Prevention models

Transcript

SoheeA school district has money for one mental health program. Option one: a curriculum for every seventh grader. Option two: a group for kids whose parents have a mental illness. Option three: extra help for kids who already show early signs of depression.

RyanSame budget, three very different bets. And the exam wants you to name each one. Welcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Today is prevention. The blueprint says Domain 6 covers theories and models of treatment, intervention, and prevention. So prevention models sit right beside therapy models on this exam.

RyanThere are two classification systems you need, and the trick is not mixing them up. Let's start with the older one.

SoheeA narrative review in Frontiers in Psychiatry by Singh and colleagues traces it back. The original preventive model, proposed by the Commission on Chronic Illness in 1957, included primary, secondary, and tertiary prevention.

RyanPrimary prevention acts before the disease occurs. The review says it includes health promotion and specific protection.

SoheeSecondary prevention includes early diagnosis and treatment. And tertiary prevention includes measures to decrease disability, and rehabilitation.

RyanSo the anchor is the course of the illness. Primary: before onset. Secondary: catch it early. Tertiary: reduce the damage once it's established.

SoheeGive me a mental health example of tertiary prevention.

RyanThe National Institute of Mental Health, NIMH, says people with schizophrenia who take part in regular psychosocial treatment are less likely to have symptoms recur or to be hospitalized. The illness is already present, and the work reduces relapse and disability. That fits the tertiary logic.

SoheeThe same review points out a weakness. This classification is highly centered on the cause of the illness, and doesn't consider how underlying cause and risk factors interact.

RyanWhich brings us to the second system. Gordon proposed a model based on the degree of risk a person is at, with the intensity of intervention set accordingly. Universal, selective, and indicated.

SoheeA universal strategy targets the whole population, whatever an individual's risk. Selective prevention targets people at higher risk than the general population. The review's examples include migrants and disaster victims.

RyanAnd indicated prevention, in that review's wording, aims at people with established risk factors who are at high risk of getting the disease.

SoheeAnother review, by Irwin Sandler and colleagues in the Annual Review of Clinical Psychology, states the definitions using the National Research Council and Institute of Medicine. The full population is universal. Individuals at elevated risk are selective. And individuals with elevated levels of the problem are indicated.

RyanNotice the two reviews word indicated a little differently. Singh's examples for indicated include things like family history. Sandler's definition, from the National Research Council and Institute of Medicine, is people with elevated levels of the problem itself. Under that definition, a risk factor without the problem points to selective, and early signs of the problem point to indicated.

SoheePause and think. Back to our school district, using the National Research Council and Institute of Medicine definitions. Curriculum for every seventh grader. Group for kids whose parents have a mental illness. Help for kids already showing early signs of depression. Label them.

RyanEvery seventh grader is universal. The group for children of parents with mental illness is selective, because the risk is the parent's illness, not the child's symptoms. And kids already showing early signs is indicated. Under Singh's wording, which lists family history under indicated, you could argue the second group is indicated too. That's why you check which definition a question is using.

SoheeAnd here's the trap. Someone might call the third one secondary prevention, and in the older system, early detection is secondary. But if the answer choices are universal, selective, and indicated, it's indicated. Read which system the question is using.

RyanSo which bet works best? Sandler's review reports that meta-analyses for preventing depression, anxiety, aggression, and alcohol use found selective or indicated programs had larger effects than universal programs.

SoheeBut the very next sentence warns: these findings should not be over-interpreted to mean universal programs aren't effective. Several meta-analyses found universal programs, though smaller in effect, had significant effects.

RyanAnd then a public health argument. A universal program with a smaller effect might have a larger impact on public health, because it reaches a larger share of the population.

SoheeSandler's review adds two cautions worth knowing. One analysis of depression prevention found larger effects for programs with homework, programs delivered by professionals, and shorter programs, among other moderators.

RyanAnd the comparison group matters. Merry and colleagues found depression prevention programs had a significant effect against no-intervention controls, but not against placebo controls. So when you read that a program works, ask: compared with what?

