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A Brief Lecture on Risk and Prevention of Psychological Disorders by CDC, NIMH, SAMHSA

 

Introduction to Abnormal Psychology and Life

Perspectives on Abnormal Psycholog

Risk and Prevention of Psychological Disorders

Diagnosis and Assessment of Psychological Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Somatic Symptom and Dissociative Disorders

Depressive and Bipolar Disorders

Eating Disorders

Substance-Related Disorders

Personality Disorders

Sexual Dysfunctions

Schizophrenia and Other Psychotic Disorders

Developmental and Disruptive Behavior Disorders

 
 
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Diathesis-Stress Model by CDC, NIMH, and SAMHSA

The diathesis-stress model assumes that stressors can interact with an existing genetic susceptibility (predisposition or vulnerability) and trigger a psychological disorder (or a mental illness).

  • Diathesis (play noun di·ath·e·sis \dī-ˈath-ə-səs\) is the genetic predisposition for both biological and psychological symptoms.
  • Stress is the body’s reaction to internal (caused internally) and external (caused by the environment) demands. Demands or stressors can be positive or negative, predictable or unpredictable, under control or out of control and vary in severity.
  • Risk factors are characteristics at the biological, psychological (such as negative and distorted thinking), family (poverty and lack of adequate health care), community, or cultural level that precede and are associated with a higher likelihood of the occurrence of mental illness. Individual-level risk factors may include a person’s genetic predisposition to a mental illness, age, race, gender and socioeconomic status (CDC).
  • Protective factors are characteristics associated that lower the likelihood of developing mental illness. Protective factors may be seen as positive countering events and involve resilience (the ability to overcome adverse circumstances).

Some risk and protective factors are fixed: they don’t change over time. Other risk and protective factors are considered variable and can change over time. Variable risk factors include income level, peer group, adverse childhood experiences (ACEs), and employment status.

Prevention

According to the Merriam Webster dictionary, “prevention is the act of preventing or hindering.” Center for Disease Control (CDC) lists three categories of preventative activities:

  1. Primary prevention refers to activities that occur before there are any signs of a disorder. an example is educating parents about healthy attachment and parenting skills. Universal prevention is similar and it is used in large groups of people. An example is an advertising campaign to prevent child abuse.
  2. Secondary prevention refers to activities that aim to identify and stop the symptoms before they become full-blown challenges. An example is Depression Screening Day in October. Selective prevention is similar to secondary prevention. However, the activities target individuals who have been identified with the risk factor to develop a particular disorder.  An example is screening family members of an individual diagnosed with an addictive disorder.
  3. Tertiary prevention refers to activities that focus to manage or reduce the symptoms after an illness has been diagnosed, and prevent relapse and further complications. It also aims to help and educate the family members on how to deal with the disorder.
Risk and Protective Factors Exist in Multiple Contexts

All people have biological and psychological characteristics that make them vulnerable to, or resilient in the face of, potential behavioral health issues. Because people have relationships within their communities and larger society, each person’s biological and psychological characteristics exist in multiple contexts. A variety of risk and protective factors operate within each of these contexts. These factors also influence one another.

Targeting only one context when addressing a person’s risk or protective factors is unlikely to be successful, because people don’t exist in isolation. For example:

  • In relationships, risk factors include parents who use drugs and alcohol or who suffer from mental illness, child abuse and maltreatment, and inadequate supervision. In this context, parental involvement is an example of a protective factor.
  • In communities, risk factors include neighborhood poverty and violence. Here, protective factors could include the availability of faith-based resources and after-school activities.
  • In society, risk factors can include norms and laws favorable to substance use, as well as racism and a lack of economic opportunity. Protective factors in this context would include hate crime laws or policies limiting the availability of alcohol.
Risk and Protective Factors Are Correlated and Cumulative

Risk factors tend to be positively correlated with one another and negatively correlated to protective factors. In other words, people with some risk factors have a greater chance of experiencing even more risk factors, and they are less likely to have protective factors.

Risk and protective factors also tend to have a cumulative effect on the development—or reduced development—of behavioral health issues. Young people with multiple risk factors have a greater likelihood of developing a condition that impacts their physical or mental health; young people with multiple protective factors are at a reduced risk.

These correlations underscore the importance of:

  • Early intervention
  • Interventions that target multiple, not single, factors
Individual Factors Can Be Associated With Multiple Outcomes

Though preventive interventions are often designed to produce a single outcome, both risk and protective factors can be associated with multiple outcomes. For example, negative life events are associated with substance use as well as anxiety, depression, and other behavioral health issues. Prevention efforts targeting a set of risk or protective factors have the potential to produce positive effects in multiple areas.

