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Abstract

Objective

Prevention strategies have made a major contribution to the considerable successes in reductions in cardiovascular disease and cancer mortality seen in recent decades. However, in the field of psychiatry, similar population-level initiatives in the prevention of common mental disorders, depression and anxiety, are noticeably lacking. This paper aims to provide a brief overview of the existing literature on the topic of the prevention of common mental disorders and a commentary regarding the way forward for prevention research and implementation.

Methods

This commentary considers what we currently know, what we might learn from the successes and failures of those working in prevention of other high prevalence health conditions, and where we might go from here. Taking cognisance of previous preventive models, this commentary additionally explores new opportunities for preventive approaches to the common mental disorders.

Results

The consensus from a large body of evidence supports the contention that interventions to prevent mental disorders across the lifespan can be both effective and cost-effective. However, funding for research in the area of prevention of common mental disorders is considerably lower than that for research in the areas of treatment, epidemiology and neurobiology. Thus, there is a clear imperative to direct funding towards prevention research to redress this imbalance. Future prevention interventions need to be methodologically rigorous, scalable to the population level and include economic evaluation. Evidence-based knowledge translation strategies should be developed to ensure that all stakeholders recognise preventing mental disorders as an imperative, with appropriate resources directed to this objective.

Conclusion

There has been a recent expansion of research into potentially modifiable risk factors for depression, and it is now timely to make a concerted effort to advance the field of prevention of common mental disorders.

Keywords

Prevention depression anxiety common mental disorders promotion

Introduction

Prevention strategies have made a major contribution to the considerable successes in reductions in cardiovascular disease (CVD) and cancer mortality seen in recent decades (Allender et al., 2008; Eheman et al., 2012; Shen et al., 2005). However, in the field of psychiatry, similar population-level initiatives in the prevention of common mental disorders, depression and anxiety, are noticeably lacking. Importantly, there is no existing prevention system within the mental health sector, which is primarily focused on service delivery. Moreover, funding for research in the area of prevention of common mental disorders is considerably lower than that for research in the areas of treatment, epidemiology and neurobiology. These funding levels do not reflect the main concerns of stakeholders in the mental health sector, who rate prevention and promotion as high priorities (Christensen et al., 2013). Research funding for promotion and prevention in mental health, already low, is decreasing and there is a further gap between research funding and disease burden, with the largest gap in affective disorders and dementia, and the smallest in eating disorders and violence (Christensen et al., 2013). The conclusions of multiple reviews now suggest substantial cause for optimism in the prevention of common mental disorders, particularly depression (Christensen et al., 2010; Cuijpers et al., 2008; Czabala et al., 2011; Forsman et al., 2011; Merry et al., 2011; Muñoz et al., 2010; Neil and Christensen, 2009; Stewart-Brown and Schrader-McMillan, 2011; Weare and Nind, 2011). However, they also identify the need to develop effective prevention strategies that can be delivered at a population level (Muñoz et al., 2010).

In order to bring about meaningful changes in the population risk of common mental disorders, an effective prevention strategy needs to identify the diversity of potentially modifiable risk factors, to translate these into causal models of common mental disorders, and to design interventions to address these risk factors. Such modifiable risk factors for common mental disorders include, social determinants of health; substance use; biogenetic factors; lifestyle factors such as smoking, diet and exercise; individual factors such as skills, behaviours and relationship skills; parenting and family functioning; school environment and engagement; as well as peers, work and community environments. This commentary focuses on the potential for addressing such factors at a population level. We use the term common mental disorders, hereafter referred to as ‘CMDs’, to refer to anxiety and depressive disorders as defined by Goldberg (Goldberg and Huxley, 1992).

