LESSONS FROM HEALTH RESEARCH



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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH LESSONS FROM HEALTH RESEARCH

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH This page in the original is blank.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 3 Prevention of Physical Illness Major advances in the prevention of health-related problems have been made during recent decades in several areas of physical health (DHHS, 1991). Broad-based governmental actions as well as communitywide preventive intervention programs based on sound experimental research designs have produced significant changes in the health behaviors of many individuals, and declines in the risk of morbidity and premature mortality have been achieved. Progress has been notable in many areas, including the three used here as illustrations: cardiovascular disease risk reduction, smoking cessation and prevention, and injury prevention. The universal preventive strategies mounted in these areas have demonstrated that effective interventions are possible even when knowledge about the mechanisms causing illness is incomplete. Two experiments on cardiovascular disease risk reduction are reviewed, as is a series of experiments on smoking cessation. For injury prevention, a different approach is taken; rather than describing experiments, the effects of broad-based governmental action are reviewed. The successful prevention campaigns in physical health can serve in several ways as a bridge in building effective mental health interventions. They provide powerful analogies and models for developing general strategic guidelines on approaches to prevention. In addition, This chapter is based, in large part, on presentations at a workshop, convened by the Institute of Medicine, that focused on findings from prevention programs in physical health that might be applicable for mental health. (See Appendix C for participants and agenda of the meeting.)

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH the prevention programs in physical health can be directly useful by suggesting approaches and techniques—such as media presentations and strategies for community organization—that have proved their value in the physical health arena and may be readily modified and adapted to mental health. CARDIOVASCULAR DISEASE Cardiovascular disease, one of the leading causes of premature death and disability in the United States, is linked by extensive research to a variety of life-style components peculiar to the industrialized twentieth century. Smoking, little or no exercise, diets high in saturated fat and cholesterol, and chronic stress can lead to high blood pressure, high blood cholesterol, and obesity, all of which increase risk of cardiovascular disease. Investigators at Stanford University have conducted two major studies designed to reduce the risk of cardiovascular disease. The prevention campaigns are based on the conviction that health risk factors associated with life-styles are most readily modified in the context of the community environment. It is important to note that although a connection between high fat intake, high cholesterol, and cardiovascular disease was reasonably well established by longitudinal data when the first of the Stanford studies began, the relative risk for cardiovascular disease (the ratio of the risk of disease or death among the exposed to the risk among the unexposed) had not been established experimentally, and the amount of change, or malleability, in the risk factors that was achievable from a community campaign was certainly not known. The prevention programs—called the Stanford Three-Community Study and the Stanford Five-City Project—have demonstrated notable success in risk factor reduction through preventive interventions before the onset of illness. The results are promising because they suggest that it is possible to change the health habits of entire communities and to mobilize existing community resources to achieve those changes. The studies have become prototypes for comprehensive programs of planned social change to prevent many chronic diseases and other social problems (Flora, Maccoby, and Farquhar, 1989). The goals of the Three-Community Study were to produce awareness of the probable causes of cardiovascular disease and of the specific measures that may reduce risk and to provide the knowledge and skills necessary to accomplish and maintain recommended behavior changes. The study encouraged reduction in body weight through caloric reduction and increased physical activity, and dietary changes to reduce

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH intake of saturated fat, cholesterol, salt, sugar, and alcohol. Cigarette smokers were educated on the need and methods for ceasing or at least reducing their daily consumption. Mindful of the powerful cultural forces that reinforce personal health habits, the investigators designed the study to combine an extensive mass media campaign with a considerable amount of face-to-face instruction. They also used three elements that had traditionally been ignored in health campaigns: (1) mass media materials devised to teach specific behavioral skills, as well as to offer general information to affect attitude and motivation; (2) the mass media approaches and, in particular, the face-to-face methods of instruction that were solidly grounded in theory and employed established social learning methods of achieving changes in behavior and principles of self-control training; and (3) an extensive analysis of the knowledge deficits and the media-consumption patterns of the intended audience, which was used to influence the campaign's ultimate design (Farquhar, Maccoby, Wood, Alexander, Breitrose, Brown et al., 1977). The Three-Community Study was carried out from 1972 through 1975 in a trio of northern California towns: one received the intense media campaign and the face-to-face education, another just the media communications, and one served as a control. The media campaign consisted of about three hours of television programming, 50 television spots shown repeatedly, several hours of radio