ABSTRACT | PDF

EDITORIAL
“Providing Mental Health Care to All”
Shyamanta Das
The theme of the 63rd Annual National Conference of the Indian Psychiatric Society (ANCIPS 2011) was “Providing Mental Health Care to All.”
Every family has one or more family members who have been touched with mental, emotional, and behavioural disorders (MEBs) including alcohol, tobacco, and other drug use during a given year, based on prevalence estimates.[1-3] Every business has one or more employees who are directly or indirectly affected by MEBs, which have multiple documented adverse impacts on health, costs, and productivity.[4-6] Schools, health care carriers, and communities are struggling with the costly burdens of these disorders via special education and behavioural difficulties.[7-14] Some of these disorders are rising in prevalence.[15-17]
Treatment by professionals is perceived as stigmatising, and many of the most vulnerable groups do not seek “treatment” because of such perceived stigma.[18] While expanding mental health professionals might be helpful in treatment issues, it is a “downstream” rather than “upstream” model.[19] A public health “upstream” model is a logical alternative.[19]
The first scientific public health approach to prevention was by John Snow, who removed the Broad Street water pump handle.[19] He stopped the deadly cholera epidemic in London.[19] His analysis and identification of water-borne disease from a single pump is an action metaphor for our own contemporary multiple, related epidemics (ie, syndemics)[20-23] of MEBs that cause so many afflictions and consequences.[19]
A public health approach to the prevention of MEBs would look much different than the existing “rationing” approaches.[19] Preventive strategies can be delivered as a matter of course or choice, rather than limiting access by families, schools, or neighbourhoods based on a “rationing model” of prevention in which only those who have positive “screening” at an individual, family, school, or neighbourhood level receive prevention services.[19] A behavioural vaccine is a repeated simple behaviour that reduces morbidity or mortality and increases wellbeing.[24-26] Like medical vaccines, behavioural vaccines can provide “herd immunity” as protection against behavioural contagion–a phenomenon well documented in behavioural and epidemiological science.[27-36]
A public health approach predicates that the risk of the problem or disease is widely distributed, and that vulnerability is common because of national, regional, or even basic human vulnerabilities.[19] MEBs pass that test, given that 20% to 25% of the population[4] experiences one or more in any given year.[37,38] Although some individuals or groups may have higher levels of vulnerability because of genetics, social conditions, or history, the overall risk of the problem or disorder is widely distributed; this means that attempts to isolate or identify the individuals or groups at risk are inefficient and prone to error.[19] When a successful public health approach has been taken, the individuals or groups who need more intensive support are easier to identify than when access is rationed.[39,40]
As mentioned earlier, a public health approach can confer “herd immunity” for the population.[41-44] When policies or practices focus only or mostly on presumed persons or groups at risk, such individuals or groups decline to participate because of perceived stigmatisation.[45] Population-level or public health approaches are often more cost effective in terms of preventive results than costly processes of identifying those at risk, recruiting participation of persons at risk, and dealing with the adverse effects of stigma.[19]
No parent, concerned family members, or concerned community person can easily purchase or obtain any evidence-based prevention strategy for MEBs.[19] It is even difficult for any normal citizen (parent, teacher, or community person) to obtain the scientific journal articles about such prevention tools that would enable citizens to “roll their own” prevention strategies successfully.[19]
Ironically, alcohol, tobacco, and illegal drugs are accessible to students on virtually every school campus.[19] Prescription drugs that are widely abused are, too frequently, promoted on TV channels, in print, on the Internet, in movies, and on the radio.[19] Your doctor gets free samples delivered to his or her office every week, by pharmaceutical sales staff.[19] Paradoxically, things that are scientifically documented to increase the prevalence rates of MEBs are easy to get.[19] Devices or entertainment that increase sleep deprivation and worsen multiple MEBs[46-48] are a mouse-click away.[19] Child-targeted foods that cause deficiency in essential brain nutrients involved in with MEB rates are advertised on children’s TV.[49-51]
Reducing exposure to adverse childhood experiences is one of the key pathways of preventing lifetime MEBs as well as high health care costs.[52-5] Triple P (a multilevel parenting support system)[56,57] is the first parenting system to demonstrate longitudinal, population-level effects for parents and children on MEBs.[19] Project Sixteen is an example of a multimodal community intervention trial aimed at preventing youth tobacco use by random assignment.[58] PeaceBuilders was one of the first evidence-based strategies with both theoretical roots and demonstrable effects.[59]
Consumer-friendly prevention “products” tend to produce easily noticed proximal benefits or “early wins” in the organisational change literature.[19] MEBs are not abstractions or “just levels” to families, teachers, or even the young people affected by those disorders.[19] A developer must pay attention to producing measurable benefit to the consumer, rather than obfuscating weak strategies by blaming the consumer for denial, resistance, laziness, or other attributions.[19]
The aetiology and epidemiology of MEBs challenges the notion that prevention, intervention, and treatment require complex evidence-based programmes.[19] Evidence-based kernels are fundamental units of behavioural influence.[60] Every kernel must have peer-reviewed, published experimental studies demonstrating effects.[19] An evidence-based kernel is an indivisible procedure empirically shown to produce reliable effects on behaviour, including psychological processes.[25] Examples of kernels include timeout, written praise notes, self-monitoring, framing relations among stimuli to affect the value of a given stimulus, and increasing omega-3 fatty acids in the diet in order to influence behaviour.[60] Behavioural vaccines are a repeated use of kernel or a simple recipe of kernels that prevent or reduce morbidity or mortality or improve wellbeing.[19] Hand washing or buckling a seatbelt are clear health examples of behvaioural vaccines.[19]
