“It is easier to build strong children than to repair broken men”
- Fredrick Douglass
Converging evidence shed new light on the potential for primary prevention in mental health for young people. Prevention in mental health should not be the responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed to implement the range of interventions required to improve long-term outcomes. However, mental health professionals have responsibility for giving direction to social, political and other healthcare groups involved in meeting mental health care needs in young people.
Peter Fonagy argues that the prevention of full-blown illness must become a priority. This idea is accepted by health policy-makers in the case of cardiovascular or liver disease. In mental health it has taken longer to appreciate this truth. Prevention and early intervention should be the core of mental health. Prevention science has yet to deliver upon its potential, argues Fonagy. It is now understood that the human brain develops in the context of social relationships. These relationships, particularly the one between child and parent are the context in which the mind emerges and develops. Influencing these relationships can serve to either optimise health or to undermine it, leading to suboptimal outcomes. The goal, in early intervention, is to minimise risk and maximise well-being.
The sciences of early development, disorder prevention and health have, according to Robert Emde, undergone huge advances in recent times. This has grown out of a greater awareness of suffering and the adverse effects of unattended early risk and has given energy to preventive interventions. Public health designations break prevention down into primary, secondary and tertiary categories. Primary prevention refers to interventions that are designed to prevent the onset of a disorder or disease before it occurs. Secondary prevention refers to interventions designed to deal with early identification of a disorder and its treatment (usually before symptoms arise). Tertiary prevention deals with interventions that treat the disorder and seek to minimise disability.
Other concepts involved in prevention science are universal, targeted and indicated designations. Universal refers to interventions that are applied on a population or community basis. These interventions are given to everyone – an example would be education about the adverse effects of smoking or alcohol consumption during pregnancy or encouraging breastfeeding. Targeted interventions are aimed at groups that are high risk for problems and examples include home visitation programmes for those living in extreme poverty or immigrant groups suffering from trauma or dislocation. Indicated interventions are aimed at those who are already identified as having a disorder, often after screening.
Emde highlights five principles of prevention. The first is that prevention deals with health as well as illness and health is understood as more that the absence of illness. Health promotion, therefore, must be considered alongside the prevention of disorder. A second principle is that prevention deals with regulation which is a central process in health. Adaptive regulation occurs between ‘enough’ and ‘too much’. This ‘golden mean’ can be applied to all levels of a system from cells to psyche to community. A third principle is that all prevention occurs in the context of culture and circumstances and such contexts must be understood and taken into account. Fourthly, all prevention involves development. The goal, therefore, is to promote healthy development and prevent disruptions in development over time. The prevention sciences are applicable across the lifespan but a privileged position is given to early experience. Lastly, Emde highlights the principle that disorders are complex. Developmental pathways are not linear and many pathways exist to disorders. Most disorders and developmental outcomes are caused by many genes rather than few and genetic influences interact with each other. Genetic expression is strongly influenced by regulatory interactions and the environment and these change as development progresses and circumstances change.
Many interventions, therefore, applied early, may be effective. In addition to specific interventions like treatment of parental depression or reduction in trauma exposure, non-specific interventions like stress reduction and social support are also likely to be important. The complex nature of development and disorder mean that early preventive interventions are not permanent immunisation against disorder. They need to be followed up with healthy environments that provide opportunity for healthy development later.