programming, weekly newspaper columns, newspaper advertisements and stories, billboards, posters, and printed material mailed to participants. The media materials incorporated elements of modeling and specific skill-building components designed to achieve participatory learning, which the investigators considered more effective than passive learning in promoting and maintaining behavior changes. For example, a televised hour-long “Heart Health Test” used self-scoring followed by instructions on how to reduce that particular risk, and another TV program modeled steps in preparation of healthful food alternatives. A specially tailored media campaign also was created for the sizeable populations of Spanish speakers in the communities. In the face-to-face component of the program, individuals identified as being at especially high risk received eight lessons (totaling 15 hours) of skills training, conducted in both group classes and at-home sessions and directed by expert counsellors trained in behavior modification techniques. During its two-year period of active community education, the project achieved a statistically significant reduction in the composite risk score for cardiovascular disease, a result of significant declines in blood pressure, smoking, and cholesterol levels. The risk score decreased

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH approximately 25 percent for the media-only community and 30 percent for the community receiving the combined campaign (Farquhar et al., 1977). Overall, the Three-Community Study demonstrated that (1) it is feasible to reach many individuals as opposed to targeting only high-risk individuals; (2) media-based strategies can be highly effective, but are even more so when supplemented with face-to-face communication; and (3) maintenance of the program requires mobilization of the community in addition to changes in individual behavior. The Stanford Five-City Project extended the scope and objectives of the pioneering Three-Community Study, in particular by emphasizing community organization and including independent population surveys. It was a low-cost, comprehensive, communitywide program with the main goal of reducing risk of cardiovascular disease (Farquhar, Fortmann, Maccoby, Haskell, Williams, Flora et al., 1985). Other objectives included analysis of cost-effectiveness, development of educational and community organization methods, and gradual transfer of program control to community organizations. Over a five-year period beginning in 1980, two medium-sized California cities received continual exposure to general education punctuated by four or five separate risk factor education campaigns per year (Farquhar, Fortmann, Flora, Taylor, Haskell, Williams et al., 1990). Three similar cities served as a control group, with the combined population of all sites reaching approximately 350,000. Education was carried out through the electronic and print media, and directly through classes, contests, and correspondence courses. Special programs were developed for Spanish-language radio, newspapers, and mass-distributed print materials. In addition, school-based programs for grades 4, 5, 7, and 10 included special sessions on nutrition, exercise, and smoking, as well as multi-factor risk reduction classes for teachers and administrators and materials on exercise and nutrition for the students' parents. Work places were another major focus, and many large businesses participated by disseminating printed information, offering workshops and classes, sponsoring contests, and assessing environmental risks (such as smoking policy and exercise facilities). Heath care professionals participated in training programs, disseminated printed materials, and implemented risk reduction programs in their practices. There also were numerous point-of-purchase efforts. For example, many restaurants, cafeterias, and grocery stores participated in specially designed health food programs, such as a menu-labeling program that stressed the importance and versatility of low-fat foods. The project's results proved quite encouraging. They definitively

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH demonstrated the effectiveness of the intervention in reducing risk factors and suggested that similar programs could be tried. Although knowledge of risk factors increased in both the experimental and the control cities, the improvement in the experimental group was significantly greater in all follow-up surveys. The knowledge apparently was put into practice, too. After 30 to 64 months, the experimental group registered an overall decrease in cardiovascular risk scores by 16 percent and a decrease in total risk score by 15 percent (Farquhar et al., 1990). On closer analysis, significant net reductions in community averages favoring the experimental group occurred in cholesterol level (about 2 percent) and blood pressure (4 percent). There also was a large decline in smoking level (13 percent) among the experimental group. The decreases in cholesterol and blood pressure, although minor by clinical standards, may in fact have a potentially large public health significance (Farquhar et al., 1990). Because changes are greater in those at high risk and these changes apply to the entire population, a significant decline in the total number of cardiovascular disease events could be anticipated. The behavioral changes are also potentially sustainable and may even spread to other individuals as the changes are woven into the fabric of the community. Not only effective, the campaign proved affordable. Over the project 's span, each adult was exposed to an average of 527 educational episodes distributed fairly evenly over time—for a total exposure of about 26 hours per adult (Farquhar et al., 1990). Of these messages, about 70 percent were sent through television and radio, principally as 30-second spots. Annual radio and television exposure thus would be less than one hour per adult. The organizational and educational program was delivered at a per capita cost for adults of about $4 per year, excluding research costs. Just as important as the specific details of the program are some broader issues that guided its development and implementation. For example, like its three-city predecessor the project was based on well-established models and theories. It effectively incorporated a communication-behavior change model, social learning theory, community organization principles, and social marketing methods. The program was designed to be comprehensive, encompassing multiple channels of communication, multiple objectives, and multiple targets of change (individuals, organizations, and larger community networks). It was also carefully evaluated at several stages, including pretesting the educational materials and conducting field assessments of whether the intended audience actually received the information.