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Debate/Perspective/Viewpoint

Preventive Psychiatry from Public Health Perspectives

Abstract N. Manjunatha
The focus in public health has been shifted to noncommunicable diseases (NCD) in last decade. Department of Psychiatry,
Mental health is gaining momentum as fifth NCD. The concept of prevention in psychiatry is new, National Institute of Mental Health
but an interesting area from public health perspectives. The concepts of primary, secondary, and and Neurosciences, Bengaluru,
Karnataka, India
tertiary prevention relevant to psychiatry are discussed. Among primary prevention interventions,
universal, selective, and indicated prevention strategies in psychiatry are discussed with examples
from published literature. Challenges in preventive psychiatric practice on issue of payments,
available standard of evidence, and best health‑care professionals for its delivery are also discussed.
There is a need to focus on preventive psychiatric interventions, especially in developing countries.

Keywords: Mental health, prevention, psychiatry, public health

Introduction However, this above classification of prevention of

There has been an interesting development in the public
health toward the prevention of illnesses including
noncommunicable diseases (NCDs) in the recent past.
Mental health, as a 5th NCD, had begun its journey with
target on the behavioral risk factors aiming to prevent
conventional NCDs. In an interesting twist, “prevention”
now is being targeted for psychiatric disorders itself which
is an interesting area of public health importance. This
article is aimed to provide conceptual framework, some
examples of community‑based preventive psychiatric
interventions, and challenges of preventive psychiatry in
the public health perspective.
Concepts of Prevention in Public Psychiatry
The prevention of physical illness in a typical public
health field is been classified as primary, secondary,
and tertiary prevention.[1] Primary prevention aims to
reduce the incidence of new cases with varieties of
interventions even before the onset of illness. Secondary
prevention aims to reduce the prevalence of the disorder
or illness in the population through early diagnosis
and treatment of diseases. Tertiary prevention aims to
reduce disability through the varieties of rehabilitation
interventions and by preventing relapses and recurrences
of the illness.
Address for correspondence: Dr. N. Manjunatha,
Department of Psychiatry, National Institute of Mental Health and
Neurosciences, Bengaluru, Karnataka, India.
E‑mail: manjunatha.adc@gmail.com
Access this article online
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DOI: 10.4103/ijsp.ijsp_38_17
physical illness is not suitable in preventive psychiatry.
An influential report of the “Institute of Medicine”[2]
has adopted a framework of preventive mental health
intervention for mental disorders given by Gordon,[3,4]
such as universal, selective, and indicated preventive
interventions are included within primary prevention of the
classic public health classification. Universal prevention
is aimed at the general population, as a whole or its part,
regardless of their risk profile of developing a psychiatric
disorder. A classical example of universal prevention
is school programs. Selective prevention is aimed at
high‑risk groups, who have not yet developed a mental
disorder. Indicated prevention is aimed at individuals who
have some symptoms of a mental disorder but do not meet
diagnostic criteria at that time. Please note that universal,
selective, and indicated prevention are aimed at subjects
who have not yet developed any psychiatric disorder. Both
concepts of typical classification of prevention of physical
illness and Gordon classification of prevention are relevant
in public mental health are relevant in low‑and‑middle
income countries where burden of treatment gap and
duration of untreated psychiatric illnesses are very high
especially.
Community‑based Preventive Psychiatric
Interventions: Some Examples
The discussion below provides some of the examples of
community interventions for prevention of psychiatric
disorders emphasizing more on primary preventive
strategies of universal, selective, and indicated preventions
and relevant secondary and tertiary preventive strategies.
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How to cite this article: Manjunatha N. Preventive psychiatry from public

health perspectives. Indian J Soc Psychiatry 2017;33:148-52.

