As Originally Published by Journal of Preventive Psychiatry and Allied Discipline, 1990.
By: Dr. Gilbert Kliman
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Preventive psychiatry is a branch of preventive or public health medicine. It aims to promote good mental health in individuals and to prevent the occurrence or reduce the incidence of psychiatric disease in a population. As in other public health endeavors, the practice of preventive psychiatry requires collaboration with allied disciplines - including political, sociological, psychological, educational, psychotherapeutic, biochemical, pharmacologic, nursing, and others.
Primary preventive psychiatry is defIned as the work of keeping healthy people healthy, from a psychiatric point of view. Primary preventive services range in content from experiential to organic.
Many approaches to primary prevention of mental illness are developing simultaneously: biologic, psychoanalytic, behavioral, cognitive, family, cultural, sociologic, political, and systems. All of these approaches may from time to time be represented in this Journal.
Primary prevention of mental and emotional disorders may occur through a variety of organic means. An approach of great importance is reduction of exposure to environmental toxins, such as lead, preventing childhood encephalopathies and associated mental retardation. Sophisticated methods of prenatal enzymatic and chromosomal study can now be applied to prospective parents, living fetuses, and mother-fetus dyads in order to anticipate, avoid, and sometimes treat biological disorders associated with psychiatric disease. Dietary measures to prevent nutritional encephalopathies are of long-standing public health significance. Similarly, the prevention of congenital syphilis (or AIDS - Ed., 1990) spares countless children from organic psychoses. Genetic counseling regarding risk of transmission of manic-depressive illness, or risk of schizophrenia, is another biologically based primary preventive psychiatric measure.
In the experiential realm, educational and socially supportive services for prospective parents may serve as primary preventive psychiatric measures, sometimes with quantifiable outcomes such as reduced incidence of abusive behavior.
Primary preventive psychiatric service occurs, for example, when wellfunctioning families with presumably mentally healthy but congenitally deformed infants are immediately fortified in dealing with their newborns. Such help may be provided by timely opinions of medical experts concerning the anatomical problems, combined with guidance and support regarding injuries to parental narcissistic functions (see Money, this issue, for a report on families whose infants have congenital anatomic gender ambiguity due to micropenis, JPP I: 1).
Primary preventive psychiatry is practiced whenever mentally healthy persons exposed to special mental health risks are given fortification against those risks. Facilitation of mourning is a widely used measure for persons suffering the hazard of death of a spouse or parent. The technology used in facilitation of mourning may come from varied disciplines. It may comprise educational transmission of knowledge about developmental differences in mourning capacity, or consist of psychoanalytic methods of interpretation. When the latter are used, the target may be an individual's defenses against grief and related affective discharge, with the preventive aim being to reduce lifelong pathologic structuralization of those defenses. Family therapy techniques may increase mutual helpfulness and healthy interactions among surviving members. Network therapy may widen and deepen the immediate mutual assistance of the extended family and community.
See Schaeffer, Kliman et a1. (JP PI: 1) regarding application of situational crisis intervention, including facilitation of mourning, to a population of children entering foster family care. As in that model, future public health inspired preventive intervention will probably give increasing attention to operationally detectable outcomes which are more than clinical. Epidemiologic impacts will be considered, but along with social systems effects and possibly within a context of ecologic cost and cost-effectiveness.
Secondary Preventive Psychiatry is defined as the work of early detection and prompt treatment of psychiatric disorders. From a public health medicine point of view, the goal is to reduce the incidence of a disease (or diseases) in a population by intervening before the disease has become fmnly established and before it becomes difficult to eradicate or treat. Prevention of chronicity is a goal of secondary preventive psychiatry, and cure - where possible - is a goal. Secondary preventive efforts thus differ sharply in aim from primary preventive efforts, because disease is already present.
Secondary preventive psychiatric methods are extremely variable, ranging from numerous forms of supportive and educational interventions for parent-infant dyads with pathologic interaction to network approaches for elderly persons who are being pathologically extruded from their family homes, to chemotherapy for prevention of recurrent manic episodes.
Early periodic screening measures are being widely applied to children, especially those who are receiving forms of public assistance, and in many public school systems. While intended to detect a wide variety of disorders, there has been a heavy emphasis on cognitive vulnerability. Even when the screening is primarily regarding cognitive vulnerability, if interdisciplinary prescriptions and interventions are provided, controlled studies show a reduction of behavioral pathology in the children served. (See Samuels and Silver, JPP I: 1).
Therapeutic nurseries for disturbed preschoolers, and many varieties of early childhood psychotherapy and chemotherapy, also may be of great value as secondary preventive measures, However, the utility of early childhood detection and treatment as prevention of adult psychiatric disorders has been little studied. Follow-ups of secondary preventive methods tend to be short term, as well as unsystematic. Mental health prediction is generally undeveloped. An example of very long-term, successful prediction, with its primary and secondary preventive implications for a disturbed mother-child dyad, is Fries' work (lPP 1:2).
Tertiary Preventive Psychiatry is not the subject of this Journal. It involves treatment of persons with late and irreversible stages of psychiatric disorders. It is rehabilitative rather than truly preventive. Since the term is self-contradictory, its use should be avoided.
Dr. Gilbert Kliman, won the International Literary Prize for Best Book concerning the Well Being and Nurture of Children, "Responsible Parenthood" and is the recipient of grants from over 50 private foundations and The National Institute of Mental Health. His research interests include the Psychological Trauma and Treatment of Severely Disturbed Children and their families, in-classroom psychotherapy.
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