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH SMOKING Smoking kills approximately 434,000 Americans each year—more than the number who die from automobile crashes, fire, alcohol, homicide, suicide, drugs, and AIDS combined. In 1990, roughly 45.8 million persons age 18 or older, 25.5 percent of all adults, smoked cigarettes (CDC, 1992a). Young people smoke at about the same rate, which means we are replacing all the adults who either die or stop smoking with new smokers. The picture would be even more grim were it not for major societal actions to discourage smoking. In the 1950s a series of epidemiological studies began to yield evidence that cigarette smoking could indeed cause lung cancer, as thoracic surgeons had been asserting for more than a decade (Breslow, 1982). Additional evidence accumulated, and in 1964 the Surgeon General of the U.S. Public Health Service issued Smoking and Health, which marked a watershed in alerting the public to the health hazards of tobacco (U.S. Public Health Service, 1964). Since then, various organizations have conducted a large number of prevention programs, and there has been a series of public policy actions aimed at reducing smoking, such as restricting advertising, increasing public education, and requiring warning labels on tobacco products. These and other actions have produced a steady decline in smoking. From 1965 through 1985, smoking prevalence among adults dropped an average of 0.5 percentage points annually, and from 1987 through 1990 the decline averaged 1.1 percentage points annually (CDC, 1992a). Overall, the decline in smoking has been steady, with the exception of a minor increase of 0.3 percent between 1990 and 1991. This increase was not statistically significant, and the 1992 prevalence rate was below the prevalence rate of 1990 (SAMHSA, 1993). In 1989 the Surgeon General issued Reducing the Health Consequences of Smoking: 25 Years of Progress (DHHS, 1989). While reporting on dramatic changes in smoking behavior, he alerted the public to the need to focus increased efforts on preventing smoking initiation and encouraging smoking cessation among high-risk populations. There have been some problems along the way, however, that are relevant for planning prevention efforts in mental health. Thomas Glynn of the National Cancer Institute's (NCI) Smoking, Tobacco, and Cancer Program has argued that, although there has certainly been success in reducing tobacco use, the early research and control activities did not provide the information necessary for even broader reductions (Glynn, 1991). That is, the series of intervention studies in the 1970s never were drawn together into a comprehensive plan of attack. Various reasons are

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH cited for this, including competing or poorly coordinated funding agency priorities, inadequate research methodologies, lack of communication across disciplines, and an insufficiently coordinated data base. In addition, most investigators focused only on single causes of smoking (such as physical dependence on nicotine) or made use of single communication channels (such as mass media or physician office-based programs) for prevention. Faced with this scattershot approach, NCI launched in 1982 the Smoking, Tobacco, and Cancer Program (STCP), a major planning and research effort to coordinate smoking prevention trials and develop large-scale comprehensive community interventions (Glynn, 1991). Lacking a consensus on how best to persuade people to quit or not begin smoking, the STCP mounted a well-planned, carefully phased three-phase campaign. First, program administrators consulted with hundreds of experts to identify areas in which significant gains could be expected. They then called for and funded research to develop and evaluate prevention and cessation interventions that would be effective, cost efficient, durable, generalizable, and widely applicable. Between 1984 and 1987, NCI began 49 large trials, most of which were to last five years, at a total cost of $82 million. Reflecting the multifactorial emphasis, these trials covered eight areas. First, there were school-based interventions with adolescents. These recognized that whatever can be done to prevent smoking by young people is doubly important, not only because it minimizes tissue damage during youth but also because it minimizes the hazard of addiction (few people start smoking after age 20, and those who do so may be less prone to addiction). There were self-help programs, based on the observation that 90 to 95 percent of all people who have stopped smoking claim they quit on their own. There were interventions conducted by physicians and dentists, who were considered a greatly underutilized resource. There were mass media interventions, which adopted many of the concepts developed in the Stanford cardiovascular risk programs. And there were interventions focused on four special populations: African-Americans, Hispanics, women, and smokeless tobacco users. At the time these trials began, the attributable risk of smoking (the rate of a disease or other outcome in exposed individuals that can be attributed to the exposure) had been fairly well established through epidemiological studies, although data were stronger for lung cancer than cardiovascular disease. There were few data, however, on the level of effect that the various types of interventions might have on smoking rates.