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Manjunatha: Preventive psychiatry in public health
This excludes the routine treatment and traditional
rehabilitation approaches of psychiatric disorders.
Primary prevention programs
Socioeconomic development of the community
The acceptability, feasibility, and success of interventions
of preventive psychiatry in any community may depend
on socioeconomic status of that particular community.
This includes the basic needs of living such as nutrition,
housing, education, economic stability, strength of
community network, and attempts to reduce harm from
addictive substances. This may not be purely a part of
health programs; however, these community interventions
will definitely have benefit in prevention of mental
disorders. These programs need strong political or social
actions.[5]
Wellness programs and positive mental health
All mental health promotional activities including wellness
programs aiming for enhancing positive mental health in
the community may also have the secondary outcome of
reducing the incidence of psychiatric disorders.[6] In turn,
positive mental health serves as a powerful protective
factor against mental illness.
Detels et al.[7] described mental disorders and positive mental
health as two overlapping and interrelated components of a
single concept of mental health and not as different ends
of a linear scale. Prevention and promotional activities
often similar activities present within the same programes
and strategies and producing different but complementary
outcomes. Similarly, promotion of mental health and
prevention of mental disorders should be understood as
conceptually distinct but interrelated approaches since both
deals primarily with the enhancement of mental health and
the influence of its antecedents.[8] In short, all promotional
and positive mental health activities are targeted for
reducing the incidence of psychiatric disorders.
Manjunatha and Saddichha[9] urged United Nations for
“Universal Mental Health Promotional Program” for “life
skill educational program” to promote “psychosocial
competence.” This life skill program is having core
components of both the promotion of mental health and
positive mental health.
The global promotion of yoga by our Hon’ble Prime
Minister Shri Narendra Modi is a classical example
of universal prevention by reinventing traditional
techniques.[10]
Wellness programs targeting senior citizens:
Research evidence
There are successful universal, selective, and indicated
interventions which improved mental health in geriatric
populations.[11] Exercise interventions and improving social
support through befriending are examples of universal
Indian Journal of Social Psychiatry | Volume 33 | Issue 2 | April-June 2017
strategies. Promising preventive interventions for selective
and indicated elder populations include the use of patient
education methods among chronically ill elderly and their
caregivers, early screening, interventions in primary care
and programs using life review techniques.
There is scientific evidence in the form of cross‑sectional
studies, and controlled trials show that exercises such
as aerobic classes and t’ai chi has shown improvement
in both physical and psychological well‑being in elder
populations.[12] These benefits include greater life
satisfaction, positive mood states and mental well‑being,
reductions in psychological distress and depressive
symptoms, lower blood pressure, and fewer falls.
An quasi‑experimental study confirms that befriending
programs for older women can significantly reduce
loneliness, depression, and increase the making of new
friends focusing on positive effects of friendship.[13]
An innovative universal, selective, and indicated strategies
for prevention of alcohol dependence
Manjunatha et al.[14] proposed universal (use of clinical
criteria of dependence on the label of alcoholic beverages
in layman languages), selective (using naltrexone for
those genetically inclined), and indicated (enquiring
about craving, tolerance, and loss of control and use of
anticraving medications [now termed as “Sinclair method”]
or behavioral strategies) preventive strategies for the
prevention of alcohol dependence in a study of 81 alcohol
dependence with a study of age‑ and order‑wise chronology
of the International Classification of Diseases‑10 criteria of
alcohol dependence during their predependence stage of
these patients [Figure 1].
Suicide preventive interventions
Any community attempts to reduce access to the means
of committing suicide have been found to be one of the
most effective measures in reducing suicides.[15] Strategies
include detoxification of domestic gas and car exhaust,
safety measures on high buildings and bridges, control
of availability of sedatives and pain‑killers, and restricted
access to pesticides.
Taxation and advertising policy of alcohol and tobacco
The cost of alcohol and tobacco is one of the largest
determinants of alcohol and tobacco use. A 10% increase
in cost of tobacco reduces about 5% and 8% of tobacco
consumption in high and in low/middle‑income countries,
respectively. In a similar way, a 10% increase in price can
reduce about 7% and 10% of the long‑term consumption
of alcohol in high and low‑income countries.[16] Eventually,
it also reduces alcohol‑related medical complications, road
accidents, family violence, etc. There are even reports of
reduction of tobacco use with increasing proportion of
pictorial graphic of ill‑health of tobacco use on cigarette
packing.
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Manjunatha: Preventive psychiatry in public health
Figure 1: Graphical representation of chronology of age‑wise above the line and order‑wise below the line for onset of dependence criteria with period
of preventive strategies
School mental health programs
There are ample of evidence for successful school‑based
programs in elementary, middle, and high schools
influencing positive mental health, and reducing
behavioral problems.[17] Targeted school‑based programs
can help reducing the aggressive and delinquent behavior
and bullying, which are important risk factors for the
development of anxiety disorders in the victims in later
life.
Workplace intervention
Work stress and unemployment are two major sources
of stressors that can contribute to poor mental health
at workplace. These stressors increase the incidence of
depression, anxiety, burnout, alcohol‑related problems,
cardiovascular illness, and suicidal behavior. Stress
management programs have been found to be effective
in preventing adverse mental health outcomes. The
universal interventions such as legal framework covering
unemployment insurance and other welfare programs
are shown to be improve job security, in turn, promote
mental health as well as prevent stress‑related psychiatric
disorders.[5]
Preventive psychiatry through protection of human rights
The social adversities of community such as child abuse,
