As we have seen, the preceding policy initiatives in the area of community mental health were inextricably intertwined with the idea of prevention. In 1964, Gerald Caplan published his classic book entitled The Principles of Preventive Psychiatry. Using public health concepts, he described three types of prevention—tertiary, secondary, and primary—as they related to mental health and illness.
The overriding goal of prevention is to reduce the prevalence or number of cases of mental disorder(s) at a specified moment in time in the population or community. Prevalence is, however, a function of both the incidence (the number of new cases diagnosed during a specified time period) and duration (the time between the initial diagnoses and recovery) of a disorder. Reducing duration, incidence, or both, reduces prevalence. Tertiary prevention reduces prevalence by decreasing the duration of a disorder. Secondary prevention can reduce prevalence either by short-circuiting the duration of a disorder or by intervening in the developmental course of a disorder before it has become fully manifested (and so labeled) to decrease in cidence. Primary prevention reduces prevalence solely by decreasing the incidence of disorder.
In tertiary prevention, the goal is to reduce the duration of an individual's career as a patient. Here, the patient has already been identified with a problem(s) in living. Thus, tertiary prevention is more appropriately referred to as rehabilitation. In secondary prevention, the goal is to identify early signs or antecedents of psychopathology in an individual so that intervention can be implemented promptly to alter the developmental course, duration, and/or severity of psychopathology. Here, short-circuiting a disorder's duration is the primary means of diminishing prevalence. Early treatment or crisis intervention represent the most common forms of secondary prevention or intervention.
In both tertiary and secondary prevention, problem identification and change take place at the level of an individual person. This distinguishes them from primary prevention. In primary prevention, the prevalence, and more specifically the incidence of a disorder, in a population or setting is reduced. Thus, primary prevention is mass in contrast to individually oriented. It also differs from tertiary and secondary prevention by occurring "before-the-fact." With regard to the nature/target of intervention, the distinction between tertiary/secondary and primary prevention is less clear. While most often the target of intervention in tertiary and secondary prevention is an individual, as we will see below, occasionally the target is the creation or alteration of a setting that a group of problem-identified individuals inhabit. However, based on the sharp differences in problem identification and the locus of change, some authors have suggested that referring to tertiary and secondary prevention as prevention makes the concept of prevention meaningless.
As early as 1964, Caplan offered a compelling definition of primary prevention:
Primary prevention is a community concept. It involves lowering the rate of new cases of mental disorder in a population over a certain period by counteracting harmful circumstances before they have had a chance to produce illness. It does not seek to prevent a specific person from becoming sick. Instead, it seeks to reduce the risk for a whole population, so that, although some may become ill, their number will be reduced. It thus contrasts with individual patient-oriented psychiatry, which focuses on a single person and deals with general influences only insofar as they are combined in his unique experience (p. 26).
In primary prevention (or "true" prevention), the level of assessment or target of intervention is not an individual, but instead the reduction of the prevalence of disorder in an entire population or setting before it occurs. A vaccine can inoculate an entire population from contracting an illness before anyone has been affected, as exemplified by the polio vaccine or fluoride in water. Similarly, effective social policies can reduce the incidence and prevalence of unwanted problems in a society, as in the case of an effective gun control policy that reduces the homicide rate or a policy of availability and accessibility of condoms for sexually active adolescents that reduces unwanted pregnancies. An example specific to mental health is pellagra that is accompanied by psychotic-like symptoms. Pellagra is a disease that stems, in part, from a deficiency of nia-cin in the diet. Today, the disease is prevented with a dietary intake that includes a sufficient amount of niacin.
In an effort to reduce the prevalence of a disease, the progression from tertiary to primary prevention points the way toward the promotion of well-being. To the degree that interventions or policies can successfully promote well-being in the population, we will have succeeded in reducing the incidence and prevalence of a wide array of disorders and undesirable outcomes.
In the subsequent sections of this article, we will utilize the preceding principles and articulate more specific ones. These principles will be underscored with the use of exemplary programs in each area: tertiary, secondary, and primary prevention, and the promotion of well-being.
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