed ready to expand. How did this come about? Why a New NIMH Report Now?

Mrazek explains that the Senate, through the General Accounting Office, for many years had been asking NIMH for an accoW1ting of what was going on in prevention research, and that Congress had never been satisfied with the replies. Finally, the Senate Appropriations Committee, particularly Senator Daniel Inouye (D-Hl), had put some specific language in an appropriations bill in 1989 that directed NIMH to commission a study by IOM.

With considerable prodding from the National Prevention Coalition, which includes some 30 organizations (APS and the National Mental Health Association being two of the most active), the Senate’s increasingly stronger and more specific directives regarding prevention research have appeared in its annual funding authorization for NIMH. In the last year, in particular, NIMH had been directed to prepare a detailed research plan, responding to the IOM report findings-hence, the 1996 NIMH plan on prevention research.

The NIMH plan calls for specific funds for prevention research centers, including funds for training of investigators.

The NIMH is also directed to undertake coordination of whatever scientific research and investigator training is now included in the efforts toward the prevention of mental disorders spread across the 23 federal agencies in 8 departments. NIH Director Harold Varmus is now preparing a plan to begin this coordination effort.

Good Science

The 1994 IOM report was to be a study of what good science was being done and what was known and what was thought to be possible in the area of primary prevention of mental disorders, not in the prevention of relapses, but in actually staving off mental disorders before the cases arose.

Mrazek says that her study committee found plenty of good science to report on in the 1994 [OM book, and preventionists agree there has been much additional progress since then, too. Mrazek emphasizes that many legislators value science highly and would much prefer to fund programs with a good scientific base than pork barrel programs that slip past the peer review process.

The 1994 IOM report emphasized that the way to do prevention research is by the method of risk reduction. While the method of simply trying an intervention and then looking to see whether it causes a reduction in cases of depression some years later inspires hopelessness in a researcher, the approach of targeting specific risk factors for depression, seeing if those factors can be reduced, and then seeing whether those changes in risk factors are followed by a reduction of symptoms over the following years, is a more practical and encouraging way to conduct a study. Mrazek also points out that the wide array of skills needed for this work (including community relations, design of training strategies for presentation by teachers, and statistical methods to assess the outcomes) implies that prevention research is best done in teams. The IOM report is written to communicate the whole scope of a rigorously evaluated scientific research program for the benefit of all the many people involved in that team from the PhD psychologists and psychiatrists, many of whom may have little training in community relations, to the social workers, many of whom have little or no training in research methods and assessment, to the ministers, teachers, principals, and parents, all of whom must be involved in any meaningful experimental trial of a preventive intervention.

Joseph Coyle, chair of the Consolidated Department of Psychiatry at Harvard Medical School, is a basic neurobiologist who was a member of the 10M panel. The panel included a very broad range of scientific viewpoints, from the social/behavioral to the neurobiological, and they all came to a consensus on a number of scientific opportunities.

Why has prevention research not taken off without a push from Congress? Competition for limited funds, explains Coyle.

Current NIH funding is so competitive that few people want to take the risk of applying for grants for long-term high-budget work. Funding seems more certain for short-term, less expensive research. And yet, he points out, hundreds of millions of dollars are being spent on programs (not via peer-reviewed grants) ostensibly designed to reduce the incidence of mental disorders, yet we are clueless as to their efficacy.

Prevention Researchers Are a New Breed

One of the most important chapters in the IOM report describes some of the prevention research that is well-designed and rigorously evaluated, conducted by the new guard of preventionist, who is more scientist than social activist or mere “do-gooder,” says Alan Kraut.

Sheppard Kellam of Baltimore is such a scientist. He has been doing prevention research for many years with the school children in his city His team has developed behavioral interventions, through randomized field trials, to reduce aggressive/disruptive behavior among first graders, an important early risk factor for later delinquency and drug use. By reducing early aggressive behavior in first grade, later antisocial behavior in middle school was prevented in significant numbers of children. Mastery Learning was tested also for its utility in reducing poor academic achievement, an antecedent of depression. Raising reading scores through the Mastery Learning Program reduced the continuity and severity of depression.

Kellam highlights the importance of the proximal-distal or risk reduction strategy for research in developing theoretical and etiological models of development. First come the community epidemiology studies, to define the antecedents for later problem behaviors. Early aggressive behavior, especially when combined with shyness, predicts a range of later problems, including continued aggressive behavior, delinquency, arrests, drug abuse, and teen pregnancy.

The Good Behavior Game aims to reduce early childhood aggressive behavior, and allows an assessment of the conditional probability that, given success in reducing early aggression, there will be a reduction in the sequelae. Not only does this provide a useful way to reduce antisocial behavior, and possibly later crime and delinquency, but it verifies early aggressive behavior’s causal role in later behavior problems.

Kellam’s recent studies of the crossover between the two interventions find that while reduction of early aggression through the Good Behavior Game has no apparent effect on academic performance or depression, the early improvement of reading skills through the Mastery Learning program decreases not only depression but also subsequent aggression and delinquency.