Risk and Protective Factors Are Influential Over Time

Risk and protective factors can have influence throughout a person’s entire lifespan. For example, risk factors such as poverty and family dysfunction can contribute to the development of mental and/or substance use disorders later in life. Risk and protective factors within one particular context—such as the family—may also influence or be influenced by factors in another context. Effective parenting has been shown to mediate the effects of multiple risk factors, including poverty, divorce, parental bereavement, and parental mental illness.

Etiology refers to the study of causes of a disorder.

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What is Epidemiology?

According to Central Disease Control (CDC), "epidemiology is the method used to find the causes of health outcomes and diseases in populations. In epidemiology, the patient is the community and individuals are viewed collectively. By definition, epidemiology is the study (scientific, systematic, and data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (neighborhood, school, city, state, country, global). It is also the application of this study to the control of health problems (Source: Principles of Epidemiology, 3rd Edition).

Basic Statistics: About Incidence, Prevalence, Morbidity, and Mortality

What is incidence?

Incidence is a measure of disease that allows us to determine a person's probability of being diagnosed with a disease during a given period of time. Therefore, incidence is the number of newly diagnosed cases of a disease. An incidence rate is the number of new cases of a disease divided by the number of persons at risk for the disease. If, over the course of one year, five women are diagnosed with breast cancer, out of a total female study population of 200 (who do not have breast cancer at the beginning of the study period), then we would say the incidence of breast cancer in this population was 0.025. (or 2,500 per 100,000 women-years of study)

What is prevalence?

Prevalence is a measure of disease that allows us to determine a person's likelihood of having a disease. Therefore, the number of prevalent cases is the total number of cases of disease existing in a population. A prevalence rate is the total number of cases of a disease existing in a population divided by the total population. So, if a measurement of cancer is taken in a population of 40,000 people and 1,200 were recently diagnosed with cancer and 3,500 are living with cancer, then the prevalence of cancer is 0.118. (or 11,750 per 100,000 persons)

What is morbidity?

Morbidity is another term for illness. A person can have several co-morbidities simultaneously. So, morbidities can range from Alzheimer's disease to cancer to traumatic brain injury. Morbidities are NOT deaths. Prevalence is a measure often used to determine the level of morbidity in a population.

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Universal, Selective, and Indicated Prevention Interventions

Not all people or populations are at the same risk of developing behavioral health problems. Prevention interventions are most effective when they are matched to their target population’s level of risk. Prevention interventions fall into three broad categories:

  • Universal preventive interventions take the broadest approach and are designed to reach entire groups or populations. Universal prevention interventions might target schools, whole communities, or workplaces.
An example would be universal preventive interventions for substance abuse, which include substance abuse education using school-based curricula for all children within a school district (by Texas Health and Human Services).
  • Selective interventions target biological, psychological, or social risk factors that are more prominent among high-risk groups than among the wider population. Examples include prevention education for immigrant families with young children or peer support groups for adults with a family history of substance use disorders.
Examples of selective prevention programs for substance abuse include special groups for children of substance abusing parents or families who live in high crime or impoverished neighborhoods and mentoring programs aimed at children with school performance or behavioral problems (by Texas Health and Human Services).
  • Indicated preventive interventions target individuals who show signs of being at risk for a substance use disorder. These types of interventions include referral to support services for young adults who violate drug policies or screening and consultation for families of older adults admitted to hospitals with potential alcohol-related injuries.
In the field of substance abuse, an example of an indicated prevention intervention would be a substance abuse program for high school students who are experiencing a number of problem behaviors, including truancy, failing academic grades, suicidal ideation, and early signs of substance abuse. Several of the DSHS youth indicated programs use the evidence-based curriculum “Reconnecting Youth,” which is designed for high school students and is TEA approved for credit (by Texas Health and Human Services).
Publications and Resources
Risk & Protective Factors

As youth grow and reach their developmental competencies, there are contextual variables that promote or hinder the process. These are frequently referred to as protective and risk factors.

The presence or absence and various combinations of protective and risk factors contribute to the mental health of youth. Identifying protective and risk factors in youth may guide the prevention and intervention strategies to pursue with them. Protective and risk factors may also influence the course mental health disorders might take if present.

A protective factor can be defined as “a characteristic at the biological, psychological, family, or community (including peers and culture) level that is associated with a lower likelihood of problem outcomes or that reduces the negative impact of a risk factor on problem outcomes.”1 Conversely, a risk factor can be defined as “a characteristic at the biological, psychological, family, community, or cultural level that precedes and is associated with a higher likelihood of problem outcomes.”2 The table below provides examples of protective and risk factors by five domains: youth, family, peer, community, and society.

