SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 3 - Prevention of Co-Occurring Disorders - Prevention Can Be Cost-Effective


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Prevention Can Be Cost-Effective

SAMHSA commissioned two studies on the provision and costs of prevention strategies for mental health and substance abuse services under managed care. The first (Dorfman, 2000) recommends six prevention programs for consideration by managed care organizations, and the second (Broskowski and Smith, 2001) estimates the costs of providing these services. Two of these interventions and their associated costs are particularly relevant to this discussion - prenatal and infancy home visits for high-risk mothers and targeted cessation education and counseling for smokers, especially those who are pregnant.

Prenatal and infancy home visits are recognized as an effective intervention for children at risk of mental disorders (Olds, 1999). SAMHSA's review of these programs under managed care found that the average per member per month costs ranged from $0.58 to $1.49, with a median of $1.03 (Broskowski and Smith, 2001). Though the costs of these programs were low, the results were significant, according to Dorfman (2000):

Significant findings included fewer subsequent pregnancies and live births, greater spacing between births, less alcohol and drug impairment, and less child abuse and neglect among mothers receiving home visits; greater weight and better scores on motor development tests among infants whose mothers received intervention; and reduced incidence of mental retardation among infants whose mothers received interventions.

Women who smoke during pregnancy are at higher risk for delivering low-birthweight babies (Slotkin, 1998; U.S. DHHS, 1990), and low birthweight has been identified as a risk factor for problem behaviors in children. Broskowski and Smith (2001) found that offering targeted smoking cessation education and counseling to pregnant women under managed care entails little in the way of initial start-up or operating costs, nor does it require any specialized staff training. Estimated savings, realized primarily through the prevention of low-birthweight babies and perinatal deaths, ranged from $3.31 to more than $17 for every dollar spent.

Classifying Prevention Strategies

Research has disclosed that most illnesses tend to result from the complex interrelationship among biological, psychological and social factors. For this reason, the IOM adopted a classification for disease prevention activities based on the relationship between the risk of an individual getting the disease compared to the costs of the intervention to prevent the disease. When describing prevention programs, people often talk about primary, secondary and tertiary prevention. Primary prevention attempts to decrease the number of new cases of a disorder. Secondary prevention is directed at prevalence and seeks to lower the rate of established cases of a disorder. Tertiary prevention seeks to decrease the amount of disability associated with a disorder (SAMHSA, 2000). The following classification of prevention interventions is adapted widely (see Figure 3.1), for both the mental health and substance abuse fields.

Universal interventions are offered to an entire population. Examples include prenatal care, smoking prevention and childhood immunization, or screening of all primary care patients for depression nationwide (Davis, 2002).

Selective interventions are targeted to groups at greater than average risk of illness than the rest of the population such as pregnant mothers with an increased incidence of drinking alcohol during pregnancy. The moderate costs are justified by the increased risk of illness. Examples include home visitation to pregnant adolescents and infant day care for low-birthweight children.

Indicated interventions are provided to high-risk individuals, their families, and to people experiencing early symptoms of a disorder. Generally, these interventions are more expensive than either universal or selective interventions and are designed either to prevent future development of a health problem or to reduce the duration or severity of an existing health problem. Examples include providing social skills or parent-child interaction training for children who exhibit signs of mental disorders and their families (SAMHSA, 2000) or children who have already started experimenting with drugs, but not at a clinically diagnosable level.

Figure 3.1 - The mental health intervention spectrum for mental disorders (Mrazek and Haggerty, 1994)

Understanding Risk and Protective Factors

Prevention research focuses on two interrelated concepts-risk and protection:

Risk factors increase the vulnerability of an individual, a group, or a community's vulnerability to substance abuse disorders or untreated conduct disorders can develop into costly adult mental health and societal problems such as delinquency, substance abuse and antisocial personality disorder.

Protective factors build resiliency in the same individual, group, or community and increase the likelihood that substance abuse and its related effects can be resisted (CSAP, 2001) or by providing youth with information about identifying the warning signs of violent behavior and how to get help if they recognize these signs in themselves or their peers (CMHS, 1999a).

Prevention programs are designed specifically to promote the reduction of risk factors and processes, and to enhance protective factors and processes (Hawkins and Catalano, 1992). Both risk and protective factors operate in multiple life domains. These include individual, family, school, peer, and community, as well as workplace and society. Further, risk and protective factors vary with the age and developmental stage of the individual.

While risk and protective factors are correlated with the development or absence of mental health and substance abuse problems, correlation does not imply causality (Davis, 2002). In fact, no one risk factor specifically causes any one disorder and a variety of combinations of risk factors may lead to the same disorder. At the same time, many risk factors are not disorder specific and may relate to the development of a number of negative outcomes, such as mental disorders (e.g., posttraumatic stress disorder, and substance abuse). Finally, multiple risk factors predict more severe outcomes. Researchers have discovered, for example, that children with two or more family risk factors for mental illness are four to 10 times more likely to develop a psychiatric disorder than children with no risk factors or only one risk factor (in Davis, 1999, Rutter et al., 1975). Biology and heredity are among those risk factors for mental disorders; for example, children of parents with depression or schizophrenia are at greater risk for the disease, possibly due to a genetic predisposition. Similarly, "the greater the number of drug abuse risk factors, the greater the risk for drug abuse" (in Davis, 1999, Glantz and Pickens, 1992).

The Concept of Resilience

Over the past 25 years, researchers studying risk factors have identified certain individuals - termed resilient individuals - who are better able to resist destructive behaviors, even in the presence of identified risk factors. While protective factors typically are defined as influences external to a person that contribute to his or her well being, resilience is conceptualized as a set of strengths internal to the individual (Wolin and Wolin, 1993). However, resiliency is highly influenced by protective factors (CSAP, 2001; Dyer and McGuinness, 1996).

Many protective factors contribute to a resilient personality. These include easy-going temperament, above-average intelligence, positive self-esteem, outgoing personality, supportive family relationships and strong bonds to family, school and community (Davis, 2002, Weinberg et al., 1999, 1998; NIDA, 1997). Just as multiple risk factors predict more severe outcomes, multiple protective factors improve one's chances for positive outcomes (Davis, 1999). In fact, researcher Emmy Werner observes that protective buffers "appear to make a more profound impact on the life course of individuals who grow up and overcome adversity than do specific risk factors" (1996).

The Need for a Developmental Approach

As noted above, risk and protective factors change as a product of an individual's age and developmental stage. The IOM organized its own conceptual framework for health promotion and disease prevention around the course of human development throughout the lifespan. As Mrazek and Haggerty (1994) note:

Each developmental phase [of life throughout the lifespan] brings new tasks to be accomplished; each is accompanied by potential biopsychosocial risk factors as well as opportunities for growth. Just as each individual is continually changing and evolving, risk and protective factors emerge and disappear over time or, if present for a long time, may express themselves differently.

Thus, prevention programs must be matched to the appropriate developmental stage of the individuals for which they are designed. This is especially true during childhood and adolescence, years of significant physical and behavioral milestones. Evidence has suggested that to be effective, prevention interventions must focus on the chosen risk factor during the precise developmental period in which it begins to stabilize as a predictor of a child's subsequent drug abuse or mental disorders (SAMHSA, 2000).

Until recently, prevention in the field of mental health and substance abuse largely has been limited to childhood and adolescence (U.S. DHHS, 1999b). Now the value of prevention across the lifespan is becoming more widely accepted. To that end, increased investigation is warranted to explore how the concept and practices of prevention can be expanded to address the needs of adults and older adults, as well.


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