The 4 types of evidence-based kernels are reinforcement, relational, physiological, and antecedent.[19] Multiple kernels can be used for indicated, selected, and universal prevention.[19] Many can be used in homes, schools, organisations, clinical practice, and even the mass media for varying levels of intensity.[19] Kernels and related behavioural vaccines have potential impact across every human developmental stage.[19] For kernels or kernels recipes (or policy or programme, for that matter) to have population-level effects on public health or public safety (eg, whole communities, counties, states, or provinces), it is necessary for the RE-AIM formula to be applied.[61,62] RE-AIM stands for Reach, Efficacy, Adoption, Implementation, and Maintenance.[19]
By any calculation imaginable, the costs associated with risky human behaviours from childhood to adulthood are the deepest well of private and public expenditures.[63] This well of despair includes violence, addictions, mental illnesses, obesity, many cancers, cardiovascular diseases, unintentional injuries, and more.[19]
Children who manifest one of the MEB “silos”, attention-deficit/hyperactivity disorder (ADHD)[19] have high probability of school failure or learning disabilities[64,65]; intentional and unintentional injuries[66,67]; conduct disorders, crime and delinquency[68]; alcohol, tobacco, and drug addictions[69]; development of other serious mental illnesses such as bipolar disorder or other mental illnesses[70]; increased cancer risk[71]; sudden cardiac death[72]; work-related problems[73]; and difficult social relationships in marriage and child-rearing as adults.[19] The behavioural footprints of ADHD help explain its fiscal footprints.[19] 
There are now multiple behavioural vaccines and evidence-based kernels that prevent, reduce the symptoms, or avert the sequelae of ADHD,[60,74-80] at a far lower cost and risk of adverse medical consequences.[19] Those behaviour vaccines or kernels, all together, do not rise to the cost of 1 or 2 months of therapy on any of the psychotropic drugs being used with ADHD-diagnosed children or youth.[19]           
The expansion of behavioural vaccines could include special calls for Small Business Innovation Research awards (SBIR) initiatives as well as special private sector incentives or state/local initiatives.[19] Cost-efficient kernels or behavioural vaccines in the IOM Report[63] like Triple P, the Good Behaviour Game, or supplementation of omega-3 deficiency can clearly prevent or reduce costly problems such as ADHD,[75,79] oppositional defiance,[75,79] conduct disorder,[75,81] or psychotic disorders.[82,83] It is useful to note that no prescription psychotropics have been scientifically documented to prevent MEBs in children or adolescents.[19] However, several evidence-based kernels or behavioural vaccines have been scientifically proven in peer-reviewed, high-quality journals to prevent costly MEBs.[39,76,77,79,82,84,85] These kernels or behavioural vaccines need to be on parity with prescription medications for the same disorders, because there is compelling emerging evidence that such kernels or behavioural vaccines are often substantially more cost effective.[19] Further, they are more correlated to positive outcomes with fewer measured adverse medical events (eg, sudden cardiac death, psychosis, suicidality, metabolic disorders, abuse of prescription drugs by others or self).[40,75,77,84,86-8]
When communities mobilise around clear, simple evidence-based prevention strategies for many or all, there is consistent evidence that rapid change in major outcomes can happen.[19] Media campaigns must urge people to join in common clear actions, rather than promote stigma, blame, fear, or mere “awareness.”[19] “Social marketing” principles for prevention have been outlined in successful behaviour-change studies.[25,89] Businesses routinely develop profit-and-loss estimates and break-even analyses for new products that have not even been sold.[19] It is also quite possible and realistic to develop similar estimators for proven and tested prevention strategies to guide policy and practice.[19]  
Academic and scientific journals are now filled with evidence-based prevention trials, almost all of them efficacy trials of individuals or schools.[19] An efficacy trial, however, is deliberately designed to insulate both the strategy and subjects (persons or settings) from the vicissitudes of real-world conditions (policies, programme staffing, resources, management issues, and so forth) that might affect the main factors being tested.[19] That said, stunning results in exquisite efficacy trials do not guarantee similar or desired results in other effectiveness trials, which has been demonstrated in a variety of controlled prevention studies.[90.91] Efficacy trials of prevention protocols may show proximal changes on knowledge, attitudes, and some behaviours, yet not show any impact on “big-ticket” outcomes sought by policy makers when put in a large-scale effectiveness trial.[92]
Early randomised trials with simple pre- and post-test data alone will seriously underestimate natural and structural sources of variability associated with effectiveness.[19] The experimental design masks important externalities and contingencies.[19] Failure in the “real world” is then almost certain.[19] Studies using repeated measures (eg, hourly, daily, weekly, or monthly) is reversible or multiple baseline experimental designs, however, do allow identification of naturally occurring contingencies and externalities.[19]
Policy and practice for the prevention on MEBs (which includes addictions) must include a public health approach to reach all children, families, and communities.[63] The response to unique individual, family, school, neighbourhood, or community risk factors will be most cost efficient, if the “pump handle of John Snow” for the contaminated well that serves all is removed first.[19]
In this spirit, wise call is to move from a “treatment-oriented” approach to prevention to a true public health approach, wherein prevention is available for every child, family, school, or community to prevent MEBs, including addictions.[63] Evidence-based kernels and behavioural vaccines offer a unique opportunity for the prevention of MEBs to happen at a public health level.[19] The fact that kernels can be used for universal, selected, and indicated prevention represents considerable cost efficiencies.[19]
The time to act is now.[63] The true wealth of a nation derives from the health of all the minds, bodies, spirits, and behaviours of its children and youth.[19] Let us act for all our futures.[19]   
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Author is Assistant Professor of Psychiatry at Fakhruddin Ali Ahmed Medical College Hospital, Barpeta.

 

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