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH In order to assess as early as possible the effectiveness of these research efforts and their readiness to be applied on a larger scale, the STCP consulted on a regular basis with the various investigators to maximize cross-fertilization. As each trial area concluded, the STCP convened the principal investigators and their key staff. These meetings resulted in a series of consensus statements based on the empirical research, which have been used to select specific prevention and cessation activities to be further explored in the second and third phases of the program. One example of the studies conducted during the first phase was school-based interventions, of which NCI funded 10 program trials. They covered both public and private schools, from elementary to high school levels. Some aimed at developing new curricula, some at revising existing curricula, and some at conducting long-term follow-up evaluations. When the investigators convened after the trials concluded, they agreed that school-based smoking prevention programs had had consistently positive effects, although the effects were modest and limited in scope. The programs have been particularly effective in delaying the onset of tobacco use, but less successful in targeting use by high-risk and minority groups (Glynn, 1989). This should perhaps come as no surprise, given the barrage of advertising and media exposure that children steadily receive. For example, a recent study concluded that by the time U.S. children are six years old, they can just as easily identify “Old Joe the Camel,” a cartoon character frequenting cigarette advertisements, as they can identify the logo for Mickey Mouse (Fischer, Schwartz, and Richards, 1991). Educational strategies to overcome such influences and boost success rates remain to be investigated, but may include earlier intervention and more frequent interventions throughout the junior high and high school years. The second phase is a $45 million effort called the Community Intervention Trial for Smoking Cessation (COMMIT). Beginning in October 1988, a number of comprehensive community-based interventions (incorporating lessons from the first-phase studies) are being tested in 11 communities in North America, against the same number of control communities. The third phase, which will incorporate findings from the first two, will be the American Stop Smoking Intervention Trial for Cancer Prevention (ASSIST). This $150 million effort is set to begin in the fall of 1993. It will introduce large-scale interventions, emphasizing coalition development and policy change, in 17 states (reaching more than 50 million people), with work being carried out by state and local health departments. NCI believes that this sharply focused and coordi-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH nated strategy is the only means by which the nation will achieve further reductions in tobacco use (Glynn, 1991). INJURIES Injuries are the leading cause of death among Americans up to 44 years of age (IOM, 1985). Because they strike younger people disproportionally —children and teenagers are common victims—injuries also are the nation's leading cause of years of potential life lost through age 65. Of the approximately 150,000 persons who die from injuries each year, roughly one third are victims of intentional violence (homicide and suicide), one third die in motor vehicle crashes, and one third are killed by falls, burns, poisoning, drowning, and other unintentional injuries (CDC, 1992b). Many more persons are injured than killed. In 1987, a total of 62 million injuries caused Americans to restrict their activities for more than 600 million person-days and spend nearly 200 million person-days in bed (Brown, Foege, Bender, and Axnick, 1990). When talking about preventing injuries, the first thing to note is that injuries are not “accidents.” Too often, injuries are described as events that “just happen,” unfortunate acts of fate beyond understanding and therefore beyond control. On the contrary, injuries are understandable, predictable, and potentially preventable. Indeed, given their importance in causing morbidity and mortality, injury prevention is increasingly becoming the focus of public health programs. Among the most notable has been the effort to improve motor vehicle safety. The National Highway Traffic Safety Administration, led by its first administrator, William Haddon, launched a major initiative in the 1960s. When the program began, there was no consensus about the relative values of various intervention options. Would, for example, seat belts save more lives than vehicle modifications or driver education? Would seat belt use cause injuries? What was clear, however, was the very strong connection between driving a motor vehicle and sustaining motor-vehicle-related injuries. The agency moved ahead with a variety of prevention programs—often in the face of considerable opposition from the automobile industry and other groups with vested economic interests. The efforts addressed the numerous factors that can play a role in causing injuries or contributing to their severity, and targeted a spectrum of audiences, including individuals, communities, businesses, regulatory agencies, and legislators. This comprehensive, well-coordinated campaign has yielded a range of safety-related advances, including increased use of seat belts; decreased drunk driving; better design and construction of