SoheeSo the district's choice isn't obvious. The targeted programs show bigger effects per person, and the universal one reaches everyone. That's exactly the kind of reasoning an exam item might ask you to weigh.

RyanNow a third framework, from the Centers for Disease Control and Prevention, CDC. The social-ecological model. CDC uses a four-level version to understand violence and the effect of prevention strategies.

SoheeThe four levels are individual, relationship, community, and societal. And the model shows how factors at one level influence factors at another.

RyanIndividual level: biological and personal history factors, like age, education, income, substance use, or history of abuse. Prevention here includes things like conflict resolution and life skills training, and social-emotional learning.

SoheeRelationship level: peers, partners, and family members. Strategies include parenting and family-focused programs, and mentoring and peer programs.

RyanCommunity level: settings such as schools, workplaces, and neighborhoods. Strategies improve the physical and social environment in those settings.

SoheeAnd societal level: broad factors like social and cultural norms, and the health, economic, educational, and social policies that maintain inequalities. Strategies include promoting protective norms and strengthening household financial security.

RyanThe key idea, in CDC's words: preventing violence requires simultaneous action across multiple levels. CDC says this approach is more likely to sustain prevention efforts over time and achieve impact on the population as a whole.

SoheeLet's make it concrete with programs CDC names. For preventing adverse childhood experiences, CDC lists Early Head Start, which serves families from pregnancy through a child's third birthday.

RyanSafeCare, which focuses on positive caregiver-child relationships, home safety, and child health. And The Incredible Years, evidence-based early intervention programs for parents, teachers, and others who work with children up to age twelve.

SoheeCDC also says that when we prevent adverse childhood experiences, we also prevent potential later involvement in violence, substance use, depression, and suicidal behavior.

RyanSuicide prevention gives us more examples. CDC describes Question, Persuade, Refer, or QPR, an hour-long training to reduce stigma and increase knowledge of risk factors, warning signs, and resources.

SoheeAnd two universal school-based programs. Youth Aware of Mental Health, for teenagers thirteen to seventeen, using discussion and role-play. And Signs of Suicide, which teaches middle and high school students to recognize signs of depression and suicide risk and seek help, and also includes screening.

RyanCDC also mentions training gatekeepers, in schools and businesses, to notice warning signs and safely refer. And treatment that puts space and time between a person in crisis and lethal means.

SoheePause and think. A district offers Signs of Suicide to every middle and high school student, and a separate parenting program for families. Is the school program universal, selective, or indicated? And at which social-ecological level does CDC place parenting programs?

RyanCDC itself calls Signs of Suicide a universal school-based program. It's offered to all students, not chosen by risk. And CDC lists parenting and family-focused programs at the relationship level, the level of peers, partners, and family members. Not the community level, which is about settings like schools and neighborhoods.

SoheeOne last reminder about substance use. SAMHSA says prevention activities educate and support individuals and communities to prevent the use and misuse of drugs and the development of substance use disorders.

RyanAnd the Singh review makes a point that ties this episode to health promotion: promotion and prevention complement each other rather than being mutually exclusive.

SoheeRecap. Primary, secondary, tertiary: from the Commission on Chronic Illness in 1957. Before onset, early diagnosis and treatment, and reducing disability and rehabilitation.

RyanUniversal, selective, indicated: Gordon's risk-based model. Whole population, people at elevated risk, and, in the National Research Council and Institute of Medicine wording, people already showing elevated levels of the problem.

SoheeTargeted programs have shown larger effects in meta-analyses, but universal programs can still work and may reach more people. And always check what a program was compared against, because a placebo control is a tougher test than no intervention at all.

RyanCDC's social-ecological model: individual, relationship, community, societal. Prevention works best with action at several levels at once.

SoheeHere's a thought to carry with you. Preparing for this exam is its own prevention plan. Small, steady habits, support around you, and catching a weak area early, before it costs you points. You're already doing that.

RyanThanks for listening to EPPP Prep.

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