A brief overview of prevention efforts to date: From conception to old age

Parenting and early life

The first few years of life are critical in modulating the likelihood of future mental health problems, with the in utero environment, quality of early parenting, as well as parent–infant relationships, central factors influencing outcomes over the life course (Jané-Llopis et al., 2011a). The Developmental Origins of Health and Disease (DOHaD) model is well established in medical research (Barker, 1997), and is increasingly gaining the attention of mental health researchers. Research examining mental health and child development outcomes following in utero stress or a range of other exposures confirms that pregnancy is a key period of development in which maternal health and mental health need to be optimised (Lewis et al., 2012a). Thus, policies and practices to support parenting and parental mental health, both in the general population and amongst those at greater risk, are particularly important.

The recent DataPrev initiative in Europe (www.dataprevproject.net) aimed to identify evidence-based programmes that effectively promote mental health and prevent mental disorders by undertaking extensive ‘systematic reviews of systematic reviews’. Stewart-Brown and Schrader-McMillan (2011) conducted such a review, examining the effectiveness of interventions targeting parenting in order to improve mental health outcomes for offspring. They noted that there was some evidence to support antenatal programmes as effective strategies to enhance parenting skills, while there was also evidence that various interventions can enhance the sensitivity of mothers to their infant and, to a lesser extent, the security of the infant’s attachment to their mother. Overall, the conclusion of this comprehensive review was that policies and programmes to support parents had great potential for improving mental health outcomes in the population.

On the other hand, the evidence is equivocal as to whether current interventions can effectively prevent the onset of post-natal depression in women (Dennis, 2005). However, there is some suggestion that interventions that focus on anxiety rather than just depression, involve fathers, have a focus on parenting skills development and improving relationships between parents may increase the chance of preventing post-natal depression (Fisher et al., 2010; Lumley et al., 2004).

Childhood and adolescence

Data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB) show that the prevalence of CMDs is highest in the 16–24 age group and decreases across the lifespan (Slade et al., 2009). Half of all lifetime case-level mental disorders start by age 14 and three-quarters by age 24 (Kessler et al., 2005). Mental health problems that arise in childhood can have consequences through to adulthood, with their outcomes imposing a major burden on society in terms of the individual, families and the health, justice and welfare systems (Heckman, 2012). Thus, a focus on both preventive interventions in children and adolescents may bring about potentially large reductions in population rates of the CMDs.

School can provide a unique environment for the implementation of programmes designed to improve mental health outcomes. Weare and Nind (2011) conducted a meta-review for the DataPrev project, focusing on mental health promotion and prevention programmes in schools. They reported on a large number of such studies that have been trialled across the globe, and concluded that there was consistent evidence of positive impact on the mental health and associated risk factors in children and adolescents. Their findings supported the effectiveness of both universal and targeted interventions, with a cumulative impact of small to moderate effect, particularly in the short term, and a greater impact on higher-risk children. They noted the importance of moving beyond an individual, classroom and curriculum focus alone to take a complex, multi-component approach that embeds programmes within the whole school as an organisation.

Traction may also be gained in contexts that are wider than the school-based settings. Christensen et al. (2010) systematically reviewed more than 40 studies that aimed to prevent depression and anxiety in young people using community-based programmes and reported positive outcomes in more than half of the reviewed studies. The majority of these interventions were undertaken in university or college students and most were based on cognitive behavioural therapies (CBTs). The recent Cochrane review by Merry et al. (2011) of studies designed to prevent depression in children and adolescents included school- and non-school-based interventions. This review concluded that some psychological interventions aimed at preventing depression appeared to be effective, while there was also evidence to suggest a positive impact on anxiety by some prevention programmes. In support of this, a recent review of school-based interventions, most of which utilised CBT-based strategies, also indicated evidence for the prevention of anxiety in children and adolescents (Neil and Christensen, 2009).

Adulthood and work

Although a focus on reducing the initial age of incident anxiety and depression is appealing in reducing the burden of mental disorders, prevention planning also needs to address evidence that many mental disorders arise later in life in reaction to traumatic events, loss-related events, chronic illness or chronic stress (Colman and Ataullahjan, 2010). While many of these factors are largely immutable, there is some evidence that universal and selective interventions in adulthood can prevent CMDs by focusing on modifiable risk factors, such as stress, and by psychological interventions (Cuijpers et al., 2008; Zalta, 2011).