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH highways and roadside structures; increased pedestrian, motorcycle, bicycle, and commercial vehicle safety; and engineering improvements in automobiles and trucks. Promoting seat belt use, for example, was a particularly important component of the national safety program, and strategies to promote their use have included both mandatory-use state legislation and encouragement through public education campaigns. Investigators assessing these efforts have found that automobile fatalities have declined markedly as a consequence of increased seat belt use. They also have observed that enforcement of seat belt laws has proved necessary to ensure continued compliance with the laws (IOM, 1989; Campbell, 1988; Williams and Lund, 1988). Overall, prevention campaigns have led to a decline in traffic fatalities by approximately 30 percent since the mid-1960s. Moreover, given the steadily increasing numbers of vehicles traveling many more miles, it is estimated that approximately 115,000 Americans would now be losing their lives in motor vehicle crashes each year if death rates common in the 1960s had not been reduced by the various safety interventions (U.S. National Highway Traffic Safety Administration, 1991). From these years of experience, Haddon led other investigators in developing systematic ways to categorize prevention strategies that may extend well beyond injuries or highway safety. One result is called the Haddon Matrix (Haddon, 1972). This concept holds, among other things, that with any injury, there is a triad of factors at work: human factors, factors involving the vehicle and related equipment, and factors involving the physical and social environments. Each of these areas represents an opportunity to devise a prevention strategy. This challenges today's investigators not to become focused on any single option, but to think freely and fully about a range of possibilities. And it means fostering cooperation among a variety of scientific disciplines, because finding solutions to complex problems typically will require a wide range of experience and skills. To break the chain of injury causation, investigators also have learned that it is best to aim at the weakest link first—that is, target the areas on which the greatest impact can be made for the smallest expenditure. In preventing injuries, this typically means modifying products or the environments in which they are used, rather than trying to modify human behaviors. For example, designing hot water heaters that do not circulate scalding water is more effective than mounting programs to remind millions of parents to be ever vigilant in not letting their children take unsupervised baths. This focus does not deny the success of behavior modification in other fields, but it does

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH reflect an awareness that persistent behavioral changes are very hard to maintain. Although all modes of injury need further investigation, one that is especially demanding—and perplexing—is violence, now recognized as a major national public health problem. Violence is linked with mental health in several ways. First, of course, violence begets mental health problems: victims of violence often experience severe emotional and psychological disturbances. Second, achieving a better understanding of mental disorders can help inform efforts to prevent such violent acts as homicide and suicide. Intertwined in this issue as well is the frequent association of alcohol and drugs with violent or abusive behavior. Researchers have addressed the problem of violence in a number of studies. For example, there is evidence from studies conducted across societies and within societies that exposure, especially among some impressionable children and youths, to scenes of aggression and violence on television and in other media fosters our acceptance and expectation of violence in America and probably contributes to the frequency of aggressive acts themselves (Rosenberg, O'Carroll, and Powell, 1992). Studies also indicate that children who witness violence directly —an increasingly frequent situation in many urban areas—often develop symptoms associated with post-traumatic stress disorder, including diminished ability to concentrate in school, persistent sleep disturbances, disordered attachment behaviors with parents or significant caregivers, and changes in orientation toward the future that lead to increased risk-taking behaviors (Groves, Zuckerman, Marans, and Cohen, 1993). Children who witness domestic violence may be particularly vulnerable to emotional and developmental problems. Many aspects of the causes of violence and how violence can be prevented remain to be empirically tested, however, and the problem is presented here primarily to illustrate a broad-scale beginning in tackling one of the most destructive and powerful problems in society today, and one with important implications for prevention of mental disorders. The Centers for Disease Control and Prevention (CDC) is now conducting a multifaceted community-based research effort devoted to youth violence prevention (Rosenberg et al., 1992). Multifaceted programs are needed because of the complex web of factors that cause violence and violence-related injuries, and community-based programs are needed to ensure community residents' involvement in, ownership of, and responsibility for the activities. Six key strategies have been identified, representing an orderly progression of research and implementation. The strategies are (1) developing prevention materials; (2) establishing community demonstration programs; (3) rigorously evalu-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH ating specific preventive interventions; (4) training public health workers, community members, and health professionals in violence prevention; (5) continuing surveillance, risk factor research, and evaluation; and (6) strengthening the capacity of state and local health departments. The CDC investigators will first help local workers describe and define the problems of violence in their community and then select appropriate interventions. Toward these ends, specialized prevention materials are being developed, including a guidebook called Prevention of Youth Violence: A Framework for Community Action (CDC, 1993). This guidebook clearly spells out some relatively simple actions (though not all have been tested) that communities can adopt on their own to reduce violence. The next steps will be to help communities implement the interventions and then to evaluate the interventions and the overall program. One facet of violence that has proved especially intractable involves firearms, particularly handguns. Firearm mortality dominates U.S. intentional injury statistics, accounting for 61 percent of all homicides and 59 