You’re on a boat in the middle of the ocean that’s slowly filling with water. It’s sprung a leak and with every passing moment the water level is rising. You grab a bucket and frantically try to scoop the water out before the boat sinks. Realising it’s not working, you grab a bigger bucket and then more buckets. You scoop in different ways, trying to see what’s more effective in displacing the water. But soon enough, it dawns on you that the only way to really address this issue is to plug the hole in the bottom of the boat to stop new water entering. Only then will you be effective in reducing the water level and ensuring your safety.
Psychologists are acutely aware that mental health conditions are a major issue in our society. We see firsthand how distressing and disruptive they can be to someone’s life. We see the research come to life in our rooms. People who experience a mental health condition are more likely to experience poor school performance, early school leaving, relationship breakdown, unemployment, homelessness, incarceration and substance misuse compared to people without a mental health condition. We see these conditions and their link to an increased risk of chronic disease such as diabetes, cardiovascular disease, cancers and a reduced life expectancy.
We also know the social and economic impacts of these conditions are profound. According to the Productivity Commission, mental health conditions cost the Australian community $200–$220 billion annually (Productivity Commission, 2020).
If we want fewer Australians to experience these negative impacts, what do we need to do differently? While more funding for frontline services is undeniably critical, this is not the only way forward. Mental health conditions are not inevitable and there is now good scientific evidence to show that we can prevent many common conditions through the widespread use of evidence-based primary prevention initiatives. We believe it’s time to rethink our approach and get serious about prevention, and we believe that psychologists are very well placed to be at the forefront of these endeavours.
There are three main explanations for Australia’s failure to reduce the prevalance of mental health conditions – the access gap (although this is closing), the quality gap (which remains highly problematic) and the prevention gap
Why is prevention important?
Despite steadily increasing per capita government expenditure on mental healthcare services over the past few decades, the prevalence of mental health conditions in Australia is rising rather than falling, the burden of psychosocial disability hasn’t changed in decades and suicide rates remain tragically high.
As a result, services are struggling to keep up with demand and individual, government and societal costs are escalating. The COVID-19 pandemic has only made things worse, with a report in the Lancet showing a staggering 11–12% increase in the prevalence of depression and anxiety disorders in Australia in 2020, and around 25% globally (COVID-19 Mental Disorders Collaborators, 2021). We don’t yet have the data for 2021–2022.
This policy failure has been well-documented and according to leading Australian psychologist Professor Tony Jorm, there are three main explanations – the access gap (although this is closing), the quality gap (which remains highly problematic) and the prevention gap (Jorm, Patten, Brugha & Mojtabai, 2017). However, while it’s clear that all three of these factors are important, governments seemingly believe progress can only be achieved by providing more services. Prevention is barely on the radar.
In every other area of health, prevention and treatment go hand-in-hand. Over the past 50 years we have seen mass immunisation programs to prevent infectious diseases; fluoridation to improve dental health; as well as public education campaigns to reduce sun-exposure and smoking, and to increase physical activity and healthy eating to prevent diabetes, heart disease and cancers. We’ve also seen a suite of legislative, vehicle design and public education measures to reduce road trauma. Most notably in recent times, prevention was front and centre of our approach to managing the spread of COVID-19 in our community.
This focus on prevention has not occurred at the expense of treatment for these conditions and issues, but in addition to this expenditure. As a result, Australia has an outstanding track record in these areas. Looking at changes in Australia’s physical health since the beginning of the 20th century to the present, we see major gains. There has been a steady reduction in mortality and increasing life expectancy.
Ultimately, we need to acknowledge that:
- our current emphasis on reducing the treatment gap is not enough to tackle this crisis
- we don’t have enough clinicians to meet demand, especially in rural and remote areas, and the public’s engagement with digital treatments remains low
- current treatments are imperfect and many people who receive the best available treatment will nevertheless experience recurrences or fail to improve, meaning that prevalence won’t change
- most new treatments are equivalent to older treatments or marginally better, suggesting it is not easy to create substantially more effective treatments, and
- the pace of discovery of new psychological therapies and pharmaceuticals is typically slow – there is no treatment panacea in sight.
So, while more and better mental healthcare services are undoubtedly important, like the leaky boat, only prevention can reduce incidence and must be given far more attention than it is. We can’t keep waiting until people are already experiencing significant mental health challenges before we step in.
What exactly is prevention?