An important consideration for such interventions is the ability to access the adult population. With a majority of adults in part- or full-time work, the workplace can be an access point for support and therefore plays a critical role in planning preventive strategies for mental and physical well-being (Wilkinson and Marmot, 2003). Moreover, there is strong evidence that a poor psychosocial work environment can increase the risk of mental disorders, particularly depression (Stansfeld and Candy, 2006; Bonde, 2008). Research in this area has focused on job stress (LaMontagne et al., 2008), effort–reward imbalance (Siegrist, 1996) and organisational justice (Kivimaki et al., 2003). There is evidence that interventions targeting job stress, particularly those that use a ‘systems approach’ (targeting both working conditions and individual skills and behaviours) can result in health benefits (Bambra et al., 2007; Czabala et al., 2011; Egan et al., 2007; LaMontagne et al., 2007). Newer research suggests that meditation can be an effective, low-cost strategy for reducing workplace stress, depression and anxiety (Manocha et al., 2011).

Older age

With an ageing population, it is critical to identify and manage risk factors for CMDs in elderly people. A systematic review and meta-analysis by Forsman et al. (2011) concluded that there was evidence for the benefit of psychosocial interventions in supporting good mental health and quality of life and for reducing depression in older adults. Poor social connectedness is a particular risk factor for depression and anxiety in old age and a review by Jané-Llopis et al. (2011a) found that social support interventions appeared to be the most effective among older adults. Another systematic review by Windle et al. (2008) confirmed benefits for interventions targeting exercise, group-based health promotion and other psychological interventions, but also noted the poor quality of the majority of studies.

Emerging evidence with potential applications for prevention of CMDs

Diet and health behaviours

Non-communicable diseases (NCDs) and CMDs are highly comorbid and often mutually reinforcing, with many shared pathophysiological mechanisms and risk factors. While the WHO states ‘there can be no health without mental health’, the new evidence in psychiatry research now suggests that the opposite may also hold true (Jacka et al., 2012b). In both developed and emerging economies, notable changes in the built environment and the globalisation of the food industry have led to substantial shifts in dietary patterns and physical activity levels, and there is now a compelling evidence base to suggest that these changes may be influencing the risk for CMDs (e.g. (Jacka et al., 2010, 2011; Lucas et al., 2011; Sanchez-Villegas et al., 2009).

This is in addition to an emerging evidence base suggesting that tobacco consumption, particularly in adolescence, is also an independent risk factor for CMDs (Johnson et al., 2000), while maternal smoking appears to increase the risk of these disorders in offspring (Ashford et al., 2008). As such, recent commentaries have presented the case for formal classification of CMDs as NCDs, based on the latest evidence regarding lifestyle as a modifiable risk factor for CMDs across the life course (Berk and Jacka, 2012; Jacka et al., 2012b). This would allow for the promotion of population-wide preventive interventions for the CMDs, targeting lifestyle behaviours, to be integrated with those promoted for the NCDs by the WHO and associated health bodies (World Health Organization, 2004). Importantly, lifestyle behaviours are now also recognised as risk factors for dementia (Cadar et al., 2012; Shah, 2013) suggesting that population health approaches for prevention of CMDs and NCDs, based on lifestyle improvement, may also be effective for a broader range of psychiatric disorders.

Reducing the use of substances such as alcohol and illicit drug use may also make potentially important contributions to preventing CMDs. Cannabis use is a risk factor for psychosis (Degenhardt et al., 2003) and depression (Horwood et al., 2012). Alcohol use is known to contribute to suicidal behaviour (Hawton et al., 2013) and two meta-analyses highlight the substantial interrelationship between alcohol use disorders and depression (Boden and Fergusson, 2012; Swendsen et al., 1998). There is good evidence that public health strategies that include taxation, and decreasing availability and promotion of alcohol, are effective in reducing alcohol-related harm (Babor et al., 2010a, b). An explicit recognition of the importance of these risk factors to the CMDs and modelling of the impact of these policy strategies on CMDs would be of substantial value in reinforcing such policies at a government level.

