In the Name of Prevention: Commentaries on "Priorities for Prevention Research at NIMH"

Correspondence concerning this article should be addressed to Richard H. Price, Department of Psychology and Institute for Social Research, University of Michigan, 3016 E Hall, Ann Arbor, Michigan 48109.
E-mail: ricprice@umich.edu

Great achievements in science policy are a happy combination of enlightened scientific vision and political opportunity. Political support is the engine driving policy acceptance. Scientific vision is the rudder guiding its course. Each is a necessary but not sufficient condition for great scientific achievement and societal benefit. When science policy fails in its aims, it is often for the lack of either scientific insight or political will. All policy statements issued in the hope of influencing scientific inquiry are, of course, mixed cases, and each case must be evaluated on its own merits. This special issue of Prevention & Treatment examines such a case—the report of the National Advisory Mental Health Council (NAMHC) Workgroup on Mental Disorders Prevention Research (2001), "Priorities for Prevention Research at NIMH."

This is the fourth major report on prevention research in mental health issued by a scientific body in the last decade. In 1993, a steering committee appointed by the National Institute of Mental Health (NIMH; e.g., Reiss et al., 1993) issued "Prevention of Mental Disorders: A National Research Agenda." This was followed in 1994 by an Institute of Medicine report, "Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research" (Mrazek & Haggerty, 1994). A third report, "A Plan for Prevention Research at NIMH," was published in 1996. Four reports on prevention research in the space of a decade should signal vital new activity in the field. In fact, these reports reflect a continuing debate on the most appropriate direction for prevention research sponsored by the NIMH.

In this edition of Prevention & Treatment, the debate continues. The full text of the NIMH report is presented first in this issue and is followed by invited commentaries from a variety of knowledgeable scientists and mental health advocates. We have invited experts in a wide range of fields, including mental health epidemiology, community-based preventive intervention, developmental psychopathology, psychiatry, and mental health economics. We have also invited commentaries from national political advocacy organizations concerned with policies aimed at promoting mental health and serving the mentally ill. Each author has commented thoughtfully on the "Priorities for Prevention Research at NIMH" report, identifying clear strengths as well as shortcomings and missed opportunities.

Bridging Prevention and Treatment

The NIMH report is followed by "Opportunities in Prevention Research at NIMH: Integrating Prevention With Treatment Research," an article by NIMH scientists Pearson and Koretz (2001). This article might be regarded as a companion piece to the NIMH report. In their article, Pearson and Koretz identify opportunities for integration across prevention and treatment research. Their formulation suggests that there are multiple bridges between the worlds of prevention and treatment, including the use of epidemiology-based designs for trials and multilevel interventions. Pearson and Koretz identify various target populations for prevention and suggest ways that prevention and treatment efforts might be sequenced in time. Finally, the authors identify multiple information sources that can help scientists strengthen the bridge between prevention and treatment. The Pearson and Koretz article is not merely a supplement to the original report; it is a clear improvement on it.

Commentaries From Researchers

The commentaries from mental health researchers in this issue of Prevention & Treatment offer a wide range of assessments, drawing out the implications of the report and asking about its value in charting new scientific directions. Reiss (2001) goes to the heart of the matter by noting the difference between the present NIMH report and earlier reports. Research advocated in this report encompasses nearly the entire spectrum of mental health interventions under the rubric "prevention," including acute care, maintenance treatment, relapse prevention, disability prevention, and comorbidity prevention. In other words, Reiss argues, the NAMHC workgroup has redefined prevention to cover so much territory that prevention loses its distinctive meaning. Reiss concludes that the proposals in the report for new directions in research do not justify the broad redefinition. For example, genuine opportunities for understanding the interplay of biological and social factors in the development of psychopathology and the ways in which preventive trials could shed light on that interplay are not explicated in the report.

From an epidemiological perspective, prevention implies the reduction of the onset of new cases of disorder. The NAMHC workgroup's definition of prevention, however, focuses on what Catalano (2001) calls "old favorites." Catalano, an epidemiologist and mental health economist, suggests that the NIMH report may serve as a justification for continuing the management of persons with already existing mental disorders. These are worthy goals but not preventive ones. He notes, for example, that the redefinition of prevention offered in the report encompasses, in a single stroke, nearly all the NIMH portfolio in services research.

