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 - Understanding Prevention


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For Sonia Gonzales, 38, the depression came first. "I was five years old, and it was horrible," Ms. Gonzales says. "I was always crying for no reason. And I was in an abusive situation. I was not able to have feelings or to go out and play. I was always being hit, and once I was almost drowned in a bathtub."

Eventually her stepmother left and the abuse stopped, but Ms. Gonzales had to grow up quickly to take care of her father, who was quadriplegic. By the time she started drinking at 18, she had both depression and post traumatic stress disorder (PTSD). Then came drugs, domestic abuse and, at 35, a crisis. "I tried suicide and ended up in a hospital," Ms. Gonzalez says. "One day it clicked with me that I was an alcoholic. I asked my case manager to be in a co-occurring program."

While in treatment, Ms. Gonzales relapsed. At age 36, her recovery began. "What made it work was the different groups they had-anger management, Twelve Step study, and WRAP," she says. WRAP is the Wellness Recovery Action Plan for people with mental illnesses, later adapted to include those with co-occurring disorders.

Life is more manageable now for Ms. Gonzales. She works as a VISTA volunteer at the Pima Prevention Partnership PWRD (People with Recovery and Disabilities) in Tucson, Arizona. Medication helps relieve her depression. She confronts the PTSD. "Before I used to hide with alcohol or drugs," Ms. Gonzalez says.


Understanding Prevention


Prevention Is Necessary

Preventing people from becoming sick is more humane and less expensive than treating them when they become ill. This is the public health approach to disease prevention and health promotion and is critical for people who have co-occurring substance abuse disorders and mental disorders. As noted elsewhere in this report, co-occurring disorders are prevalent, costly in both economic and human terms, and result in unnecessary disability, family dysfunction and often inappropriate involvement in the criminal justice system. Young people and people over the age of 65 are at special risk of co-occurring disorders. Prevention is very different from treatment in that there are no clinics, credentialing of practitioners, third party payers and so forth. Typically, prevention programs use existing service systems for the implementation of research based prevention program components.

Defining Prevention

In 1998, the National Institute of Mental Health Ad Hoc Committee on Prevention Research offered a broad definition of prevention activities:

Prevention refers not only to interventions that occur before the initial onset of a disorder, but also to interventions that prevent co-morbidity, relapse, disability, and the consequences of severe mental illness for families (NIMH, 1998).

This definition acknowledges that prevention strategies may be effective not only in keeping a substance abuse disorder from occurring, but also in delaying onset of a substance abuse disorder or mental disorder, reducing the severity of one or both disorders, or preventing relapse in a person who has experienced one or both disorders. The programs described in this chapter as well as the full range of SAMHSA's substance abuse disorders and mental disorders prevention activities reflect this more inclusive definition. Thus, consistent with the 1988 IOM Report, disease prevention and health promotion are two key components of the public health approach to healthcare in this country (IOM, 1988). Prevention is an essential part of a continuum that includes treatment and rehabilitation. Prevention efforts may occur at any point along this continuum.

Research studies reveal that to be effective, prevention programs must be comprehensive, family-focused, and include appropriate cultural, developmental and gender perspectives. In addition, they need to focus on risk and protective factors that are both identifiable and modifiable (SAMHSA, 2002c; Davis, 2002; CSAP, 2000; Greenberg, 1999; Olds, 1999; CMHS School Violence Prevention Program, 1999; U.S. NIDA, 1997a; GAO, 1995; Mrazek and Haggerty, 1994).


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