New pharmacological approaches

Risk process research suggests another potential avenue for prevention of CMDs involving the use of established agents such as statins, aspirin and anti-hypertensive medications, which lower cardiovascular risk by modifying either biomarkers of risk such as inflammation or proximal risk phenotypes such as hypertension. There is intriguing new evidence that similar biomarker pathways, inflammation and oxidative stress, may confer risk for the development of depression (Pasco et al., 2010b) and that similar pharmacological interventions may thus reduce depression risk (Pasco et al., 2010a; Stafford and Berk, 2011). This is an entirely new area of investigation. Equally, there are data that selected nutrients may play a role in depression risk, which also opens up potential therapeutic opportunities (Jacka et al., 2012a; Pasco et al., 2012).

Internet and associated technologies

The use of the internet and associated technologies to deliver interventions, education, health resources and access to support is an approach with a rapidly emerging evidence base in mental health research. This new technology is transforming the way in which people access health care and information and allows for the dissemination of health interventions in a way that was not fully anticipated a decade ago (Christensen and Petrie, 2013). The evidence for online treatments for both anxiety and depression as an effective alternative to face-to-face treatment is rapidly strengthening (Andrews et al., 2010; Cuijpers et al., 2011). Australia is highly active in the development and implementation of such programmes, including MoodGym (Christensen et al., 2004); those offered through Virtual Clinic in NSW (Andrews and Titov, 2010); and online parenting programmes (Yap et al., 2011). These programmes are shown to be effective, have high levels of adherence and are acceptable to consumers (Gun et al., 2011). Such a cost-effective and widely accessible method of delivery offers great scope for the scaling up of many psychological therapies already established as effective prevention strategies for depression and anxiety. It also has substantial potential for increasing mental health literacy and the reduction of stigma (Christensen and Petrie, 2013).

What can we learn from those in other fields?

The need to consider many complex and interrelated factors echoes that seen in other prevention fields, offering those working to prevent CMDs the opportunity to learn from those who have gone before. The best example of successful prevention strategies is that of tobacco control and CVD prevention; CVD is commonly comorbid and shares a bidirectional relationship with CMDs. There is much to learn from the successes and failures of decades of research in prevention in these areas that can inform CMD preventive efforts.

Lessons from tobacco control and the prevention of CVD

The reduction in deaths from CVD in developed economies represents a population health success story, with mortality rates increasing for most of the 19th century, peaking in the 1960s and 1970s and then undergoing a rapid reduction (Allender et al., 2008). The population health approach to reducing CVD mortality in the west over the last 60 years was built on the foundation of solid epidemiological evidence about the modifiable risk factors, namely unhealthy diet, physical inactivity, and, perhaps most importantly, tobacco use. The pattern of the decline in smoking prevalence, which accounts for around 40% of the population-attributable risk for myocardial infarction, largely parallels the reduction in risk of CVD mortality (Yusuf et al., 2004). Changes to tobacco consumption took decades and required a variety of intervention approaches operating across different domains, including tax policy, school interventions, clean indoor air regulations, agricultural initiatives, advertising campaigns, medical care initiatives, community mobilisation, and political action. While optimism in developed countries needs to be tempered by rising smoking rates in many developing countries, the key message to the mental health field is that the most effective interventions are often complex, policy based and multifaceted. Here a range of translation and implementation issues needs to be addressed by working closely with communities and consumers in order to maximise integration into existing service delivery and policy structures (Lewis et al., 2012b). One of the key lessons from tobacco control is that policy change is crucial and can be far more cost-effective than individual behavioural interventions (Carter et al., 2009).