A number of the commentaries emphasize the dangers of a narrow or exclusive focus on mental disorders as outcomes in designing and conducting prevention research. Reiss (2001) observes that current classification systems are inadequate in defining nosological boundaries and that the current interest in comorbidity may reflect the fact that underlying disorders do not match currently prescribed diagnostic boundaries. Shinn and Toohey (2001) argue that ignoring health, criminal justice, developmental outcomes, and educational outcomes in prevention research in mental health will omit preventive outcomes that have a critical impact on the costs of dysfunction and economic benefits of prevention.

In his commentary, Heller (2001) observes that the mental health treatment system has had difficulties in reaching populations in need of treatment services. Populations with genuine mental health problems are, for a variety of reasons, unwilling or unable to gain access to mental health treatment. This does not qualify the current treatment system as an ideal base for launching population-based preventive efforts. Broadening the definition of prevention to include already expressed clinical disorders carries with it the corollary assumption that treatment facilities have the capacity to reach and engage vulnerable populations in the community in preventive trials and services. Heller is skeptical and offers persuasive examples of community-based prevention intervention research as an alternative.

In his review, Nathan (2001) notes the need for more interdisciplinary work within NIMH that recognizes the complex interplay of mental disorder, drug and alcohol abuse, health outcomes, and social functioning. He suggests advantages of combining the work, and even the agencies, of the National Institute on Drug Abuse (NIDA), the National Institute of Alcohol Abuse and Alcoholism (NIAAA), and NIMH, where coordination benefits could accrue if they were merged. All of these commentaries speak to the risk of lost scientific opportunities for prevention research in narrowing attention to current diagnostic approaches to mental disorder. A related note is sounded by Seligman (2001), who observes that little attention has been paid to the importance of protective factors in prevention research. Seligman argues that the current NIMH report does little to remedy this.

Greenberg and Weissberg (2001) assert that the scientific opportunities for understanding the promotion of competence are substantially neglected in the NIMH report. Coping skills and protective factors are likely to be key mediators linking environmental challenge to disorders, and learning the mental health consequences of promoting competence should be an essential ingredient of the prevention agenda for mental health. Greenberg and Weissberg also spell out an agenda for prevention services research, which they describe as the next frontier in the field of prevention. They point to critical processes of implementation and institutionalization that must be realized if community groups and organizations are to bring hard-won scientific knowledge to life for the benefit of vulnerable populations.

Muñoz (2001) makes a compelling argument to retain a focus on the prevention of the onset of disorders, rather than diffusing scientific efforts across the whole spectrum of mental health interventions as recommended by the NIMH report. He also makes a case for the primacy of preventive intervention in the NIMH prevention agenda. Muñoz notes that perinatal depression in mothers—for example, where fetal brain development is at risk—can galvanize creative interdisciplinary work among neuroscientists, epidemiologists, and preventive intervention researchers. Muñoz argues that collaborative prevention research designed to identify connections between maternal stresses, biochemical pathways, and neural development can highlight critical points for preventive intervention. The lesson is clear. Well designed preventive trials can then serve as tests of hypotheses about cross-generational etiological pathways and also provide early prototypes for preventive services.

Commentaries From Mental Health Advocates

The perspectives of advocates in evaluating new expressions of science policy are an indispensable ingredient in gauging its likely reception and lasting impact. We include commentaries on the NIMH report from two well-known national advocacy organizations. Wood and Wainscott (2001) comment on behalf of the National Mental Health Association (NMHA), and Cowdry (2001) comments from the perspective of the National Alliance for the Mentally Ill (NAMI).

Both commentaries find some strengths in the report. The NMHA, with a long and distinguished record of supporting the goal of prevention in the field of mental health, praises the report’s call for a more integrated approach to prevention research spanning services and policy research, and in particular, encourages more effort in the area of prevention services research. Wood and Wainscott (2001) urge the NIMH to implement the recommendations outlined in the report to encourage collaboration with communities in bridging the gap between prevention research and practice.