Structured Skills Training Gets Results

Richard Price is the director of the Michigan Prevention Research Center of the Institute for Social Research, University of Michigan, where an experimental preventive intervention called “The JOBS Project for the Unemployed” has been developed, a program of structured skills training for unemployed persons. It is designed to do the double function of helping the subjects get reemployed and helping them to avoid the depression that often accompanies unemployment. In pilot programs in Michigan, California, and Maryland, Price and associates have developed a structured program of group training, a cognitive and behavioral program that is designed to both increase and exercise the participants’ job searching skills, including the needed skills for dealing with the setbacks and failures, and to increase the participants’ control of their own situation and their awareness of that contro1. Participants are randomized to the experimental condition, which entails the full series of training group meetings, versus a control condition, in which the individuals receive in the mail a useful but brief package of information on job-hunting skills and strategies.

Participants in the JOBS program gel reemployed more quickly and in higher paying jobs than the controls, and they have lower levels of depressive symptoms-even those participants who do not find employment are less depressive, suggesting that the increased feeling of control over their lives that comes from the job-search training and the cognitive-behavioral inoculation against failure does help to compensate for the lack of work, which was originally shown to be the primary risk factor for depressive symptoms in this population.

Zero-Sum? Not!

There is a further issue that can only delight members of Congress from either side of the aisle, and that relates to the question of whether or not job search assistance may be a zeroum game. What is the net result for the total economy if a program helps an individual to get a job? If that same job could have gone to someone else under another set of circumstances, this jobs program might be merely redistributing unemployment. The program participant hones his or her job-hunting skills, and beats out another applicant who is not in the program. The corollary is that if the program were expanded, it would become less and less effective, because everyone would now have better job hunting skills, and the level of play would be set higher, with the same number of winners and losers as before. Price addresses this issue in his publications, and when asked about it, he gives the answer that economists have given to this objection. “That would be true if the labor market were perfectly efficient already, but there is such a thing as ‘frictional unemployment,’ in which workers and vacant jobs have trouble finding each other. Because the effect of this program is to increase the efficiency with which people find jobs, as well as to increase the goodness-of-fit between workers and jobs by promoting optimal choices among jobs, the net result should actually be a total increase in employment, and an increase in productivity for the economy as a whole.” The demonstration that this is true in this case was beyond the scope of Price’s research project, but others (economists) have done studies to show that this can happen, and the hypothesis is very attractive.

Case Reduction

As of 1994, when the IOM report was published, there were no published examples of preventive mental interventions that had demonstrated a reduction in diagnosed cases of a mental disorder. There were significant reductions on several continuous scale measurements of depressive symptomology, and there were significant reductions in investigator-defined numbers of subjects who exceeded some threshold for “extreme or severe symptomology,” but now there is a study by Gregory Clarke of the Oregon Health Sciences University, in which a primary intervention to prevent depression has shown a statistically significant reduction of DSM-criteria-diagnosed cases of depression in the experimental group. Although this represents a milestone of sorts, neither Clarke nor others want to make too much of the distinction between reducing depressive symptomology and reducing the number of individuals who meet the criteria for DSM major depression. In fact, as far as the costs and benefits are concerned, other research has shown that increases in depressive symptomology that do not reach the diagnostic threshold for major depression are associated with greater overuse of medical and social services than can be attributed to increases in cases as such.

Sandra McElhaney is the Director of Prevention at the National Mental Health Association (NMHA), and has served on one of the NIMH committees that have met to define and outline the direction of research. “We have been inching forward,” she says, “even in the present budget climate, which is not favorable to any health and human services program, we are making progress. Congress supports the IOM report, and NIMH is taking the lead in the coordination of prevention research across the many federal agencies. I credit the people of NMHA and APS for their diligent efforts over the years to make this happen.”

Saving Government Money

Will all this save the government any money? Each of the reports gives an estimate of the immense costs to society of mental disorders, which affect about one person in five at some time. Not only do we all pay for the disorders themselves through health care and insurance costs, but mental disorders remove workers from the economy, leading to less overall productivity. The argument in favor of an overall benefit to society for any successes in prevention research is excel1ent. Nonetheless, those in the field insist on being cautious about making the claim that prevention might be justified on a purely economic basis. “Prevention isn’t cheap,” says Mrazek, “and few would want to suggest that there would be savings up front.” However, at least in the short run, the current strategy of focusing on the role of NIMH as coordinator truly does have dollar-saving potential, because it may enable us to eliminate redundant projects. In addition, Kraut points out that a tremendous amount of money is already going into programs that are supposed to prevent adverse behavioral outcomes in society, without sufficient evidence that those programs are efficacious, or even that those programs are informed by scientific findings.

Half of the money spent by the federal government on the prevention of spouse and child abuse, for instance, is spent by the Defense Department, and yet there is virtually no rigorous evaluation of these programs.

The total estimate of expenditures in 1991 by the Department of Health and Human Services for prevention of mental disorders, including alcohol and substance abuse, and without the inclusion of assessment in the programs, came to some $2 billion. Of that total, only $20 million (1 percent) was for prevention of the initial manifestation of mental disorders. In that situation, “prevention” meant 99 percent for treatment after the occurrence of disorder and 1 percent for rigorous prevention intervention research to delay or avoid the disorder altogether.

This imbalance in expenditures was not the result of a misrepresentation, but, rather, derived from the lack of consensus as to the definition of prevention.'” The IOM (1994) and NIMH (1996) proposed spending $50-60 million annually over a period of years to build an effective and efficient prevention role for the mental health system with emphasis on coordination of the fragmented and overlapping field. This latter amount is, as Long characterizes it, “a practical and prudent amount.” Paul M. Rowe

• The IOM recommended that the term “prevention” be reserved for only those interventions that occur before the initial onset of a disorder.