Cost-effectiveness of prevention

Prevention can be very cost-effective. As a notable example, while the USA invests 95% of its trillion-dollar health budget on treatment rather than prevention (Heckman, 2012), Cuba invests a major proportion of its comparatively meagre health budget on prevention and has key indices including infant mortality and life expectancy rates identical to that of the USA (Campion and Morrissey, 2013). James Heckman, writing in the journal Health Economics (Heckman, 2012), highlights the importance of interventions in childhood to avert the enormous costs to the individual and society associated with mental health problems in adulthood. The particular role of education in causally influencing health outcomes, including positive health behaviours and mental health, gives rise to the understanding that by investing in early life, via education and policies aimed at supporting families, later costs to the health, welfare and criminal justice systems are averted. Similarly, successfully addressing workplace stress and related mental health problems, which manifest in absenteeism, staff turnover and a loss of productivity (Czabala et al., 2011), is likely to benefit business and governments.

A recent systematic review in Australia identified ten strategies that have evidence for cost-effectiveness as universal, selective or indicated approaches to preventing mental disorders (Vos et al., 2010). Clear evidence of cost savings was found for problem-solving post-suicide attempt and treatment for individuals at ultra-high risk for psychosis. A further five interventions were found to be very cost-effective: screening and bibliotherapy to prevent adult depression; screening and psychological treatment to prevent childhood/adolescent depression; screening and bibliotherapy to prevent childhood/adolescent depression; responsible media reporting for the reduction of suicide; and parenting intervention for the prevention of childhood anxiety disorders (Vos et al., 2010).

Four strategies were also found to have strong evidence for cost-effectiveness in preventing alcohol-related harm including: volumetric tax on alcohol; a tax increase of 30% on alcohol products; advertising bans; and raising the minimum legal drinking age to 21. Two further strategies were evaluated as very cost-effective: a brief alcohol intervention with or without telemarketing and support; and licensing controls (Vos et al., 2010). This report also concluded that a 10% tax on ‘junk’ food would be a highly cost-effective strategy for improving physical health outcomes in Australia; the new data regarding the impact of these foods on mental health suggests that this may be additionally pertinent for CMDs and dementia.

However, preventive efforts in cancer and CVD suggest that efforts to address risk factors for depression such as tobacco and alcohol use and poor nutrition are likely to face vigorous resistance from vested interests. In this sense, the actual costs of such strategies to the public purse may be low, but the political costs are higher. Public health advocacy has played an important role in developing effective strategies to combat the influence of vested interests in the field of tobacco control (Berridge, 2007; Brandt, 2007; Chapman, 2007; Proctor, 2011) and advocacy would appear to be an important necessity in the advancement of the prevention agenda in mental health. Such advocacy will need to take into account that, in prevention, the costs, including political costs, are incurred in the short term, while the benefits are more distal. As such, the arguments for the importance, benefits and cost-effectiveness of investments in prevention need to be cogent, compelling and widely understood.

Where to from here?

The consensus from the large body of evidence thus far reviewed supports the contention that interventions to prevent mental disorders across the lifespan can be both effective and cost-effective. However, it is still not established as to whether there are long-term sustainable effects. Embedding effective intervention components within the health system as well as in the education and care systems to achieve long-term sustainable impacts is a major challenge facing those in mental health prevention research, as well as in prevention research more widely. The process requires a range of different solutions and policy responses from governments, communities and industry. However, there are some specific actions that can be taken in the shorter term in order to support the prevention agenda in Australia and more widely.