Cowdry (2001; at NAMI) argues that the NIMH should continue to focus on severe and persistent mental illness, which has long been the top priority of NAMI. He remains skeptical about the degree to which the report will shape the NIMH portfolio and believes that only changes in basic science will make a difference in the long-term direction of the field of prevention. Cowdry is wary of the breadth of the recommendations in the NIMH report and places his faith in waiting for basic scientific breakthroughs that he believes will make prevention a viable field of research and practice in mental health.

Continuing the Debate

Historians of science have argued that scientific fields go through long periods of "normal science," when a single conceptual paradigm dominates the field of inquiry (Kuhn, 1962). The dominant NIMH paradigm for intervention with mental health problems has been the idea of treatment. That is, according to the NIMH, once disorders manifest themselves, they should receive treatment, whether in mental hospitals, in psychotherapy sessions, or through the administration of pharmacological agents.

Public health has long benefited from an alternative paradigm more congenial to prevention research and practice (Kaplan, 2000). It is a perspective that is as attentive to whole populations and the identification of pathways to disease and disorder. The public health perspective also recognizes the utility of multiple intervention strategies to reduce risk, including educational and policy interventions. The public health paradigm has been notably successful as a framework for reducing the incidence of new cases of infectious disease, and there is reason to believe that it can be successful with more complex, multiple vector disorders such as depression. Some mental health researchers are considering the public health paradigm to expand the agenda for treatment research (Norquist, Lebowitz, & Hyman, 1999), but treatment, rather than prevention, remains the dominant paradigm.

Of course, prevailing paradigms are held not just by scientists but also by the public and political advocates. Thus, dominant paradigms such as the treatment paradigm in mental health research powerfully influence the discourse of science policy, and the present NIMH report is no exception. The debate about the viability of the treatment paradigm to serve the mental health needs of all citizens, and serve them well, will intensify as more compelling examples of successful preventive intervention accumulate. The present NIMH report on "Priorities for Prevention Research at NIMH" and the commentaries in this issue of Prevention & Treatment suggest that the debate is far from over.

References

Catalano, R. (2001). Bold advocacy for a timid agenda. Prevention & Treatment, 4, Article 20. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040020c.html.

Cowdry, R. (2001). An advocate for individuals with severe and persistent mental illness looks at prevention research. Prevention & Treatment, 4, Article 28. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040028c.html.

Greenberg, M. T., & Weissberg, R. (2001). Commentary on "Priorities for Prevention Research at NIMH." Prevention & Treatment, 4, Article 25. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040025c.html.

Heller, K. (2001). Prevention research priorities: Forward movement and backward steps in the NAMHC workgroup recommendations. Prevention & Treatment, 4, Article 22. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040022c.html.

Muñoz, R. F. (2001). How shall we ensure that the prevention of onset of mental disorders becomes a national priority? Prevention & Treatment, 4, Article 26. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040026c.html.

Nathan, P. E. (2001). A modest proposal. Prevention & Treatment, 4, Article 23. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040023c.html.

National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research. (2001). Priorities for prevention research at NIMH. Prevention & Treatment, 4, Article 17. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040017a.html. (Reprint of Publication No. 98-4321, 1998, Bethesda, MD: National Institutes of Health)

Norquist, G., Lebowitz, B., & Hyman, S. (1999). Expanding the frontier of treatment research. Prevention & Treatment, 2, Article 1. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0020001a.html.

Pearson, J. L., & Koretz, D. S. (2001). Opportunities in prevention research at NIMH: Integrating prevention with treatment research. Prevention & Treatment, 4, Article 18. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040018.html.

Reiss, D. (2001). "Priorities for prevention research at NIMH:" Will expanding the definition of prevention research reduce its impact? Prevention & Treatment, 4, Article 19. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040019c.html.

Seligman M. E. P. (2001). Comment on "Priorities for Prevention Research at NIMH." Prevention & Treatment, 4, Article 24. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040024c.html.

Shinn, M. B., & Toohey, S. M. (2001). Refocusing on primary prevention. Prevention & Treatment, 4, Article 21. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040021c.html.

Wood, J., & Wainscott, C. (2001). "Priorities for prevention research at NIMH": The mental health advocates’ perspective. Prevention & Treatment, 4, Article 27. Available on the World Wide Web: http://journals.apa.org/prevention/volume4/pre0040027c.html.