percent of suicides, with the burden falling most heavily on minority and disadvantaged populations (Prevention of Violence and Injuries Due to Violence, 1991). For years, this issue had been approached strictly as a political or philosophical matter, with the debate polarized into those who favored some form of gun control and those who were against it. Beginning in the early 1980s, the CDC set about to change the nature of the debate by studying the problem scientifically, beginning with epidemiological studies, moving to analyses of risk factors and possible causes, and then developing an array of possible interventions and looking at their effectiveness. Many of the studies are reviewed elsewhere (Taubes, 1992). For example, researchers learned that firearm attacks on family members and intimate acquaintances are at least 12 times more likely to result in death than are assaults using other weapons. When a woman is killed with a gun, the attacker is five times more likely to be her spouse, an intimate acquaintance, or a member of her family than to be a stranger. In another study, researchers compared overall rates of assaults, homicides, and suicides in two cities—Seattle and Vancouver—that were strikingly similar in all aspects but one: handguns were much easier to obtain in Seattle. The cities turned out to have similar levels of criminal activity, but homicide was 60 percent higher, and homicide by firearms was 500 percent higher, in Seattle than in Vancouver. Building on such studies, researchers are evaluating the effects of common approaches to preventing firearm injuries—including such interventions as prohibition of carrying guns in public, restrictive licensing, waiting periods for obtaining guns, and harsher sentences for crimes committed with guns.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Although conventional and innovative interventions remain to be more fully explored, some actions already have been proposed (Rosenberg et al., 1992). There is little controversy regarding children having unsupervised access to loaded guns—it is clear that controlling access to weapons can significantly limit accidental death among adolescents who may be suicidal or prone to impulsive acts. Alternatively, handguns themselves can be modified to reduce some of their lethal potential. For example, Smith & Wesson once manufactured a handgun advertised as being child-proof. Now discontinued, the gun could be fired only by depressing a special lever, which a child's hand would not be large enough or strong enough to accomplish. Such actions can begin to save countless lives as we develop and test effective and acceptable methods of reducing ready access to the most dangerous types of guns. Again, programs to break the chain of causation of injuries should be aimed at the weakest link, and modifying products and environments (for example, limiting access to guns) might yield the greatest impact. FINDINGS AND LEADS The underlying message from the prevention efforts in cardiovascular disease, smoking, and injuries reviewed here, of course, is that prevention can and does work—people have avoided injuries, reduced cardiovascular risk rates, and quit or never started smoking cigarettes. Some adults, and youth have modified their life-styles as a result of multifaceted change strategies directed at individuals, groups, organizations, and communities. And people often have adopted such changes in the face of countervailing pressures, because the health habits altered are influenced heavily by social norms, peers, and environmental and economic factors. Paying close attention to the road signs these efforts have posted will help speed the journey that we must begin—immediately and together—toward preventing mental disorders and promoting mental health. Other general lessons that, if carefully selected and applied, will contribute to success in developing mental health interventions include the following: Preventive interventions for specific disorders are typically developed through a series of phases, each step building on its predecessor and supporting its successor. The general stages are (1) recognizing and defining the problem; (2) delineating the risk factors involved; (3) conducting more detailed studies to describe the relative power of different risk factors, individually and in combination, and to describe

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH protective factors; (4) developing and testing a variety of approaches to intervention to decrease risk and increase protection; (5) conducting large-scale confirmatory studies of the most promising interventions; (6) implementing and evaluating the interventions in large-scale demonstration projects at multiple sites; and (7) transferring the knowledge gained from the intervention programs into the public domain as widely and rapidly as resources allow. Many areas of mental health are at the early stages of this development (that is, definition of risk factors), and longitudinal studies and other research efforts are only beginning to identify causal pathways. Some disorders, however, are ready (or nearly so) for various types of experimental preventive trials to begin. This report will identify where numerous disorders stand along this learning curve, which may help in planning the most appropriate next steps. Preventive interventions need not always wait for complete scientific knowledge about etiology and treatment. There is a distinction between knowing how to treat a disorder and knowing how to prevent it. Having effective treatment is not always necessary for effective prevention. For example, treatments for AIDS and fetal alcohol syndrome remain under active investigation, yet successful prevention is already possible. In addition, although there is no totally satisfactory treatment for lung cancer, smoking cessation interventions have proved effective. Similarly, the fundamental biological mechanisms at work when a risk factor is associated with an adverse outcome may or may not be completely understood before undertaking prevention, or the relative importance of the risk factors may not be fully known. Indeed, preventive intervention