For researchers

Research agenda

Clearly there is a need for more investment in prevention-focused research and this research needs to occur on a number of fronts. Pressing goals include the quantification of the burden of disease associated with particular risk factors in order to set priorities and criteria for interventions. Other priorities include the incorporation and evaluation of prevention interventions within the mental health sector; explication of the contribution of social, cultural, economic and environmental factors to lifestyle behaviours and their interactions with mental health; and the inclusion of mental health outcome measures into planned large-scale whole of community interventions, such as those undertaken as part of the National Partnership Agreement on Preventive Health, in order to assess the impact of improving lifestyle behaviours on CMDs as well as NCDs. Developing evidence in this field will allow for leveraging on the extensive knowledge base in the field of NCD prevention in order to formulate governmental policies and public health messages regarding the prevention of mental disorders using lifestyle-modification approaches (Jacka et al., 2012b).

There is also the imperative to ensure the matching of interventions to the most critical and plastic periods of development. Given the relatively small focus on preventions aimed at the perinatal and early childhood years, there is a need for further research on children under 8 years old, both in terms of risk factors and interventions to address these (Davis et al., 2011). We also need to develop a better understanding of how to identify and reach high-risk families in high-risk communities. Building on what is already known about the utility of school-based interventions (Weare and Nind, 2011), there needs to be further development and evaluation of large-scale interventions in schools designed as universal prevention strategies, as well as those embedded in family and community settings.

Implementation studies will be necessary across many settings but is likely to be particularly appropriate for those situations in which we know what to do but less about how to do it. For example, we know that increasing perceived job control in the workplace is likely to impact on the prevalence of depression, but less is known about how best to do this. Implementation research can also help to address issues of tailoring, sustainability, large-scale roll-out and integration with service delivery systems, including the mental health service sector.

New research should also balance the current focus on mostly single-target interventions with multi-level, multi-component interventions to address family, school and community environments. The ‘Communities that Care’ approach, which incorporates interventions tailored to a community’s specific profile of risk and protection, offers a model for such interventions (Hawkins et al., 2008). Another good example is the European Alliance Against Depression programmes that have successfully harnessed community groups, health professionals and the general public to target and reduce depression and suicidal behaviour (Hegerl et al., 2013). This model has now been adopted in more than 100 regions in Germany and Europe and offers an exciting glimpse into the possibilities for such programmes in Australia.

Methodological rigour

However, it is not sufficient to propose, develop and implement new research without attention to ensuring methodological rigour. In the recent Cochrane review of interventions to prevent depression in young people, the authors noted the significant limitations of the available studies, with no equivalent comparison/control groups used in most cases and some concerns around the validity of the measures used to assess mental health outcomes (Merry et al., 2011). They also noted the lack of evidence for lasting effects. In the meta-analysis of school-based programmes for promotion and prevention, Weare and Nind (2011) noted the lack of methodological rigour in many of the studies of school-based interventions, noting that many programmes were poorly implemented and lacked consistency and fidelity, causing them to become diluted and reducing their ability to demonstrate impact. Conversely, the interventions that were effective were ones that were implemented carefully and with fidelity. Windle et al. (2008) also noted the very poor quality of the majority of studies in their review of preventions for mental health problems in older adults. Czabala et al. (2011) were unable to draw firm conclusions regarding the efficacy of workplace-based interventions, due to the methodological limitations of the studies reviewed; many of the studies had samples that were too small and with insufficient follow-up periods. Without clear evidence of effectiveness, it is far more difficult to make a case for investment in prevention. As such, it is critical that future studies in the prevention field are developed with methodological diligence, ensuring adequate sample sizes, duration and follow-up periods. Given the fact that many outcomes will only manifest many years after the intervention (Jané-Llopis et al., 2011b), particularly in regards to interventions in childhood and adolescence, long-term follow-ups of both mental health and functional outcomes should be built into the methodology wherever possible. Measured outcomes should also quantify delays in progression to illness in high-risk groups, as well as reductions in incidence. These imperatives necessitate adequate support by funding agencies. New interventions should also build on the substantial body of knowledge that already exists regarding what works and what doesn’t to avoid duplication of resources (Jané-Llopis et al., 2011b).

