Psychiatric Services
Paper B Syllabic content 6
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Images/Figures with CC-BY-SA license if they are used in this material.
,
1. Preventative strategies in psychiatry
Prevention psychiatry is the reduction of mental disorders and behavioral problems by (1) identifying risk
and protective factors, and (2) Applying evidence-‐‑based interventions.
Most psychiatric disorders are thought to have a biological or sociological aetiology that produces the ‘hit’
for later development of the disorder. For a time after this insult, the patient may exhibit prodromal
disturbances that are usually not picked up clinically. This prodrome later develops into full-‐‑blown
clinically diagnosable disorder. This disorder can have various outcomes: disability, death or recovery.
This natural course of a disease provides us with various nodes of intervention
1. Insult to prodrome node -‐‑ averting a clinical disorder
(primary)
secondary
rehabilitation
2. Prodrome to diagnosis node – •Biological •clinical
insult
•prodrome
disorder
•outcome
early diagnosis (secondary) (recovery,
disability or
3. Diagnosis to outcome node -‐‑ death)
prevention of disability (tertiary) Primary
tertiary
Type Aims Methods Examples
Primary To reduce the incidence of the Elimination of aetiological E.g. vaccines. Reducing
Prevention disease by preventing the factors, increasing host resistance, adverse social factors for
development of new cases the reduction of risk factors, and psychiatric disorders
blocking modes of disease
transmission
Secondary To reduce the total number of Early identification and prompt Screening programmes and
Prevention existing cases by more rapid treatment of illness early intervention, crisis
effective intervention that support programmes e.g.
shortens the duration of illness mammography, pap smears
Tertiary To reduce the prevalence of It may not be possible to Relapse prevention,
Prevention residual defects or disabilities eliminate fully the sequel of the rehabilitation
that are consequences of the illness, but the goal of tertiary
illness prevention is for individuals to
reach their highest level of
functioning.
Prevention could result in
o Reduction of specific disorders: Reduced incidence and prevalence, delayed onset. e.g. Substance
abuse, depression, PTSD
© SPMM Course 2
,
o Reduction of risky behaviours e.g. substance use, unsafe sex
o Reduction of negative outcomes: This will minimize adverse psychosocial impact of mental
illnesses. e.g. suicide, teen pregnancy, school dropout, delinquency
o Promotion of mental health and wellness
In psychiatry currently as our knowledge of ‘insults’ is limited, most prevention is tertiary. Early
intervention program in psychosis is an example of secondary prevention. Public health initiatives such as
eradication of poverty, maintaining healthy diet etc. could prevent certain, at least milder forms of mental
illnesses – these could be termed as primary prevention strategies. Interventions aimed at high-‐‑risk
groups are usually secondary preventions. Rehabilitation can also be considered as a tertiary prevention
aimed at reducing further disabilities. It is not appropriate to delay the initiation of rehabilitative
techniques until acute treatment is complete, because it is not always clear whether the symptoms being
treated are merely part of the acute process or will continue after acute treatment.
Institute of Medicine classification
There are two ways of classifying prevention strategies. In addition to the traditional public health
definitions of primary, secondary, and tertiary prevention, a newer classification was put forth by Institute
of Medicine in 1994. The traditional public health classification encompasses a broad range of
interventions that include routinely used treatments (i.e., tertiary prevention, or the treatment of
Type Targets Examples
Universal An entire population. E.g. Fluoridation of drinking water,
preventive fortification of food products, seat belt
Desirable for everybody in the eligible population
intervention laws, media campaigns, and drinking age
regardless of one’s level of risk for the disease,
limits to prevent substance abuse
disorder, or adverse outcome
Selective Members of a population with higher than average Lifestyle modification and
preventive risk factors. A risk group may be identified based pharmacological management of
intervention on psychological, biological, or social risk factors hyperlipidemia, group-‐‑based
psychological treatments for children of
depressed parents
Indicated Members of a population with subsyndromal Detection and targeted treatment of the
preventive symptoms of a disorder (or diagnosed with another metabolic syndrome, early intervention
intervention associated disorder). High-‐‑risk individuals may be in psychotic prodrome
identified as having minimal but detectable signs or
symptoms foreshadowing a disease or disorder—or
a biological marker indicating a predisposition to a
disorder—although diagnostic criteria for the
illness are not yet met
established disease to reduce disability). However, the newer IOM classification focuses prevention on
interventions occurring before the onset of a formal DSM/ICD disorder. In fact, the IOM report specifically
© SPMM Course 3
,
states that the term prevention is reserved for those interventions that occur before the onset of the
disorder, whereas treatment refers to interventions for individuals
who meet or are close to meeting diagnostic criteria.
