Journal of Primary Prevention, 7(4), Summer 1987
Major Mental Disorders We do not know how to prevent schizophrenia or major depressive disorders. But research on risk factors for these disorders has suggested directions for work that may lead to preventive interventions. Schizophrenia and major depressive disorders are severe mentalemotional disabilities and comprise a substantial proportion of the overall burden of illness. One quarter of the hospital beds in the country are occupied by persons with schizophrenia. An unknown but certainly considerable percentage of the homeless suffer from schizophrenia. An estimated 15% to 25% of the population experience at least one episode of disabling depression during their lives. An estimated 20,000 suicides a year are attributable to depression. There is significant knowledge about risk factors for these major disorders. For both schizophrenia and depressive disorders, a family h i s t o r y - - h a v i n g a first-degree relative who suffers from the diso r d e r - - i s a risk factor. Studies, including those of adopted offspring and identical twins, have strongly suggested that a genetic factor is involved. Research has also identified environmental factors such as stressful life events (for depression) or family conflict and low socioeconomic circumstances (for schizophrenia) as risk factors. There has been encouraging progress through biomedical research in identifying biochemical factors characteristic of persons suffering from major mental disorders. There have been advances in diagnosis and treatment, such that programs combining medication and family support and other interventions make it possible in many cases to forestall recurrent episodes, diminish their severity and shorten the duration. Thus far, however, efforts directed toward prevention of the first episode, which is the focus of this report, have not been given priority. This aspect deserves much more serious and substantive research support.
Schizophrenia It is the area of prevention of schizophrenia that is of most concern to critics of prevention efforts. There is strong disagreement among mental health professionals and advocates, particularly family members, as to whether resources should be directed primarily toward biochemi221
© National Mental Health Association i986
222
Journal ofPrimary Prevention
cal or psychosocial research. Clearly there are both biological and environmental factors involved in schizophrenia. The causality of schizophrenia is not known and need not be known before pursuing prevention-oriented research. The knowledge base about risk factors and life course for schizophrenia is substantial. Well-established risk factors include a family history of schizophrenia, family conflict, school maladjustment, lack of social competence and low socioeconomic circumstances. There is some genetic basis in schizophrenia. Children of a parent with schizophrenia have a greater than average chance of developing the disorder. If adopted into a normal family, they are still at increased risk. However, children of a parent with schizophrenia are at an even greater risk when they are raised in a disturbed family environment. Schizophrenia usually is first diagnosed in early adulthood. Preventive interventions probably will have to begin much earlier. Most prevention-oriented research on schizophrenia focuses on the offspring of persons with schizophrenia. Research on risk factors has identified certain subgroups of such offspring as at particularly high risk. Difficult pregnancy of the mother and difficult delivery, signs of neurological or attentional deficits during childhood and problems in social behavior are among these identifying factors. Effective programs for such children have not yet been developed but are the next logical step in efforts to prevent schizophrenia--first to see if these factors can be changed and then to see if changing them will reduce the incidence of schizophrenia. This area of research should be pursued aggressively for the benefit of these children and the knowledge it will provide about the development of schizophrenia. Depression
Research on depression is complicated by the fact that depression coyers a wide range of dysfunction. Distinctions must be made between bipolar (manic-depressive) and unipolar (depressive), psychotic and nonpsychotic, and degrees of severity. Our concern in this section is with severe major depressive disorders, both bipolar and unipolar; they are characterized by profound disruption in mood and biological function. There is strong evidence for a genetic basis for depressive disorders, especially for bipolar disorders. Biomedical research in the past decade has identified neurotransmitter deviations, hormonal dysfunction and other biochemical characteristics of persons with depression.
Major Mental Disorders
223
Stressful life events have been identified as a risk factor for depressive disorders. High risk groups include patients with medical illnesses such as cancer, stroke or chronic renal disease, the recently bereaved and persons undergoing great stress such as separation, divorce or unemployment. Specific learned behavior and the absence of social support also seem related to risk. Studies of early personality characteristics of persons with depression yield confusing results. We do not have a clear picture of the life course for persons with depression before onset of symptoms. That information could suggest appropriate early preventive interventions specific to depression. Given the strong evidence that children of parents with depression are at risk, research to identify further subgroups at specific risk and develop preventive interventions is critical. Mental health professionals working w i t h parents with depression must be aware of the risk for offspring and develop and provide preventive services.