Scalability

Effective universal prevention strategies must also be able to reach the broader population (Muñoz et al., 2010). In this sense, planning at the initial stage of the intervention needs to take into consideration the generalisability and scalability of the proposed methodology. Internet-based interventions are offering a viable new method of delivery that is low cost, readily implemented and effective in many cases (Christensen and Petrie, 2013) and the potential application of new technologies to interventions should be considered from the outset.

Economic evaluation

However, it is important not only to develop effective preventive strategies, but also to ascertain whether investment in these strategies is cost-effective, both within and beyond the health system (McDaid and Park, 2011). The findings from the DataPrev project demonstrated that, while there were many effective interventions identified, most of these have not been subject to economic evaluation (McDaid and Park, 2011). This reduces the potential for advocacy and translation. As such, standardised tools used to allow for economic modelling should be integrated into all planned interventions in order to afford the extrapolation of short- and long-term costs and benefits to the population level.

Knowledge translation

The fact that mental disorders can be prevented and that it is cost-effective to do so needs to be better communicated to policy makers and the wider community. Prevention of mental (and physical) ill health must be recognised as an imperative by all members of society, with appropriate resources allotted to it at every level. As there is no existing prevention system within the mental health sector, many areas both within and outside of the formal sector will need to be engaged in creating a comprehensive prevention system for mental health. For this to happen effectively, knowledge translation must be at the forefront of the agenda. A recent systematic review of barriers and enablers to evidence-based policy development noted that there was little good evidence regarding the use of research in informing public policy and that actions to change this were urgently required (Orton et al., 2011). A new cluster randomised controlled trial, currently under way, aims to examine and evaluate a programme of strategies to increase the use of research evidence in informing public health decisions in local governments (Waters et al., 2011). Such knowledge translation research is useful for the prevention agenda in Australia and elsewhere.

In order to optimally engage the key agencies to ensure the translation of such research findings into informed public health policy, research needs to be targeted for use by decision makers and evidence presented in a form that is most useful for end users (Petticrew et al., 2004). Building meaningful and reciprocal relationships between researchers and end users will help to facilitate good knowledge translation. It also behoves researchers to identify policy questions that require answering at the outset, in order to match research outcomes to the needs of end users (Jané-Llopis et al., 2011b).

Moreover, improvements in mental health literacy in key groups, including those working in school welfare, general practice and community health (Mann et al., 2005) and improvements in the mental health literacy of the general public (Jorm et al., 1997), whilst being essential in their own right, also supports the prevention agenda; if the community understands the burden of mental disorders and the potential for prevention, constituents are more likely to support resource allocation to prevention initiatives.

For policy makers

Poverty and disadvantage have substantial negative impacts on well-being (Ludwig et al., 2012) and increase the risk for CMDs. As such, effectively improving the environmental determinants of health, including poverty, discrimination, education, employment opportunities, access to health care, social inclusion, and unsafe environments, will have a substantial impact on mental health outcomes. These are central issues for governments everywhere; however, explicit recognition of the costs of not adequately addressing these factors, in light of the massive burden of CMDs, must be widely understood and elevated to the national agenda. Mental health service planning frameworks should explicitly address prevention and mental health promotion. Importantly, we need to concentrate investments in supporting parents and families and in adequately funding an educational system that fully recognises the importance of promoting and supporting the development of individual-level competencies that build mental health (Anderson and Jané-Llopis, 2011).

The close connectedness and overlap between mental and physical health means that measures to improve physical health will have a positive benefit for prevention of mental disorders and vice versa. This needs to be more fully recognised and meaningful efforts made to change the design of the living environment to increase actions that promote both physical and mental health, such as physical activity and healthy eating. In a recent speech to the United Nations General Assembly, the head of the WHO, Dr Margaret Chan, cited the estimates that over the next 20 years NCDs will cost the global economy more than US$30 trillion. She acknowledged that all countries across the globe will soon be unable to afford the costs associated with the increases in lifestyle-mediated diseases and stated that ‘the response to these trends must come with equal power, with top-level power that can command the right protective policies across all sectors of government’ (Chan, 2011). In other words, it is only the highest level of government that has the power to challenge the transnational corporations that are driving the increase in NCDs (Moodie et al., 2013). The new recognition of lifestyle practices as contributors to CMD risk strengthens the imperative to urgently address the issue of unhealthy environments and access to unhealthy commodities (Moodie et al., 2013) at the level of national policy.

