Elsevier

The Lancet Psychiatry

Volume 5, Issue 7, July 2018, Pages 591-604
The Lancet Psychiatry

Review
Preventive strategies for mental health

https://doi.org/10.1016/S2215-0366(18)30057-9Get rights and content

Summary

Available treatment methods have shown little effect on the burden associated with mental health disorders. We review promising universal, selective, and indicated preventive mental health strategies that might reduce the incidence of mental health disorders, or shift expected trajectories to less debilitating outcomes. Some of these interventions also seem to be cost-effective. In the transition to mental illness, the cumulative lifetime effect of multiple small effect size risk factors progressively increases vulnerability to mental health disorders. This process might inform different levels and stages of tailored interventions to lessen risk, or increase protective factors and resilience, especially during sensitive developmental periods. Gaps between knowledge, policy, and practice need to be bridged. Future steps should emphasise mental health promotion, and improvement of early detection and interventions in clinical settings, schools, and the community, with essential support from society and policy makers.

Introduction

Although interest in early detection to prevent progression to severe mental health disorders such as schizophrenia and recurrent major depression is increasing, knowledge of risk factors and developmental trajectories has not yet been widely applied to clinical practice and public health.1 Psychiatry has traditionally been based on treatment and prevention of progression and disability in individuals with established illness (ie, tertiary prevention). Although many medical specialties have joined forces with public education and health associations to reduce risk factors for diseases such as myocardial infarction,2 preventive initiatives for mental health have received far less attention. Scientific evidence gathered from other areas of medicine, along with increasing knowledge of developmental risk factors preceding psychiatric illness, and preliminary findings supporting preventive inter-ventions, indicate that our field could move toward the more ambitious goals of universal prevention of vulnerability, selective prevention in high-risk subgroups, and indicated prevention of full or more severe expression of illness in individuals already showing early manifestations.3 The reality is that less than 5% of mental health research funding goes on prevention research, even in countries that invest in prevention.4

In this Review, we will first summarise the various possibilities for mental health prevention throughout development, and the evidence supporting them. We will then review the potential limitations associated with these approaches, and potential ways to overcome them.

Section snippets

Preventive interventions

Prevention in mental health aims to reduce the incidence, prevalence, and recurrence of mental health disorders and their associated disability. Preventive interventions are based on modifying risk exposure and strengthening the coping mechanisms of the individual.5 Effective interventions require the identification of causal risk factors6 and can target both generic risk factors, which are likely to be shared by different disorders, and disease-specific factors. Most preventive programmes will

Universal preventive interventions

Universal prevention of mental health disorders addresses generic risk and protective factors in the general population. Such interventions are likely to affect the global probability of developing psychiatric and other disorders in a non-specific fashion. A holistic approach to health, integrating psychosocial and physical aspects of wellbeing, might be especially valuable in this regard. Results from a meta-analysis89 of 67 cluster trials reported that the WHO Health Promoting School

Is it worth investing in mental health prevention?

Despite mounting scientific data supporting the efficacy of early intervention and prevention in psychiatry, a gap still exists between research evidence and clinical and public health practices. Can this be attributed to economics? Improving long-term outcomes, and reducing long-term adverse consequences of poor mental health (eg, secondary disorders, criminality, and unemployment), make many early mental health interventions cost-effective for society.35, 109 This cost-effectiveness is in

The role of mental health professionals in mental health prevention

Some of the general risk factors for mental disorders, such as social exclusion or economic inequality, cannot be directly addressed by psychiatrists. Universal interventions in the general population require a public mental health approach, and will probably need to be delivered by professionals from other medical specialties, such as obstetricians and general practitioners, or other sectors such as education. We believe that it is the duty of mental health professionals to increase awareness

Conclusions

Increasing evidence suggests that preventive interventions in psychiatry that are feasible, safe, and cost-effective could translate into a broader focus on prevention in our field. Universal, indicated, and selective prevention strategies might be effective in improving psychological wellbeing or preventing mental disorders throughout development, although further evidence is required. There is a precedent for implementing safe universal interventions, despite incomplete evidence, from other

Search strategy and selection criteria

We identified references for this Review through PubMed searches for articles and previous reviews published from inception to December, 2016, using the key terms “prevention”, “high-risk”, “risk factors”, “promotion”, “resilience”, “development”, “staging”, and “early intervention” in combination with the terms “psychiatry”, “mental health”, and “psychopathology”. Articles identified by these searches that related to the main topics covered in the manuscript, and relevant references cited in

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