Sunday, August 3, 2008

From Prevention to Preemption: A Paradigm Shift in Psychiatry

Universal prevention has been a focus of psychiatric research for the past 4 decades. Using a public health approach, research has shown that mitigating major risk factors, such as poverty and early life stress, and promoting protective factors can improve behavioral outcomes. In other areas of medicine, we have observed how similar preventive approaches have reduced deaths from cancer and infectious disease. By contrast, while reducing environmental stress and providing better maternal support improve general behavioral outcomes (by preventing the development of antisocial behavior, for example), there are few, if any, examples of preventive approaches in psychiatry that reduce either the morbidity or the mortality of our most disabling illnesses—such as schizophrenia and bipolar disorder.1,2

What can be done to improve the impact of preventive interventions in psychiatry? Do we have effective pre- ventions that are not being implemented? Or do we need new approaches
to reduce morbidity and mortality? While we certainly can do much more to implement what we already know, it may soon be time for us to consider a shift from universal prevention provided in the broad population to “preemptive” approaches. Preemptive interventions target those at greatest risk for mental illness and those with subdiagnostic signs or symptoms, and they provide what previously has been labeled “selective” and “indicated” prevention.3


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