Summary

Building the evidence base for action on prevention of CMDs involves considering the developmental origins and risk factors for mental disorders over the life course, the optimal settings for interventions, and the complex relationships between these factors. Such a life course approach begins with intensive support to families in pregnancy and early childhood, continues through to supporting child and adolescent health through interventions for children in families and schools, establishes community prevention systems that modify physical conditions and coordinates preventative interventions to reduce risk factors at the health system and community level, promotes physical and mental health for adults at worksites and other settings, and the elderly in both the community and aged care. Importantly, it encourages and supports social and emotional competencies, strong social connections, a healthy diet and regular physical activity from youth into old age, and reductions in social and economic inequities, through governmental policies, leadership and investment in programmes. It is important to also understand that, while there are some major areas of overlap between the NCDs and CMDs, mental health problems have unique risk factors, some of which have not been well studied. Nevertheless, partnering with agencies and disciplines sharing this agenda will be a highly leveraged exercise and is likely to be critical to success.

In an ideal world we would create a system from ground up that recognises the essentiality of physical and mental health promotion and protection at every level and in every setting: ensuring healthy public policies; creating healthy environments; ensuring adequate support for individuals and families; and ensuring social connectedness through strong community programmes. Pragmatically, we are left with the enormous and complex task of retrofitting programmes to existing systems. However, we now have potent tools at our disposal and the foundation of a strong evidence base on which to build a solid system that values prevention equally to treatment.

The Alliance for the Prevention of Mental Disorders

In an effort to encourage more strenuous efforts to achieve population reductions in CMDs, our group of researchers working in the areas of preventive psychiatry and psychology formed the ‘Prevention Partnership’. As a first activity we organised a symposium (held 14 September 2012) that aimed to bring together interested scientists and population health leaders to present ideas and discuss strategies for progressing the preventive agenda in mental health research. The symposium invited experts across multiple disciplines outside of psychiatry and psychology, from obesity and CVD prevention, health economics and advertising, to present and share their knowledge regarding what works and what doesn’t work, what is achievable, what is cost-effective and how best to translate new insights into population health messages and policies. This meeting raised many questions and offered numerous points of view and concluded with a clear consensus to progress the prevention agenda within mental health, with a particular focus on CMDs, and to form a new society that aims to support an increased focus on the prevention of mental disorders. This society, now called the ‘Alliance for the Prevention of Mental Disorders’, held its first meeting in Melbourne, Australia, in February 2013 and was officially launched in May 2013 in Canberra, Australia. All those interested in developing and promoting prevention in mental health research and practice are welcome to join and can do so by contacting the corresponding author.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Prevention of common mental disorders: What can we learn from those who have gone before and where do we go next?

Abstract

Objective

Methods

Results

Conclusion

Keywords

Introduction

A brief overview of prevention efforts to date: From conception to old age

Parenting and early life

Childhood and adolescence

Adulthood and work

Older age

Emerging evidence with potential applications for prevention of CMDs

Diet and health behaviours

New pharmacological approaches

Internet and associated technologies

What can we learn from those in other fields?

Lessons from tobacco control and the prevention of CVD

Cost-effectiveness of prevention

Where to from here?

For researchers

Research agenda

Methodological rigour

Scalability

Economic evaluation

Knowledge translation

For policy makers

Summary

The Alliance for the Prevention of Mental Disorders

Footnotes

Funding

Declaration of interest

References