Major Mental Disorders We do not know how to prevent schizophrenia or major depressive disorders. But research on risk factors for these disorders has suggested directions for work that may lead to preventive interventions. Schizophrenia and major depressive disorders are severe mentalemotional disabilities and comprise a substantial proportion of the overall burden of illness. One quarter of the hospital beds in the country are occupied by persons with schizophrenia. An unknown but certainly considerable percentage of the homeless suffer from schizophrenia. An estimated 15% to 25% of the population experience at least one episode of disabling depression during their lives. An estimated 20,000 suicides a year are attributable to depression. There is significant knowledge about risk factors for these major disorders. For both schizophrenia and depressive disorders, a family h i s t o r y - - h a v i n g a first-degree relative who suffers from the diso r d e r - - i s a risk factor. Studies, including those of adopted offspring and identical twins, have strongly suggested that a genetic factor is involved. Research has also identified environmental factors such as stressful life events (for depression) or family conflict and low socioeconomic circumstances (for schizophrenia) as risk factors. There has been encouraging progress through biomedical research in identifying biochemical factors characteristic of persons suffering from major mental disorders. There have been advances in diagnosis and treatment, such that programs combining medication and family support and other interventions make it possible in many cases to forestall recurrent episodes, diminish their severity and shorten the duration. Thus far, however, efforts directed toward prevention of the first episode, which is the focus of this report, have not been given priority. This aspect deserves much more serious and substantive research support.
Schizophrenia It is the area of prevention of schizophrenia that is of most concern to critics of prevention efforts. There is strong disagreement among mental health professionals and advocates, particularly family members, as to whether resources should be directed primarily toward biochemi221
© National Mental Health Association i986
222
Journal ofPrimary Prevention
cal or psychosocial research. Clearly there are both biological and environmental factors involved in schizophrenia. The causality of schizophrenia is not known and need not be known before pursuing prevention-oriented research. The knowledge base about risk factors and life course for schizophrenia is substantial. Well-established risk factors include a family history of schizophrenia, family conflict, school maladjustment, lack of social competence and low socioeconomic circumstances. There is some genetic basis in schizophrenia. Children of a parent with schizophrenia have a greater than average chance of developing the disorder. If adopted into a normal family, they are still at increased risk. However, children of a parent with schizophrenia are at an even greater risk when they are raised in a disturbed family environment. Schizophrenia usually is first diagnosed in early adulthood. Preventive interventions probably will have to begin much earlier. Most prevention-oriented research on schizophrenia focuses on the offspring of persons with schizophrenia. Research on risk factors has identified certain subgroups of such offspring as at particularly high risk. Difficult pregnancy of the mother and difficult delivery, signs of neurological or attentional deficits during childhood and problems in social behavior are among these identifying factors. Effective programs for such children have not yet been developed but are the next logical step in efforts to prevent schizophrenia--first to see if these factors can be changed and then to see if changing them will reduce the incidence of schizophrenia. This area of research should be pursued aggressively for the benefit of these children and the knowledge it will provide about the development of schizophrenia. Depression
Research on depression is complicated by the fact that depression coyers a wide range of dysfunction. Distinctions must be made between bipolar (manic-depressive) and unipolar (depressive), psychotic and nonpsychotic, and degrees of severity. Our concern in this section is with severe major depressive disorders, both bipolar and unipolar; they are characterized by profound disruption in mood and biological function. There is strong evidence for a genetic basis for depressive disorders, especially for bipolar disorders. Biomedical research in the past decade has identified neurotransmitter deviations, hormonal dysfunction and other biochemical characteristics of persons with depression.
Major Mental Disorders
223
Stressful life events have been identified as a risk factor for depressive disorders. High risk groups include patients with medical illnesses such as cancer, stroke or chronic renal disease, the recently bereaved and persons undergoing great stress such as separation, divorce or unemployment. Specific learned behavior and the absence of social support also seem related to risk. Studies of early personality characteristics of persons with depression yield confusing results. We do not have a clear picture of the life course for persons with depression before onset of symptoms. That information could suggest appropriate early preventive interventions specific to depression. Given the strong evidence that children of parents with depression are at risk, research to identify further subgroups at specific risk and develop preventive interventions is critical. Mental health professionals working w i t h parents with depression must be aware of the risk for offspring and develop and provide preventive services.