PREVENTION PARADOX
Risk and protective factors
Universal prevention approaches achieve
¬ Risk factors predate the associated disorder; while some
maximum benefit in practice by reducing
are easily identifiable and are malleable via a preventive
disease burden at a population level, but they
intervention, some may not be changeable.
offer only a small benefit to the individuals
o Biological risk factors include genetic vulnerability, who receive such intervention.
adverse prenatal event (traumatic, toxic, infectious) At population level, high-‐‑risk individuals
who will get maximum ‘individual’ benefit
o Psychological/Psychosocial risk factors include
from prevention approaches contribute only
family discord, parenting skill deficits
to a small proportion of disease burden.
o Social/Environmental risk factors include This was first described by Geoffrey Rose in
availability of drugs and firearms, extreme 1981
economic and social deprivation etc.
¬ Protective factors predate the associated disorder; while some are easily identifiable and are
promotable via a preventive intervention, some may not be. Examples include support from caring
adults, good school performance, conflict resolution skills, and positive role models clear and
consistent discipline in the family.
Socio-‐‑cultural Level Risk
Neighborhood Family Level Risk
violence
Poverty
unemployment
homelessness
Maternal age at chuildbirth
Individual Level Risk
War
Loss of caregiver
political violence
Maltreatment
Discrimination
poor parenting
Single parenthood
Low educational acainment, Stress reactivity
Parental substance abuse or Cognitive disabilities; below-‐‑average
psychopathology
intelligence History of premature birth, Genetic
Intrafamilial conflict
liabilities
© SPMM Course 4
Paper B Syllabic content 6
© SPMM Course
We claim copyright only for our own text material, productions and adaptations. We claim no rights to
© SPMM Course 1
Images/Figures with CC-BY-SA license if they are used in this material.
,
1. Preventative strategies in psychiatry
Prevention psychiatry is the reduction of mental disorders and behavioral problems by (1) identifying risk
and protective factors, and (2) Applying evidence-‐‑based interventions.
Most psychiatric disorders are thought to have a biological or sociological aetiology that produces the ‘hit’
for later development of the disorder. For a time after this insult, the patient may exhibit prodromal
disturbances that are usually not picked up clinically. This prodrome later develops into full-‐‑blown
clinically diagnosable disorder. This disorder can have various outcomes: disability, death or recovery.
This natural course of a disease provides us with various nodes of intervention
1. Insult to prodrome node -‐‑ averting a clinical disorder
(primary)
secondary
rehabilitation
2. Prodrome to diagnosis node – •Biological •clinical
insult
•prodrome
disorder
•outcome
early diagnosis (secondary) (recovery,
disability or
3. Diagnosis to outcome node -‐‑ death)
prevention of disability (tertiary) Primary
tertiary
Type Aims Methods Examples
Primary To reduce the incidence of the Elimination of aetiological E.g. vaccines. Reducing
Prevention disease by preventing the factors, increasing host resistance, adverse social factors for
development of new cases the reduction of risk factors, and psychiatric disorders
blocking modes of disease
transmission
Secondary To reduce the total number of Early identification and prompt Screening programmes and
Prevention existing cases by more rapid treatment of illness early intervention, crisis
effective intervention that support programmes e.g.
shortens the duration of illness mammography, pap smears
Tertiary To reduce the prevalence of It may not be possible to Relapse prevention,
Prevention residual defects or disabilities eliminate fully the sequel of the rehabilitation
that are consequences of the illness, but the goal of tertiary
illness prevention is for individuals to
reach their highest level of
functioning.