The language in mental health is ever-evolving and constantly debated, making it challenging to get agreement on key terms and definitions. Prevention is a prime example. In the physical health field the terms primary, secondary and tertiary prevention were originally coined to describe the different stages where public health practitioners or clinicians could intervene to change the trajectory of a disease. Primary prevention was defined as preventing disease onset, secondary prevention was about early detection and treatment to prevent disease progression, while tertiary prevention was about effective management to prevent disability and handicap.
In 1994, Mrazek and Haggerty from the US Institute of Medicine came up with a new way to categorise prevention. For them prevention was all about ‘primary’ prevention rather than secondary or tertiary prevention. It was about preventing a condition from happening in the first place by modifying the underlying risk and protective factors linked to a particular disorder.
They therefore argued there were three main categories of primary prevention interventions – universal prevention initiatives targeted to the whole population, selective prevention interventions targeted to groups at increased risk, such as people with a positive family history of a mental disorder, and indicated prevention initiatives that targeted people at very high risk, such as those with subthreshold symptoms suggestive of an emerging disorder.
Crucially, they proposed a clear distinction between ‘prevention’ and ‘early intervention’ although they acknowledged the line between the two is somewhat blurry. For Mzarek and Haggerty, prevention is about preventing the onset of a disorder, while early intervention is about diagnosing and treating a disorder as soon as possible after it has occurred.
This distinction is critical as it helps us to recognise that prevention is primarily a population mental health endeavour rather than a clinical endeavour. It operates at a group or community level and focuses on causes rather than conditions. As an endeavour, it borrows heavily from health promotion and public health practice, rather than clinical care, and requires us to focus not just on individual behaviour change but on structural and societal change as well.
How can we prevent mental health conditions?
We’re all familiar with the fact that to prevent skin cancer we need to limit UV exposure. Likewise, if we want to prevent heart attacks and strokes, we need people to eat healthfully, exercise regularly, not smoke, and keep their cholesterol levels and blood pressure under control. In short, we need to modify the balance of risk and protective factors linked to conditions. This same principle applies to the prevention of mental health conditions, although its application is more complex.
Mental health conditions are multifactorial in origin and result from the complex interaction of numerous individual and environmental risk and protective factors. The list of factors is quite extensive and includes a wide range of biological, psychological, social and economic factors. While some risk and protective factors appear more important than others, each factor has some influence and needs to be addressed in some way. To be effective we therefore need to address as many of these factors as possible and we need to manage this complexity in a coordinated way.
For Mzarek and Haggerty, prevention is about preventing the onset of a disorder, while early intervention is about diagnosing and treating a disorder as soon as possible after it has occurred
Prevention – what works?
The suggestion isn’t that we can prevent everyone from experiencing a mental health condition – much like we can’t prevent every case of skin cancer or heart disease – but we know enough to prevent many more people from experiencing behavioural disorders, anxiety conditions and depression, and we have some emerging evidence on how to prevent conditions such as eating disorders and schizophrenia, even if only among those showing subtle early symptoms (Carbone, 2020). And most certainly, as in every other scientific endeavour, further investment will result in even more answers.
Right now, there is research evidence that health behaviours such as regular physical activity, healthy eating and good sleep hygiene are effective in the prevention of depression and anxiety. For example, a Black Dog Institute study found that as little as one hour of physically activity a week prevented 12% of new cases of depression (Harvey et al., 2018).
There is also considerable evidence that psychological skills-building programs that utilise techniques derived from psychology treatments such as CBT, interpersonal therapy, acceptance and commitment therapy and dialectical behaviour therapy, can also help to avert depression and anxiety. These techniques can be taught to people with no past or current experience of a clinical condition through online programs or face-to-face workshops facilitated by trained mental health professionals or even non-mental health professionals like educators in schools. The research around indicated prevention is particularly strong with a meta-analysis by Professor Kim Cuijpers and others (2021) showing such programs can reduce the rate of new disorders by 20% among participants compared to non-participants over a 12-month period.
There is also good evidence that parenting and family strategies that focus on secure attachment, parenting style, communication skills, boundary-setting and conflict resolution are effective in the prevention of internalising disorders and externalising disorders. These latter strategies are also effective in preventing child maltreatment. This is also important because adverse childhood experiences like child maltreatment are a major risk factor for most mental health conditions. Indeed, there is data to suggest that preventing adverse childhood experiences could potentially lead to a 30% reduction in the incidence of mental health conditions – making the prevention of childhood trauma one of the most critical targets for preventive practice (Jorm & Mulder, 2018).