Risk and Protective Factors for Mental, Emotional, and Behavioral Disorders in Adolescences

Table of Contents for Colors

Risk Factors

Domains

Protective Factors

  • Female gender
  • Early puberty
  • Difficult temperament: inflexibility, low positive mood, withdrawal, poor concentration
  • Low self-esteem, perceived incompetence, negative explanatory and inferential style
  • Anxiety
  • Low-level depressive symptoms and dysthymia
  • Insecure attachment
  • Poor social skills: communication and problem-solving skills
  • Extreme need for approval and social support
  • Low self-esteem
  • Shyness
  • Emotional problems in childhood
  • Conduct disorder
  • Favorable attitudes toward drugs
  • Rebelliousness
  • Early substance use
  • Antisocial behavior
  • Head injury
  • Marijuana use
  • Childhood exposure to lead or mercury (neurotoxins)

Individual

  • Positive physical development
  • Academic achievement/intellectual development
  • High self-esteem
  • Emotional self-regulation
  • Good coping skills and problem-solving skills
  • Engagement and connections in two or more of the following contexts: school, with peers, in athletics, employment, religion, culture
  • Parental depression
  • Parent-child conflict
  • Poor parenting
  • Negative family environment (may include substance abuse in parents)
  • Child abuse/maltreatment
  • Single-parent family (for girls only)
  • Divorce
  • Marital conflict
  • Family conflict
  • Parent with anxiety
  • Parental/marital conflict
  • Family conflict (interactions between parents and children and among children)
  • Parental drug/alcohol use
  • Parental unemployment
  • Substance use among parents
  • Lack of adult supervision
  • Poor attachment with parents
  • Family dysfunction
  • Family member with schizophrenia
  • Poor parental supervision
  • Parental depression
  • Sexual abuse

Family

  • Family provides structure, limits, rules, monitoring, and predictability
  • Supportive relationships with family members
  • Clear expectations for behavior and values
  • Peer rejection
  • Stressful events
  • Poor academic achievement
  • Poverty
  • Community-level stressful or traumatic events
  • School-level stressful or traumatic events
  • Community violence
  • School violence
  • Poverty
  • Traumatic event
  • School failure
  • Low commitment to school
  • Not college bound
  • Aggression toward peers
  • Associating with drug-using peers
  • Societal/community norms favor alcohol and drug use
  • Urban setting
  • Poverty
  • Associating with deviant peers
  • Loss of close relationship or friends

School, Neighborhood, and Community

  • Presence of mentors and support for development of skills and interests
  • Opportunities for engagement within school and community
  • Positive norms
  • Clear expectations for behavior
  • Physical and psychological safety

Adapted from O’Connell, M. E., Boat, T., & Warner, K. E.. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: The National Academies Press; and U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (2009). Risk and protective factors for mental, emotional, and behavioral disorders across the life cycle. Retrieved from http://dhss.alaska.gov/dbh/Documents/Prevention/programs/spfsig/pdfs/IOM_Matrix_8%205x11_FINAL.pdf

Resources

Mental Health: A Report of the Surgeon General
This Report of the Surgeon General on Mental Health is the product of a collaboration between two federal agencies, the Substance Abuse and Mental Health Services Administration and the National Institutes of Health. The report provides an overview of mental health as well as a section targeted at children’s mental health. One of the key sections focuses on the risk and protective factors related to mental health in children.

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Serious Mental Illness (SMI) Among U.S. Adults

  • While mental disorders are common in the United States, their burden of illness is particularly concentrated among those who experience disability due to serious mental illness (SMI).
  • The data presented here are from the National Survey on Drug Use and Health  (NSDUH), which defines SMI as:
    • A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders);
    • Diagnosable currently or within the past year;
    • Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); and,
    • Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
  • In 2014, there were an estimated 9.8 million adults aged 18 or older in the United States with SMI. This number represented 4.2% of all U.S. adults.
Prevalence of serious mental illness among U.S. adults by sex, age, and race in 2014

Any Mental Illness (AMI) Among U.S. Adults

  • Mental illnesses are common in the United States.
  • The data presented here are from the National Survey on Drug Use and Health  (NSDUH), which defines any mental illness (AMI) as:
    • A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders);
    • Diagnosable currently or within the past year; and,
    • Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
  • AMI can range in impact from no or mild impairment to significantly disabling impairment, such as in individuals with serious mental illness (SMI), defined as individuals with a mental disorder with serious functional impairment which substantially interferes with or limits one or more major life activities.
  • As noted, these estimates of AMI do not include substance use disorders, such as drug- or alcohol-related disorders. For statistics and other information about drug- and alcohol-related disorders, please visit the statistics pages of the National Institute on Drug Abuse  (NIDA), the National Institute on Alcohol Abuse and Alcoholism  (NIAAA), and the Substance Abuse and Mental Health Services Administration  (SAMHSA).
  • In 2014, there were an estimated 43.6 million adults aged 18 or older in the United States with AMI in the past year. This number represented 18.1% of all U.S. adults.
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Any Disorder Among Children

Mental disorders are common among children in the United States, and can be particularly difficult for the children themselves and their caregivers. While mental disorders are widespread, the main burden of illness is concentrated among those suffering from a seriously debilitating mental illness. Just over 20 percent (or 1 in 5) children, either currently or at some point during their life, have had a seriously debilitating mental disorder.

