Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0139aPrevention in Mental Disorders of Late LifeBarry D. Lebowitz and Jane L. PearsonNational Institute of Mental Health, Bethesda, MD, USAINTRODUCTIONIn its influential 1994 report, Reducing Risks for Mental Disorders:Frontiers for Preventive Intervention Research, the Institute ofMedicine (IoM) of the US National Academy of Sciences 1assessed the state of knowledge in prevention research andidentified directions for future scientific development. The indexof this substantial volume contains no entries for ‘‘aging’’, ‘‘aged’’,‘‘elderly’’, ‘‘geriatric’’ or ‘‘gerontological’’. In a section onillustrative preventive intervention research programs, examplesare given of two service programs, one for caregivers of patientswith Alzheimer’s disease and one for widows, that are consideredto have relevance to prevention. The authors could identify norandomized controlled preventive trials in the area of aging.Prevention in the mental health field has been seen, traditionally,as an area that has been implicitly restricted to thoseconcerns designed for application to issues in childhood andadolescence. If anything, prevention in geriatrics was seen as anoxymoron. Very simply, prevention was taken to mean youth.Theory and research in prevention were restricted to issues ofchild development and intervention early in the life course.Why be concerned with prevention in late life? As is wellcovered in other sections of this text, there is the demographicimperative brought about by the overall aging of the worldpopulation and, in particular, by the aging of the olderpopulation. As pointed out in the classic papers by Gruenberg 2and Kramer 3 , the same dynamics—public health measures,technological development and lifestyle changes—that createdthis growth in the overall population were also relevant to growthof the population of those with chronic illnesses and disabilities.They conclude that, in the absence of cures or effective preventivestrategies, we will see an explosion in the number of older personswith serious and persistent disabling illnesses, particularly mentaldisorders. The availability of more efficacious treatments and theaccessibility of appropriate services in the community combinedto produce huge gains in the life expectancy of those with mentaldisorders who, in earlier times, would have died long beforereaching old age. This demographic imperative leads to theconclusion that prevention must be an important part of theagenda of geriatric psychiatry.The traditional public health view derives from infectiousdisease and is divided into primary, secondary and tertiaryprevention. Primary prevention is directed toward maintaininghealth by isolating the causes of disease and eliminating orcounteracting them. Secondary prevention is directed towardenhancing recovery by case identification and prompt interventionearly in the course of illness. Tertiary prevention is directed towardthose already ill and emphasizes treatment and rehabilitation 4 .There is a growing consensus that the traditional public healthview is not optimal. The components of this approach, including,for example, concepts such as pathogens, risk factors, diseasevectors and definitions of caseness, do not translate easily intopsychopathology or chronic disease. The 1994 IoM report 1 adaptsa scheme developed by Gordon 5 to characterize preventiveinterventions as universal (targeted to a general population),selective (targeted at individuals at increased risk) or indicated(targeted to individuals with minimal levels of signs orsymptoms).Universal interventions are broad public health measuresintended for an entire population or for significant geographic,socioeconomic or categorical subgroups within it (e.g. ruralresidents, low-income older persons, or pregnant women).Universal interventions (e.g. iodizing salt) may reduce risk for alarge segment of a population but in all likelihood do not haveimpact on those already at high risk or those who would not havebeen at risk at all. Cost–benefit assessment is a clear decisioncriterion for the development and implementation of universalinterventions, since they would, by necessity, involve exposure ofmany individuals not at risk for development of an illness.Selective interventions are targeted toward those individuals atsignificantly increased risk of developing the particular illness orcondition. Genetic loading and positive family history, otherillnesses, or psychosocial or environmental transitions are allexamples of factors that might be used to target selectivelypreventive interventions. Although selective interventions mayseem easy, careful efforts are needed to assure proper identificationand to avoid stigmatization or unnecessary fear.Indicated interventions are targeted on those individuals whoare already symptomatic and in whom early intervention mayalter the longitudinal course or optimize the outcome of theillness. The underlying assumption is that significant advantage isgained when preventive interventions are extended to concernswith function and disability in those who already have an illness.Interventions directed at minimizing post-treatment relapse orrecurrence would also fit within this category 41 .Following recommendations of the National Advisory MentalHealth Council 6 , this chapter is based on assumptions that anappropriate approach to prevention must: (a) be tied closely totreatment; (b) have strong connections to service systems andservices; and (c) be based upon models of etiology, pathophysiologyand risk. Following Kraemer et al. 7 we use ‘‘risk’’ and ‘‘riskfactor’’ narrowly to indicate an empirically demonstrated agent orexposure that influences the likelihood of an event in a definedpopulation. Preventive interventions are those directed atreducing risk of the development, exacerbation or adverseconsequences of mental disorders.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd