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Position Statement 48: Prevention of Mental Health and Substance Use Disorders in Young People

Policy

The evidence regarding the benefits of systematic prevention and promotion programs is strong, and Mental Health America believes that the promotion of mental health and the prevention of mental health and substance use conditions should be central to the nation's public health agenda[1,2].  Evidence based programs have been developed that will have positive effects not only on an individual's health but also on multiple social health issues in educational achievement (since mentally healthy children can take fuller advantage of learning opportunities) and the economy (since mentally healthy adults can be more effective in their job performance), among other social goods. Investing in the mental health promotion and prevention of mental and substance use conditions in youth will have long term positive effects for individuals, communities, and the nation as a whole[3,4.]

Background

Mental health and substance use conditions affect large numbers of young people. According to the Institute of Medicine ("IOM"), almost one in five young people have one or more such conditions at any given time. A 2007 review of the epidemiological literature indicates that mental illnesses are a developmental disorder, with fifty percent of lifetime diagnoses occurring in the mid-teens and with a U.S. median age of onset of 14[5]. Although symptoms occur during the two years prior to meeting diagnostic criteria, treatment lags diagnosis by an average of 10 years[6.] Mental health conditions have life-long effects that include high psychosocial and economic costs, not only for the young people, but also for their families, schools, and communities. Beyond the financial costs, mental health and substance use conditions interfere with young people's ability to accomplish developmental tasks, such as establishing healthy interpersonal relationships, succeeding in school, and making their way in the workforce.

In 2009, the IOM released its seminal report: "Preventing Mental, Emotional and Behavioral Disorders among Young People."[7] According to the IOM, clear windows of opportunity are available to prevent mental health and substance use conditions from developing into serious disorders before they occur. Risk factors are well established, preventive interventions have been rigorously tested and are available, and the first symptoms typically precede a disorder by 2 to 4 years. Because mental health and general health problems are interwoven, improvements in mental health will also improve overall health. Yet the approach has largely been to wait to act until a disorder is well-established and has already done considerable harm. All too often, opportunities are missed to use evidence-based approaches to prevent the occurrence of disorders, establish building blocks for healthy development in young people, and limit the environmental expo¬sures that increase risk.

Interventions that prevent disorders before they manifest offer the best opportunity to protect young people. "Mental health promotion" was defined broadly by the IOM, consistent with international bodies like the World Health Organization, to include: "efforts to enhance individuals' ability to achieve developmentally appropriate tasks (developmental competence) and a positive sense of self-esteem, mastery, well-being, and social inclusion and to strengthen their ability to cope with adversity."[8] Such interventions can be integrated with routine health care and wellness promotion in schools, families, and communities. School-wide Positive Behavior Support is a particularly promising approach to mental health promotion in schools. (See MHA Position Statement 45, "Discipline and Positive Behavior Support in Schools"). Thus, wellness promotion, in addition to interventions that reduce the rate of problematic behaviors and those that reduce environmental risk, has become a new focus: changing "from thinking that youth problems are merely the principal barriers to youth development to thinking that youth development serves as the most effective strategy for the prevention of youth problems."[9]

Screening for risk in the family and for precursors of a disorder in young people is also essential. (See MHA Position Statement 41: Early Identification and Treatment, which addresses this issue.) According to the IOM, a range of policies and practices that follow up on mental health promotion and "universal" prevention interventions by targeting young people with specific risk factors ("selective" or "indicated" interventions) have proven to be effective at reducing and preventing mental health and substance use disorders. But this position statement focuses on promotion and "universal" prevention, rather than on risk factor identification, screening and follow-up treatment, which are the critical next steps in the prevention agenda.

A recent study by the National Research Council and the IOM reviewed the research on the prevention of mental disorders and substance abuse among young people and recommended multiple strategies for enhancing the psychological and emotional well-being of young people. Research demonstrates the value of:

  • Strengthening families by teaching effective parenting skills; improving communication; and helping families deal with potential problems (such as substance use), disruptions (such as divorce) and adversities (such as parental mental illness or poverty).
  • Strengthening individuals by building resilience and skills and improving cognitive processes and behaviors.
  • Promoting mental health in schools by offering support to children encountering serious stresses; modifying the school environment to promote socially adaptive behavior; developing students' skills at decision making, self-awareness, and conducting relationships; and coping with potential violence, aggressive behavior, and substance use.
  • Promoting mental health through health care and community programs by promoting and supporting socially adaptive behavior, teaching coping skills, and targeting modifiable life-style factors that can affect behavior and emotional health, such as sleep, diet, activity and physical fitness, sunshine and light, and television and computer use.

The key to most of these approaches is to identify biological, psychological, and social factors that may increase risk. Some of these risks reside in specific characteristics of the individual or family environment (such as parental mental illness or substance abuse or serious family disruptions), but they also include social stresses such as poverty, violence, lack of safe schools, and lack of access to health care. Most risk factors tend to come in clusters and are associated with more than one disorder. Currently, treatment interventions tend to isolate single interventions focused on specific family adversities (bereavement, divorce, parental psychopathology, parental substance use, parental incarceration), but there is growing evidence that well-designed prevention interventions reduce a range of problems and disorders and that these efforts need to be sustained over the long term. These programs can help children, families, and schools build strengths that support well-being. A focus on prevention and wellness can have multiple benefits that extend beyond a single disorder.

Call to Action

Officials at the local, state, and federal levels all play a role in mental health promotion and the prevention of mental health and substance use disorders. Many providers and agencies are responsible for the care, protection, or support of young people: the child welfare, education, and juvenile justice systems, as well as medical, mental health, and substance abuse providers and community organizations. Yet resources within these agencies are scattered, not coordinated, and often do not effectively support prevention programs or policies. No public system is formally charged with the responsibility of carrying out the critically important work of promoting health by fostering resilience and promoting well-being. The result is a patchwork that does not perform as an integrated system and fails to serve the needs of many young people and their families.

Leadership is necessary to make systematic prevention efforts a high priority in the health care system as well as an integral aspect of the network of local, state, and federal programs and systems that serve young people and families. Leaders at the national, state, and local levels need to pursue specific strategies, such as partnerships among families, schools, courts, health care providers, and local programs to create coordinated approaches that support healthy development, as described in the IOM report and in this position statement.

Policy Implications

Broad Strategies. National leadership is necessary to make systematic prevention efforts a high priority in the health care system as well as an integral aspect of the network of local, state, and federal programs and systems that serve young people and families. Leaders at the national, state, and local levels should pursue specific strategies, such as:

  • A national initiative to develop an inter-departmental strategy that identifies specific prevention goals, directs multiple federal agency resources toward these goals, and provides guidance to state and local partners.
  • Development of state and local systems involving partnerships among families, schools, courts, health care providers, and local programs to create coordinated approaches that support healthy development.
  • Investment in prevention and promotion, including setting aside resources for evidence-based prevention in mental health service programs (such as the federal mental health block grant program) and investment in proven prevention approaches by school systems.
  • Workforce training, including development of prevention training standards and training programs across disciplines including health, education, and social work.
  • Long-term tracking of the prevalence and frequency of mental health and substance use disorders.
  • Continued research on both the efficacy of new prevention models and real-world effectiveness of proven prevention and wellness promotion interventions.
  • Adaptation of research-based programs to cultural, linguistic, and socioeconomic subgroups.
  • Public education, with mass media and the internet offering the opportunity to greatly expand the reach of specific messages about risk factors and available resources, to reduce stigma, and to deliver some kinds of interventions.
  • Early childhood safety net, including policies to help ensure families' financial security, provide safe neighborhoods and schools, improve access to health care and other services, and provide enriched early childhood environments.
  • Tools to equip young people who are at risk with the skills and habits they need to live healthy, happy, and productive lives are available. What is lacking are the will, social policies, and collaborative strategies to adequately fund prevention programs that support the healthy development of the nation's young people.

Affordable Care Act and Medicaid Strategies. While advocating for this broad prevention agenda, it is essential that we secure access to funding for prevention. Private insurance will cover more screening and prevention services under the new Patient Protection and Affordable Care Act federal health care reform law, and MHA will be vigilant in monitoring its implementation as the Affordable Care Act essential benefit package is developed. But in the meantime, Medicaid is the key. Affiliates and mental health advocates should consider strategies to incorporate community-based prevention efforts into each state's Medicaid program. This will require waivers and creative interpretations of the cost-neutrality requirement for Medicaid waivers. Among the strategies that should be considered are:

  • Develop state-based coalitions to design waiver proposals and approach the state Medicaid authority to seek a Section 1115 waiver of medical necessity and other criteria to permit group-based interventions.
  • Design cost-benefit research to assess cost savings for preventive services within both Medicaid and other government programs.
  • Petition the Center for Medicare and Medicaid Services to consider long-term Medicaid and other government savings that result from the funding of evidence-based preventive services.

Effective Period

The Mental Health America Board of Directors adopted this policy on March 5, 2011. It is reviewed as required by the Mental Health America Public Policy Committee

Expiration: December 31, 2016

 

  1. Source: Institute of Medicine Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults, 2009.
  2. As applied to young people, the term "mental health or substance use conditions" as used in this policy statement is intended to mean the same thing as the federal term "emotional or behavioral disturbance."
  3. Brown H. & Strugeon S. , "Healthy Start of Life and Reducing Early Risks. In: Hosman, C., Jané-Llopis, E., & Saxena S., Eds. Prevention of Mental Disorders: an Overview on Evidence-based Strategies and Programs. Oxford, Oxford University Press (2002).
  4. World Health Organization Prevention of Mental Disorders, Effective Interventions and Policy Options. (2004). http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf
  5. Kessler, R.C., Amminger, G.P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustün, T.B.,
    "Age of Onset of Mental Disorders: a Review of Recent Literature." (2007) Curr. Opin. Psychiatry 20(4):359-64.
    http://www.ncbi.nlm.nih.gov/pubmed/17551351
  6. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E. E., "Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication." (2005)
    Arch. Gen. Psychiatry 62:593-602. http://www.ncbi.nlm.nih.gov/pubmed/15939837
  7. Released on March 12, 2009. http://www.iom.edu/Reports/2009/Preventing-Mental-Emotional-and-Behavior... Mental Health America acknowledges the IOM for the basic outline of this position statement.
  8. Id., p. 67
  9. (Washington, DC: Center for Youth Development and Policy Research, Academy for Educational Development 1991), at 3 (emphasis supplied). A New Vision: Promoting Youth Development.Pittman, K.J. and Fleming, W.E.,

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