Sunday, December 17, 2006

Where’s the Health in Mental Health? How Current Public Mental Health Mucks up the Prevention Paradox Involving Few to Benefit Few – Esther Hill

Each year one in two Americans has a diagnosable mental disorder (Office of Minority Health, n.d.). With such a high prevalence of illness, public health practitioners have a hefty responsibility. Epidemiologist C.E.A. Winslow (1920) offers a definition of public health that puts this responsibility into perspective. Winslow states, “Public health is the science and art of preventing disease, prolonging life, and promoting health through organized community effort.” Hence, public health practitioners are responsible for the prevention of mental illness, the prolonging of life and the promotion of mental health through organized community effort. Unfortunately, current public mental health interventions fail to meet these objectives.
In 2006 the federal government allocated $3,206,000,000 to the Substance Abuse and Mental Health Services Administration (SAMHSA) (U.S. Department of Health and Human Services, n.d.). From the Department of Health and Human Services, the Surgeon General’s Report describes how this money is used within the programs and departments to which it is distributed. Funds are used for direct treatment of mental illness including outpatient and inpatient treatment, medication, partial hospitalization, and residential programs. Mental health funds are also used toward interventions, which focus on prevention of physiological developmental conditions such as safe sex education to prevent HIV and syphilis in children and measles vaccinations with the objective of preventing neurobehavioral problems in both incidences. There are also preventative programs such as Head Start, the Carolina Abecedarian Project, and the Infant Health Development Project which all focus on early education of young children. Such programs have been shown to reduce antisocial behavior and improve cognitive functioning. While it is obvious that efforts are being made to address mental health, a closer examination reveals the costly inappropriateness of these interventions.
Epidemiologist Geoffrey Rose’s work provides a framework of social and behavioral theory to identify the primary failures of the current interventions in public mental health. Rose discusses the appropriateness of focusing interventions on a high-risk population versus the entire population. In the case of mental health, current interventions focus solely upon the high-risk group or rather the group with most severe conditions. Yet, examination of Rose’s work reveals that the target population is too limited in current mental health interventions, and a population strategy should be employed. Secondly, Rose points out that public health is responsible for incidence reduction, and the failure of current interventions to reduce incidence fails to address the burden of disease. Aside from the burden of poor mental health, Americans pay a hefty economic price to treat mental illness and account for the lower productivity that results from mentally ill persons inability to function normally. Finally, current interventions commit the ultimate sin in terms of social and behavioral science by neglecting to consider the social context of the disease. Focusing primarily on existing cases and treatment reveals little about the contextual factors leading to the incidence of mental illness. How can public health practitioners prevent future cases if they don’t know who is becoming ill, with what illness and under what conditions?

Where’s the public in public mental health?

When assessing public health intervention, Rose saw value in either focusing efforts on the high-risk population or using a population strategy depending upon the health condition. A recent study (Woodall et al, 2004) evaluating the use of the prevention paradox on a jail/treatment program’s ability to reduce DWI arrests illustrates an appropriate public health condition for applying a population strategy. The study results showed that the intermediate-risk group accounted for the most crashes. Since the courts deal primarily with the high-risk individuals, the researchers concluded that they the court’s intervention will not have a major impact on reducing alcohol-related crashes as a whole. Mental health presents a similar condition in which targeting the intermediate-risk group would yield a greater absolute reduction of cases.
Current interventions in mental health target primarily the population receiving treatment for a mental illness and the children enrolled in the early childhood prevention programs. Unfortunately, fewer than half of adults that are diagnosable with a mental illness get help and only one-third of children get help, so the target group actually includes only a portion of mentally ill and high-risk individuals that need treatment or prevention services (Office of Minority Health, n.d.). The failure to utilize a population strategy results in failure to treat illness and promote health at the level that incorporates large numbers of society or rather at the public level.

Where’s the health in public mental health?