Any Disorder in Children. Lifetime Prevalence of 13-18 year olds. Demographics (for lifetime prevalence)

The Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES)  includes prevalence data for children ages 8 to 15; a slightly younger age range than the data from the NCS-A chart above. These data show that approximately 13 percent of children ages 8 to 15 had a diagnosable mental disorder within the previous year. The most common disorder among this age group is attention-deficit/hyperactivity disorder (ADHD), which affects 8.5 percent of this population. This is followed by mood disorders broadly at 3.7 percent, and major depressive disorder specifically at 2.7 percent.

12-month prevalnce for children, 8 to 15 years

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Use of Mental Health Services and Treatment Among Adults

The Substance Abuse and Mental Health Services Administration (SAMHSA) examines the mental health treatment each year through the National Survey on Drug Use and Health (NSDUH)  . In 2008, 13.4 percent of adults in the United States received treatment for a mental health problem. This includes all adults who received care in inpatient or outpatient settings and/or used prescription medication for mental or emotional problems.

Use of mental health services and treatment among adults.  Mental health service use/treatment among U.S. adults (2004-2008)

SAMHSA’s National Survey on Drug Use and Health (NSDUH)  also found in 2008 that just over half (58.7 percent) of adults in the United States with a serious mental illness (SMI) received treatment for a mental health problem. Treatment rates for SMI differed across age groups, and the most common types of treatment were outpatient services and prescription medication.

Use of mental health services and treatment among adults. Service use/treatment of serious mental illness among U.S. adults by age and type of care (2008).

SAMHSA’s National Survey on Drug Use and Health (NSDUH)  further found in 2008 that 71 percent of adults who had major depression used mental health services and treatment to help with their disorder.

Service Use/Treatment Among U.S. Adults with Depression.

The chart below is a further breakdown of the treatment data for 2008 shown in the chart above. It shows the treatment rate for women and men, as well as that for three different age groups of adults. Generally, women and adults over 50 were more likely than men and younger adults to use services for depression.

Service Use/Treatment Among U.S. Adults with Depression by Sex and Age.

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Use of Mental Health Services and Treatment Among Children

Data from the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES)  show that approximately half (50.6 percent) of children with mental disorders had received treatment for their disorder within the past year. There were some differences between treatment rates depending on the category of mental disorder. Children with anxiety disorders were the least likely (32.2 percent) to have received treatment in the past year.

Mental Health Service Use for Children(8–15 years)

Use of mental health services and treatment among children.  Mental health service use for children ages 8-15 in terms of percent with disorder

Demographics Associated with Mental Health (MH) Service Use:

  • Females are 50 percent less likely than males to use MH services.
  • 12–15 year olds are 90 percent more likely than 8–11 year olds to use MH services.
  • No differences were found between races for mood, anxiety, or conduct disorders. Mexican Americans and other Hispanic youth had significantly lower 12-month rates of ADHD compared to non-Hispanic white youth.

Data courtesy of CDC

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Inmate Mental Health

From the Department of Justice's Survey of Inmates in State and Federal Correctional Facilities (2004) and Survey of Inmates in Local Jails (2002) indicate that the rate of mental health problems differ by the type of correctional facility. In this study a mental health problem was defined as receiving a clinical diagnosis or treatment by a mental health professional. Inmates in local jails had the highest prevalence of mental problems, with nearly two thirds of jail inmates (64.2 percent) satisfying the criteria for a mental health problem currently or in the previous year.

Inmates with 12-month mental health problem:  56.2% in state prison; 44.8% in Federal prison; 64.2% in local jail.  Data courtesy of DOJ.

The Department of Justice’s Survey of Inmates in State and Federal Correctional Facilities (2004) and Survey of Inmates in Local Jails (2002) also indicate that fewer than half of inmates who have a mental health problem have ever received treatment for their problem. A third or fewer received mental health treatment after admission. These rates differ depending upon the type of correctional facility.

Mental health treatment among prison/jail inmates.

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Behavioral Health Treatment Services Locator

Behavioral Health Treatment Services Locator By entering your zip code at findtreatment.samhsa.gov, you can quickly find alcohol and drug abuse treatment or mental health treatment facilities in your area. This service is courtesy of the Substance Abuse and Mental Health Services Administration (SAMHSA) which works to "to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services." (SAMHSA)

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