At an organisational level, there is good evidence that school-based programs are effective for the prevention of depression, anxiety and behavioural disorders. Multi-component programs that focus on teaching style, embedding social and emotional learning and resilience programs in the curriculum, parent liaison, anti-bullying policies, positive school ethos and connections with external services, produce better results than single component strategies. There is also evidence that workplace programs that aim to reduce psychosocial risk factors such as high demand/low control/low support jobs, workplace bullying and harassment, or exposure to occupational violence, can in turn help to prevent depression and even PTSD in some instances.
At a societal level there is some evidence that certain strategies may be effective in the prevention of risk factors such as racism, discrimination and family violence and these are then likely to contribute to reductions in mental ill-health, given how toxic these factors are. Likewise, it’s very likely that social policies to prevent social disadvantage, support full employment, provide income adequacy and ensure stable housing will also contribute to a reduction in the incidence of mental disorders, although direct empirical evidence of their flow-on impact in preventing mental health conditions is currently limited. That said, there is no doubt that all these initiatives would contribute to creating a kinder, more equal and more compassionate society.
Importantly, there is also good evidence to show that many of the strategies that can be used to prevent mental health conditions are cost-effective, since they are usually inexpensive but produce considerable short- and long-term savings (National Mental Health Commission, 2019).
What’s happening now?
Sadly, despite the availability of numerous evidence-based prevention interventions there is a significant gap between what works and what’s happening on the ground. Very few of the evidence-based effective and cost-effective prevention programs that are available are being systematically implemented at a national scale with close attention to program fidelity and implementation quality. Likewise, many of the critical social policies to tackle the social determinants of mental ill-health are lacking.
Ultimately our current approach to prevention consists of:
- groups of researchers doing great research but who are not able to take effective programs to any substantial scale
- a small group of mental health organisations working on prevention, but who only have the resources to offer a limited number of initiatives or achieve limited reach, and
- groups working on the prevention of ‘social’ issues such as poverty, child abuse, family violence and bullying – all of which indirectly help to prevent mental health conditions – who don’t consider themselves part of the preventive mental health response and don’t connect and collaborate with these efforts.
There’s no clear leadership, planning, coordination or recurrent resourcing in sight. As a result, we’re pedalling but we’re not moving forward.
What’s really needed?
We have a mental healthcare system to help people get well. We now need a preventive mental health system to help people stay well. While Australia has the beginnings of this system, it is quite rudimentary and needs to be enhanced if we want to make genuine progress on prevention.
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The World Health Organization has developed a framework that outlines the core elements required to create a healthcare system (WHO, 2007). We believe this model can be adapted and used to define the elements needed to create an effective prevention-focused population mental health system. These key building blocks are: i) funding, ii) leadership and governance, iii) safe, effective and cost-effective interventions, iv) program delivery systems and infrastructure, v) workforce, vi) health data and vii) research.
What’s next?
Recently there have been some green shoots of hope about this new way forward. State governments such as those in Western Australia and Victoria are starting to pay more attention to this issue, and have developed (or are developing) prevention frameworks and plans to guide their investments. Likewise, the Federal Government is gradually providing more support for school-based mental health promotion, preventive parenting programs and workplace mental wellbeing. But progress is glacial, and prevention remains the poor second cousin of mental healthcare with only 1% of the Federal mental health budget spent on prevention.
It is true that we cannot ignore the needs of people who are already unwell. However, it is short-sighted to pit prevention against treatment as if they were mutually exclusive endeavours. Decision-makers need to understand the importance of doing both side-by-side as we’ve done in the ‘physical’ health realm for decades. We need a National Preventive Mental Health Office to be established in the Commonwealth Department of Health to provide leadership on this matter, and for at least 5% of the federal mental health budget to be dedicated to prevention.
Mental health conditions are not inevitable, and we have the knowledge and the programs to prevent many common conditions from occurring right now. Nationally and internationally, psychologists like Tony Jorm, Helen Christensen, Ricardo Munoz, Kim Cuipjers and others have been at the forefront of these endeavours and the profession is exceptionally well placed to continue to lead this work.
By having a strong and a concurrent focus on prevention and treatment, we’ll finally be able to make real in-roads into reducing the personal, social and economic toll of mental health conditions in our community.
The boat is filling with water. Should we reach for the buckets, or plug the hole?
We should do both.
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