Prevention of psychiatric disorders: Where do we stand?

“An ounce of prevention is worth a pound of cure” – Benjamin Franklin “Intellectuals solve problems; geniuses prevent them” – Albert Einstein “Treatment without prevention is simply unsustainable” – Bill Gates. The quotes mentioned above reflect the thoughts of some of the most brilliant and respected minds seen by humanity. Anyways, it requires no brains to understand the importance of prevention of diseases. Since school days, we have been taught prevention is better than cure. Hence, there is no requirement to elaborate on the benefits that prevention can bring. Psychiatric conditions are no exception. Prevention of psychiatric disorders holds promise to decrease the burden as well as the cost of care and help individuals and their families in more than one manner.[1,2] However, the prevention of mental disorders should not be confused with the promotion of mental health. The two seem related, but there are some distinctions, as simply the absence of mental disorders cannot be deemed as good mental health.[1] This article shall restrict discussion to the prevention of mental disorders only. The idea or concept of prevention of psychiatric disorders is not new. By the beginning of the 8th decade of the 20th century, people had started discussing the topic of prevention of psychiatric disorders.[2] However, it took some time for some work and evidence to be generated. By 2005, a meta-analysis of randomized controlled trials on this topic was published.[3] Over the last 20 years, many more research papers have been published that describe various strategies, their feasibility, and efficacy in preventing psychiatric disorders. Some may wonder how reasonable it is to think/plan for the prevention of psychiatric disorders, given the fact that we do not have a reasonable understanding of the etiopathogenesis of psychiatric disorders.[4] Our knowledge in this regard is far behind what we know about infectious or cardiovascular diseases. If such thoughts cross one’s mind, one must think of the exemplary work of John Snow, who could effectively control the cholera outbreak in London.[5] He did so by carefully analyzing the epidemiology of cholera cases, wherein he could map the distribution of cases in the city and match them with the source of water supply.[5] The role of bacteria in causing cholera and its mode of spread through water were not known then. Our current knowledge of the epidemiology of psychiatric disorders tells us that the majority of them (except dementia) have onset in late childhood, adolescence, and early adulthood.[1,4] Thus, if we focus our efforts on this developmentally sensitive period of life, we might be able to prevent or may delay the onset of psychiatric disorders or decrease their severity. A host of prenatal and childhood issues have been implicated in the onset of psychiatric disorders. Thus, providing good prenatal care, avoiding maternal stress, providing adequate nutrition to the mother, avoiding drug use during pregnancy, having a conducive environment during childhood, and reasonable parenting could help. A good education, a conducive school environment, avoiding bullying, and fostering development-based education could also help. Later, handling issues during adolescence and preventing exposure to drugs are extremely important.[1,2,4] It is easy to notice that many of the issues discussed fall beyond the purview of a psychiatrist or medical practitioner. Instead, these factors relate to a healthy and balanced family and society. Some authors have provided a list of modifiable and nonmodifiable risk factors for psychiatric disorders and have advised to take a life course perspective.[4] Modifiable risk factors include reducing inequality, improving access to resources, education, employment, nutrition, and healthcare services, and creating a good social network and meaningful relationships. As discussed earlier, modifying many of these “modifiable” factors is not easy and requires massive inputs at the macro level and micro level from society and the leadership of a country.[4] The aspects of prevention discussed above here relate to primary and universal prevention. Then, some strategies could be used for selective and indicated prevention, for example, high- or ultra-high-risk groups for psychosis, people exposed to trauma (abuse, exploitation, or disaster), or those at risk for the development of dementia. The subject is voluminous, and it is not possible to discuss these interventions in this article. Many strategies have been tried and have been found to be helpful. Interested readers could read some of the papers cited in this article. They shall provide a brief overview of the studies conducted. Where Do We Stand? The subject seems promising, but it is full of challenges. The lack of adequate resources and infrastructure dedicated to the prevention of psychiatric disorders is a big hurdle. The treatment gap in psychiatric disorders is high, not just in India but across the world.[6,7] Given the current state of affairs, the existing resources are dedicated to providing care to the sick. Prevention is something that has not been able to gain reasonable attention. Existing mental health programs focus on treatment, which may be deemed secondary and tertiary prevention. Our country’s health programs focus on preventing infectious diseases, malnutrition, mother and child health, and noncommunicable diseases. They may add to the prevention of mental disorders as a by-product but not as a primary focus. Our country’s existing National Mental Health Program has mentioned prevention as one of its mandates.[8] Still, the people working on the ground primarily serve those who are acutely sick. Sparing time and energy for activities related to prevention gets difficult. Further, the people at the forefront, i.e. the psychiatrists, also lack training in prevention.[1] Their training is mainly on subjects related to diagnosing and managing acute and chronic conditions and may be about rehabilitation. Due to these issues, the prevention of psychiatric disorders takes a back seat in the real world. The Way Forward… It is reasonably agreed that efforts put into the prevention of psychiatric disorders, especially the common mental disorders and those associated with drug abuse, can yield good results. What is really required is dedicated and focused effort in this direction. To seek more resources, there is a need for more research on this topic. More evidence and robust evidence generated through good-quality studies can help seek more funding and change public health policies and programs in a favorable direction. Teaching, talking, and discussing about mental health and disorders in schools could also make a lot of difference. Everyone remembers the lessons on hand hygiene and healthy diet taught in school days, but probably no one discussed mental health then! It is high time we start doing that. Impressions created in the early years, when the mind is naïve and ready to take impressions, can go a long way in creating desired attitudes and mindsets. With advances in medicine and other aspects of society, the burden of infectious diseases is coming down quickly and so is the fate of many currently prevalent noncommunicable diseases. Shortly, psychiatric disorders shall be one of the leading medical conditions that shall trouble societies and countries. Prevention would be paramount, and every penny spent would be paid back. After all, there is no health without mental health!