violence, war, discrimination, poverty, and lack of access
to education have been shown as risk factors for the
onset of psychiatric disorders. Any government policies
of protection of basic human rights will have a powerful
preventive strategy for mental disorders.[5]
Secondary prevention programs
Early screening and intervention by strengthening primary
care psychiatry
There are three examples of secondary prevention strategies
with early screening and treatment at primary care are
150
briefed below. The patients with common mental disorders
such as depression, anxiety disorders, and somatization are
known to consult their primary care physicians worldwide
before consulting psychiatrists, but under‑diagnosed and
receive symptomatic treatments. Any community‑based
innovative programs which reduce duration of these
untreated illness will definitely have impact in preventive
psychiatry.
”Manochaitanya programme” of Government of
Karnataka, India
The Government of Karnataka started “Manochaitanya
programme” in public and private partnership with Indian
Psychiatric Society‑Karnataka Chapter with aim to integrate
psychiatric care at all primary health centers (PHCs) across
state. Manochaitanya clinic (MCC) is been functioning at
every government’s PHCs of state on every Tuesdays with
subtitle “Super‑Tuesday.” “MCC” is providing primary
psychiatric care by PHC doctors. Government and private
psychiatrists are providing psychiatric care at every taluk
(subdistrict) hospitals at least once a month across state.
This kind of program will definitely have impact on
secondary prevention of psychiatric disorders through the
strategies of early diagnosis and treatment.[18]
Integrating mental health with noncommunicable diseases
There are developments to integrate mental health with
care of NCDs which will also promote the secondary
prevention of common mental disorders by early diagnosis
and treatment.[19]
Universal screening of depression
The US Preventive Services Task Force recommends
screening for depression in the general adult population,
including pregnant and postpartum women, especially at
primary care settings and provided treatment algorithm.[20]
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Manjunatha: Preventive psychiatry in public health
Tertiary prevention programs
The classic example of tertiary prevention in psychiatry
these days is disaster mental health.[21] Interesting readers
on disaster mental health are suggested to read further in
available literatures.
Challenges in Preventive Psychiatric Practice
Discussions below are some of the challenging issues
regarding the practice of preventive psychiatric
interventions.
Who should pay for prevention?
Most important questions often arise “who will pay
for preventive intervention?” Will government sponsor
or else insurance companies pay for these preventive
interventions? Most often, people spend from their out
of the pocket for treatment in India. Most of the medical
insurances in India are not covering any treatment
of psychiatric treatment, so, where is the question of
insurance for preventive interventions for psychiatric
disorders. In this scenario, how practical is it to propagate
preventive psychiatry in Indian scenario? Recently
launched “Universal Health Insurance Scheme” by the
Government of India does not mention anything about
coverage of preventive strategies.
Considering above limitations, there is a need to explore
the value based, culturally acceptable popular low‑cost
preventive interventions be promoted as wellness programs
such as yoga, and meditation for the general population in
Indian settings? Further research can throw an insight on it.
Standards of evidence
Two important scientific methodologies such as unsuitability
of standard randomized controlled trial (RCT) and
statistical power problem which is hindering the progress
in assessing the effectiveness of any community‑based
preventive psychiatric interventions are discussed.
The “gold standard” way to establish a treatment method
is “RCT.” However, this standard RCT has limitations in
prevention and health promotion research. Hence, there are
many variants of RCT such as cluster‑RCT are been tried
in public health interventions.
The estimating sample size for assessing the effectiveness
of any community‑based preventive psychiatric
interventions is very huge, for example, around 30,000
population for 20–30 years for universal prevention, and
10,000–15,000 for 5–8 years for selective prevention which
makes feasibility of preventive trial is very tough. Hence,
majority of preventive trial in psychiatry is focusing on
indicated prevention.[22] This “power problem” is related
to the lack of understanding of the exact pathways leading
to mental disorders and to the very low specificity of most
known risk factors. This low specificity implies that most
subjects who are exposed to the risk factor do not develop
Indian Journal of Social Psychiatry | Volume 33 | Issue 2 | April-June 2017
the disorder and that one such risk factor by itself is not
sufficient to produce the disorder.[23]
Who will practice preventive psychiatry either
general practitioner, psychiatrist versus mental
health professionals?
There are few psychiatrists are available for huge burden
of psychiatric disorders in India and providing mainly
secondary and tertiary prevention interventions. Activities
of preventive psychiatry drain away the available human
resources for secondary and tertiary prevention. In this
case, who will provide intervention of primary preventive
psychiatry? In general, generalists, either general
practitioners or yoga or practitioners of complementary
and alternate medicine, are roped in providing primary and
secondary prevention which looks very cost‑effective. In
this way, definitely integrating psychiatry in primary care
physicians is badly in need for our country. The role of
practitioners other than psychiatrists including other mental
health professionals is need to be tapped for providing
primary preventive strategies.
Conclusions and Future Directions
There is few evidence available for community‑based
preventive psychiatry in all levels of preventions.
Future psychiatric research should be focussed on
culturally acceptable low‑cost evidence‑based preventive
interventions. There is a need to develop huge manpower
from generalist’s cadre to provide low‑cost primary
preventive interventions. There is need to strengthen the
primary care psychiatry. Future training of psychiatry and
mental health education should emphasis on preventive
psychiatry. There is a scope of super‑(sub) specialty of
psychiatry, i.e., Doctorate of Medicine in “Public Mental
Health” where preventive psychiatry is presumed to be an
integral part of the curriculum. The prevention of mental
disorders should be a public health priority in every
socioeconomic policies of country.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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