Early Detection and Prevention of Mental Health Problems
: Developmental Epidemiology and Systems of Support E. Jane Costello Department of Psychiatry and Behavioral Sciences, Duke University This article reviews the role of developmental epidemiology in the prevention of child and adolescent mental disorders and the implications for systems of support. The article distinguishes between universal or primary prevention, which operates at the level of the whole community to limit risk exposure before the onset of symptoms, and secondary or targeted prevention, which operates by identifying those at high risk of developing a disorder. It discusses different aspects of time as it relates to risk for onset of disease, such as age at first exposure, duration of exposure, age at onset of first symptoms, and time until treatment. The study compares universal and targeted prevention, describing the systems needed to support each, and their unintended consequences. In this article we discuss how epidemiology, the study of patterns of illness in time and space, can help to prevent mental health problems by preventing either their occurrence or their causes. Preventing something is usually easier if we can reliably detect the problem, or its cause, or both. We tend to assume, probably with reason, that it is better to detect a problem or its cause earlier rather than later in the course of the disorder and that that systems of support will be strengthened if detection occurs early.
A case can be made against this argument for early intervention (think of all those tonsillectomies and umbilical hernia operations later shown to be a complete waste of resources). But until proven otherwise, epidemiology is ethically bound to operate on the assumption that early detection is a service that it can and should provide to the health care system. TYPES OF PREVENTION What should we be trying to prevent? Of course we want to prevent disease, but disease has many precursors, consisting both of early symptoms and of risk factors that increase the likelihood of disease. Public health has tried to create a manageable taxonomy of risk by classifying exposures according to the level of response best designed to prevent either risk or disease (Gordon, 1983; Mrazek & Haggerty, 1994; Rothman & Greenland, 1998). At the most extreme level (“indicated” prevention) we enforce treatment, or even lock people away, to prevent their harming others or themselves. Isolating or quarantining cases for the safety of the community has been used for centuries to limit the spread of infectious diseases; psychiatry is one of the few areas of chronic disease medicine that still has recourse to this type of prevention.
“Targeted” prevention projects are designed for individuals who have symptoms of a disorder or a clearly recognized risk factor (e.g., parental bereavement as a risk factor for depression; Sandler et al., 2010). “Universal” or “primary” prevention describes public health activities designed to reduce risk for the whole population In this article we present the case that most mental health problems are prevented by aspects of the way we live that have little to do with identification, treatment, or “targeted prevention” at the level of existing symptoms. Epidemiology can be used to identify ordinary everyday aspects of life, like having two parents or being born full-term, which we don’t think of as mental health interventions but which can be shown to be protective. Sometimes, however, the good- © E. Jane Costello This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author(s) have been asserted. Correspondence should be addressed to E. Jane Costello, Department of Psychiatry and Behavioral Sciences, Suite, 22, 905 W Main St, Durham NC 27701. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hcap. Journal of Clinical Child & Adolescent Psychology, 45(6), 710–717, 2016 Published with License by Taylor & Francis Group ISSN: 1537-4416 print/1537-4424 online DOI: 10.1080/15374416.2016.1236728 enough system of daily life fails.
At that point, epidemiology can be used to identify who needs care, of what kind, and to monitor the adequacy and effectiveness of that care. Taken together, these functions of epidemiology help to answer questions about the extent to which systems of support for the basic aspects of life are cost-effective for preventing mental illness, compared with the more focused systems of care that we bring into play when things go wrong. Many of the articles in this special issue take as their focus various emotional and behavioral problems for which specialized systems of care have been devised. Here, the concern is rather how many of those problems might never have developed in the first place given a solid groundwork of support. It turns out that not only do many kinds of primary prevention avoid the costs of screening and the pain of stigma but they often prevent a wide range of health and developmental problems, in addition to mental illness, and so can be highly cost-effective.