Prevention of psychiatric disorder

A cynic might say that a work called Prevention of Psychiatric Disorder would be in danger of winning a prize for the world's shortest book. But this would be too negative a view. In fact, most mental health professionals spend most of their time on prevention in the sense of secondary prevention.

Secondary prevention is reduction of severity of existing disease and prevention of relapse by means of early detection and treatment. Prevention of relapse may be achieved by drug therapy, psychotherapy, and/or social support for patients who have recovered from an episode of mental illness. This most important work is done by trying to optimize the care of existing psychiatric patients.

Tertiary prevention, so called, means reduction of the handicaps that may result from established disease, as in rehabilitation programmes to prevent patients from becoming needlessly disabled for employment and community services to reduce the burden on families. It really merges with secondary prevention in the community mental health team environment; for example, if the patient's family are involved in the care of the patient, they will be entitled to a 'carer's assessment' under the terms of the Care Programme Approach. And links can be forged with local schemes for returning people to work, such as Employment Direct, Job Centre Plus, etc.

The value of early detection of relapse in existing patients is not in dispute. Education of patients and carers is vital. When education extends to organized campaigns directed at other health professionals and the general public, however (as in the Royal College of Psychiatrists' recent 'Defeat Depression' campaign), it becomes more controversial. It is clearly in the interests of the drug companies who tend to pay for such campaigns that diagnosis of depression should be increased. Increased prescription of antidepressant medication will then follow. However, there is a danger of medicalizing normal states of distress.

Use of screening questionnaires (Chapter 3) in medical settings, has been advocated. However, screening has not so far, at least in the case of depression, met standard UK criteria for introduction on a routine basis (Gilbody et al., 2006).

Primary prevention is prevention of disease from developing in the first place. The following list of measures might be important for psychiatry, although hard evidence of effectiveness is not available for all of them:

• medical and public health measures to avert damage to the brain:

- genetic counselling and prenatal diagnosis (Chapter 19)

- improved care during pregnancy and childbirth

- improved infant welfare services including immunization

- control of infections, such as meningitis and HIV disease

- avoidance of nutritional deficiencies

- reduction of alcohol and drug misuse

- reduction of pollution such as atmospheric lead

- prevention of accidents, and hence of head injury, as, for example by using seat belts and crash helmets

- provision of adequate housing.

• psychological approaches:

- counselling for the bereaved, divorced, and other groups known to have a high risk of illness

- crisis intervention for victims of major trauma has been advocated in the form of debriefing; however, contrary to expectations, this has been found to be harmful in some cases. It appears that most people cope better from their own resources; perhaps being forced to talk about the experience again serves to retraumatize (Rose et al., 2002). - social work with disturbed families with particular emphasis on counterbalancing adverse effects on children.

Many of the measures noted above under primary prevention are outside the sphere of influence of psychiatrists. Concentrating on secondary and tertiary prevention is more practical and has the additional benefit of focusing services on those most in need.

References

Aitchison, K., Gonzalez, F. J., Quattrochi, L. C. et al. (2005) Psychiatry and the 'new genetics':

hunting for genes for behaviour and drug response. Br J Psychiatry 186, 91-92. Gilbody, S., Sheldon, T. and Wessely, S. (2006). Should we screen for depression? BMJ 332, 1027-1030.

Rose, S., Bisson, J. and Churchill, R. et al. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2, 10.1002/14651858. CD000560.

Tandon, K. and McGuffin, P. (2002). The genetic basis for psychiatric illness in man. Eur J Neurosci 16, 403-407.

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