Prevention could result in
o Reduction of specific disorders: Reduced incidence and prevalence, delayed onset. e.g. Substance
abuse, depression, PTSD
© SPMM Course 2
,
o Reduction of risky behaviours e.g. substance use, unsafe sex
o Reduction of negative outcomes: This will minimize adverse psychosocial impact of mental
illnesses. e.g. suicide, teen pregnancy, school dropout, delinquency
o Promotion of mental health and wellness
In psychiatry currently as our knowledge of ‘insults’ is limited, most prevention is tertiary. Early
intervention program in psychosis is an example of secondary prevention. Public health initiatives such as
eradication of poverty, maintaining healthy diet etc. could prevent certain, at least milder forms of mental
illnesses – these could be termed as primary prevention strategies. Interventions aimed at high-‐‑risk
groups are usually secondary preventions. Rehabilitation can also be considered as a tertiary prevention
aimed at reducing further disabilities. It is not appropriate to delay the initiation of rehabilitative
techniques until acute treatment is complete, because it is not always clear whether the symptoms being
treated are merely part of the acute process or will continue after acute treatment.
Institute of Medicine classification
There are two ways of classifying prevention strategies. In addition to the traditional public health
definitions of primary, secondary, and tertiary prevention, a newer classification was put forth by Institute
of Medicine in 1994. The traditional public health classification encompasses a broad range of
interventions that include routinely used treatments (i.e., tertiary prevention, or the treatment of
Type Targets Examples
Universal An entire population. E.g. Fluoridation of drinking water,
preventive fortification of food products, seat belt
Desirable for everybody in the eligible population
intervention laws, media campaigns, and drinking age
regardless of one’s level of risk for the disease,
limits to prevent substance abuse
disorder, or adverse outcome
Selective Members of a population with higher than average Lifestyle modification and
preventive risk factors. A risk group may be identified based pharmacological management of
intervention on psychological, biological, or social risk factors hyperlipidemia, group-‐‑based
psychological treatments for children of
depressed parents
Indicated Members of a population with subsyndromal Detection and targeted treatment of the
preventive symptoms of a disorder (or diagnosed with another metabolic syndrome, early intervention
intervention associated disorder). High-‐‑risk individuals may be in psychotic prodrome
identified as having minimal but detectable signs or
symptoms foreshadowing a disease or disorder—or
a biological marker indicating a predisposition to a
disorder—although diagnostic criteria for the
illness are not yet met
established disease to reduce disability). However, the newer IOM classification focuses prevention on
interventions occurring before the onset of a formal DSM/ICD disorder. In fact, the IOM report specifically
© SPMM Course 3
,
states that the term prevention is reserved for those interventions that occur before the onset of the
disorder, whereas treatment refers to interventions for individuals
who meet or are close to meeting diagnostic criteria.
PREVENTION PARADOX
Risk and protective factors
Universal prevention approaches achieve
¬ Risk factors predate the associated disorder; while some
maximum benefit in practice by reducing
are easily identifiable and are malleable via a preventive
disease burden at a population level, but they
intervention, some may not be changeable.
offer only a small benefit to the individuals
o Biological risk factors include genetic vulnerability, who receive such intervention.
adverse prenatal event (traumatic, toxic, infectious) At population level, high-‐‑risk individuals
who will get maximum ‘individual’ benefit
o Psychological/Psychosocial risk factors include
from prevention approaches contribute only
family discord, parenting skill deficits
to a small proportion of disease burden.
o Social/Environmental risk factors include This was first described by Geoffrey Rose in
availability of drugs and firearms, extreme 1981
economic and social deprivation etc.
¬ Protective factors predate the associated disorder; while some are easily identifiable and are
promotable via a preventive intervention, some may not be. Examples include support from caring
adults, good school performance, conflict resolution skills, and positive role models clear and
consistent discipline in the family.
Socio-‐‑cultural Level Risk
Neighborhood Family Level Risk
violence
Poverty
unemployment
homelessness
Maternal age at chuildbirth
Individual Level Risk
War
Loss of caregiver
political violence
Maltreatment
Discrimination
poor parenting
Single parenthood
Low educational acainment, Stress reactivity
Parental substance abuse or Cognitive disabilities; below-‐‑average
psychopathology
intelligence History of premature birth, Genetic
Intrafamilial conflict
liabilities
© SPMM Course 4