trials—based on sound scientific theory and carefully conducted and evaluated—may themselves help to delineate mechanisms and to quantify the relative impact of various risk factors. The Stanford group's program illustrates the value of this approach to prevention. Consider one risk factor: cholesterol. When the program began in 1970, scientists had established that there was a connection between high cholesterol levels in the body and increased risk of heart attack. They theorized that excessive dietary cholesterol might cause elevated levels in the body, which in turn might raise blood pressure, but they did not know precisely what effect reducing dietary cholesterol would have on cholesterol levels in the body, or what effect dietary change would ultimately have on rates of morbidity and mortality. Their solution was to target a constellation of related risk factors and employ a variety of intervention methods, and then determine the combined effect on health status. The immediate goal was achieved: promoting

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH behavioral changes decreased risk of disease. The long-term goal of decreasing overall mortality requires further assessment. Over the years, researchers have delineated many of the mechanisms and relative risks involved—but had the Stanford group waited for fuller understanding of how and to what degree risk factors had an effect, their prevention insights might have been delayed by a decade or more. In addition, in classic epidemiological terms, the amount of morbidity and mortality from vehicular injuries that could be affected by Haddon 's proposed changes was certainly not known at the time intervention policies were adopted. But to wait until those studies had been done would not have been nearly as useful as what he did, which was to advocate and implement changes and to study carefully their effects —another example of the use of a prevention strategy both as an intervention and as an investigative tool. Preventive interventions should be based on well-established theoretical frameworks. A scientific theoretical orientation to the causation and mechanisms of a disorder is helpful in identifying “targets of opportunity” where intervention may best take place, and a developmental theoretical orientation helps in deciding when throughout an individual 's development to direct intensive intervention. Established theories also should guide how interventions are conducted. For example, many programs have used the principles of social learning theory. This model of self-directed behavior change assumes that people are able to regulate their own behavior and to participate actively in the learning and application of behavior change skills. The components of self-directed change include problem identification, goal setting, training in self-monitoring, and active training in the skills needed both to make changes and to avoid relapses. A cornerstone of the theory is that active practice of a new skill is more likely to achieve lasting change than is written or verbal persuasion or watching other people acting as models of a new behavior (Farquhar, Fortmann, Flora, and Maccoby, 1991). Social marketing principles then can help bridge the gap between theories and action. Among other things, social marketing calls for developing messages, products, or services from the perspective of the consumer, which allows the campaign designer to tailor messages to specific audiences. Preventive interventions typically are most effective when they consider multiple domains of intervention. This means using numerous communication channels to reach a variety of people repeatedly with a range of educational materials. The idea is that individuals are more likely to adopt new behavior if encouraged to do so in many ways and from many directions.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH The Stanford program, for example, incorporates a wide range of communication channels—from electronic and print mass media to face-to-face personal counseling and mediated group sessions, from billboards and grocery store displays to the latest technologies of interactive personal computer systems and laser discs. Moreover, the components reinforce each other wherever possible; radio spots promote a contest that includes printed educational materials that in turn promote another radio program. This saturation can develop into what might be called environmental synergy, in which the sum of the messages becomes greater than their parts. Preventive interventions should focus on the community, both in planning and in implementation. Foremost, community involvement opens many doors for reaching people with educational materials. With local cooperation, materials can be routed through schools, work sites, recreation centers, churches, stores, and voluntary organizations. Community members also can be recruited as facilitators; for example, health care professionals can distribute materials and advice during patient visits. In general, as people come to feel that a program is “theirs,” they are more likely to participate and to retain beneficial new behaviors. Special attention may need to be given to critical subpopulations within a community. For example, in recognition of the disproportionate burden of violence that minority groups frequently bear, the Centers for Disease Control and Prevention has sought extensive input in developing its youth violence intervention guidelines from community minority leaders and others who already have implemented innovative prevention programs in urban centers. Also, as mentioned earlier, the Stanford program developed special programs for Spanish-speaking community members. Developing community strength also may prove crucial for the long-term vitality of prevention efforts. The Stanford group, for example, believes that adoption of prevention programs by existing community organizations—including schools, hospitals, health agencies, and citizens groups—is generally necessary to supply ongoing reinforcement and reminders and to provide new knowledge and skills as they become needed (Farquhar, Fortmann, Flora, Taylor, Haskell, Williams et al., 1990). The form this process of “institutionalization” takes may vary considerably, but one possible model is to develop a council or consortium of local agencies that deal with health education and prevention programs. This not only will ensure an adequate base of expertise, but also may cut territorial wrangling and maximize interagency cooperation. Preventive intervention programs should be rigorously designed, and the programs and their components evaluated extensively. This