Health promotion at the community level performs the public service of reducing the burden of disease on society and there is great incentive for promoting public mental health. According to the Global Burden of Disease assessment of 1990, five of the ten leading causes of disability in the world were mental illnesses (Murray, 1996). In 1996 alone the United States spent an estimated $150 billion directly and indirectly on mental health (Healthy People 2010, n.d.). Sixty-seven billion dollars went to direct costs, including the 3.2 billion allocated to SAMHSA for programming, and the rest is used in treatments at medical and psychiatric institutions (Department of Health and Human Services n.d.). Indirect costs accumulate from a variety of sources including crime, incarceration, welfare, teenage pregnancy, marital problems, and school dropout. For example, 14% of high school dropouts and 4.7% of college dropouts suffer from a psychiatric disorder (American Psychiatric Association, n.d.). Indirect costs are also accrued from lower productivity of mental ill persons and work absenteeism. Not only is the individual’s personal income affected, their family is affected, the company they work for is affected, and consequently the economy is effected.
The prevention paradox, as proposed by Rose, illustrates how a population strategy can reduce the burden of disease. The paradox is based upon the assumption that what causes an individual case may not be the cause of incidence in the population. Under the prevention paradox the entire population is involved and benefit is bestowed upon the population, not necessarily the individual. For example, Hatziandreu et al (1989) used a cost-effectiveness analysis to estimate the benefits of a population-based health promotion program. The researchers estimated that regular exercise led to a net gain of 1,138.3 Quality Adjusted Life Years (QALYs) over the 30-year study period with the cost per QALY gained of $11,313. As Rose’s theory explains, the individual does not reap economic gain from exercising, but at the population level, s/he is less likely to suffer from CHD which decreases his/her individual burden and societal burden. Focusing on the treatment of illness, such as coronary heart disease, does little to promote health. An intervention that unearths the health in mental health will further augment economic health.

Where’s the disease prevention in public mental health?

“How did this individual get this illness at this particular time?” (Rose, 1985). This is the question that Rose encouraged his medical students to consider. His words outline what public health practitioners need to know in order to prevent a problem. Who is becoming ill? What is the illness? What are the contextual factors, such as social and cultural, causing the illness at this particular time?
The manifestation of mental illness can to some extent be considered a product of the society in which an individual lives. Consider bulimia nervosa. Risk factors for the disorder include individual characteristics chemical imbalance of neurotransmitters, dysfunctional familial patterns, low self-esteem, impulsivity, incompetence of conflict resolution, parental rigidity, and age. (American Psychiatric Association, 2000). However, the disorder is associated with environmental factors such as cultural standards of beauty, culture of dieting, population-wide concern with weight and shape (Austin, 2001). The availability of food is a more logistical factor albeit an environmental characteristic relating to the etiology and prevalence of the disorder. Hence, the behavioral choices and health outcomes of the bulimic are determined by the individual’s predisposition but also by the social and cultural environment in which the individual lives.
Population-based strategies that focus on prevention regardless of risk factors are especially effective in cases of mental illness such as eating disorders due to the population-level epidemiology. One example of this appropriateness is the Planet Health Intervention Study (1997), which divided adolescents into risk groups based on self-reported dieting practices. After controlling for the effects of intervention, the researches found that the largest number of cases occurred in the moderate-risk group, a finding that reiterates Rose’s theory. Had the Planet Health Intervention only focused on the high-risk group, they would have failed to prevent the largest number of cases. In order to prevent mental illness, it is necessary to consider the contextual factors contributing to the etiology and address those factors in the intervention strategy.


The responsibility of public health is to prevent disease and promote health at the population level. In the field of mental health, interventions must not be limited to high-risk individuals but rather must target populations that will reduce the greatest burden on society. This requires consideration of contextual factors influencing the etiology of disease when developing preventative efforts. In closing, current interventions in public mental health fail because they focus upon treatment of mental illness within a small target population when focus upon prevention of illness and promotion of health is what is needed.

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Healthy People 2010 (n.d.). Leading health indicators. Retrieved November
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Htziandreu E.I., Koplan J.P., Weinstein M.C., Casperse C.J., & Warner K.E. (1989). A
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Murray C.J.L. & Lopez A.D. (1996). The global burden of disease: Summary. World
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National Institute of Mental Health (2006). The numbers count: Mental disorders in
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Office of Minority Health. (n.d.). Eliminate disparities in mental health. Retrieved
November 10, 2006, from the Center for Disease Control Web site:
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2006, from the United States Department of Health & Human Services Web site:
Rose G. (1985). Sick individuals and sick populations. International Journal of
Epidemiology, 14, 32-38.
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Blogger Michael Siegel said...

This is a great use of Rose's prevention paradox to demonstrate the failure in our current approach to mental health. This is one area where for some reason, public health seems to focus only on the most extreme cases, and to focus on treatment. With almost all other chronic diseases, we are willing to focus on the population, and to institute specific prevention programs. But little is done to prevent mental illness on a population basis. The focus is clearly on treatment of extreme cases. Hopefully, this critique will help bring attention to the need to develop a broader approach to mental health.

8:22 AM  
Anonymous Anonymous said...

I was unaware of the substantial amount of money allotted by the federal government to the improvement of those with mental health, and I agree that it is so important to utilize these funds in the most effective way possible -- and that includes a more broad effort beyond the targeted effort that has been most prevalent.

8:19 AM  
Anonymous Juliane Scrivens said...

I think it is really interesting that you bring up how so much of the government's efforts to combat mental health problems is focusing on such a small portion of the population. This is a portion of our population that rarely is given a voice. Great job at calling attention to a subject that I haven't seen discussed very often.

2:34 PM  
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