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH should occur as the program is being developed (formative evaluation), while it is being conducted (process evaluation), and after it has been completed (summative evaluation). In the Stanford programs, for example, investigators first analyzed the needs of the targeted audience to discover the interests, educational status, media use, and other characteristics of different subsections of the community, which helped determine the proper location and time for educational activities. They also developed prototypes of educational materials and programs and tested them among sample audiences to determine the appropriate content and method of delivery. When the prevention campaign was under way, investigators carefully monitored the introduction of educational materials into the community to assess what was working and what needed to be revised. This process evaluation identified some of the factors that influenced participation in various aspects of the program, dictated how much was learned, and determined whether an event or program actually affected behavior. During and after the intervention, investigators collected data on a number of health outcomes. They also evaluated specific risk reduction strategies (e.g., smoking cessation, dietary counseling) to determine their effects on individual knowledge, attitudes, and behavior. For example, the effects of a quit-smoking contest with 500 participants were evaluated through several measures: a mail survey of contest finishers, a telephone survey of selected nonrespondents, a carbon monoxide assessment of contestants who quit, and a one-year follow-up examination of those who tested positive for carbon monoxide—an indicator for smoking (King, Flora, Fortmann, and Taylor, 1987). Data from this study allowed investigators to see both the successes and the shortcomings of the contest. The findings showed that the quit rate for contestants was twice as high as the rate in the general population in the control communities, and the cost of the program—including its evaluation—was lower than that of traditional antismoking classes or groups. Program planners concluded that the contest could be strengthened by extending the program to add a relapse prevention element and by the use of incentives to maintain abstinence. Prevention efforts must increasingly recognize the many areas of overlap between physical health and mental health. To cite just one example, the causes and consequences of violence are not only physical but psychological. Traumatic brain injuries, frequently caused by gun shots or automobile and motorcycle crashes, induce severe mental disturbances in thousands of persons each year. Even victims of violence who recover from their physical injuries frequently bear long-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH lasting psychological scars. Indeed, entire communities can be destabilized by continuing outbreaks or threats of violence, reducing the quality of life and perhaps helping to perpetuate the cycle of violence. The integration of physical and mental aspects of health care in prevention will require a broad interdisciplinary approach. Prevention efforts require a significant and sustained commitment on the part of the federal, state, and local governments and coordination across disciplines and agencies. The prevention programs in physical health are complex and multifaceted, reflecting the nature of the health problems they are designed to address. Similarly, mental health interventions typically will be complex and multifaceted. There are likely to be multiple points in the causal chain where preventive interventions could be applied, which will require us to consider a wide range of prevention strategies. Outcomes will need to be assessed not only in the short term but also in the long term. Furthermore, as is true in the physical sciences, multidisciplinary approaches drawing on expertise from numerous scientific domains—ranging from the physical and mental health fields to the social sciences, education, political science, and communications—will prove most fruitful. It is therefore imperative that prevention efforts for mental disorders be carefully and systematically coordinated by the federal, state, and local governments across the gamut of agencies that will be involved. As the history of prevention programs in smoking and highway safety vividly illustrates, coordination within the government is crucial to success. While the federal government has a critical role in setting priorities and providing support for prevention services and research, state and local governments have important public health responsibilities, not only to set and enforce relevant laws and regulations, but also to generate their own hypothesis-driven prevention programs whose outcomes can be fully assessed. An equally great challenge will be to muster the national political will—and corresponding financial support—required to move expeditiously ahead. Such an investment was necessary in order to move forward in cardiovascular disease, smoking, and injury prevention. The cost of prevention programs, based on the experience of some of the physical health care models, will not be small (Farquhar et al., 1990), and benefit-cost analyses are imperative as the prevention field moves ahead. However, the cost of not beginning to design and implement mental health intervention programs may be even greater. Given the successes in prevention of physical illness, the energies of citizens and communities can surely be harnessed to prevent mental disorders.

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