Panel: Government Must Work Harder to Prevent Mental Illness in Young People

The US government should take stronger action to prevent mental, emotional, and behavioral disorders in children and youths, according to a report by the Institute of Medicine (IOM) and the National Research Council.

In 1994, the IOM outlined the need for more research on preventing mental disorders. Since then, a strong body of evidence has emerged suggesting that interventions in childhood or adolescence can be very effective at preventing mental disorders or reducing their negative consequences throughout life, according to the new report (http://www.nap.edu/catalog.php?record_id=12480). Based on such evidence, the report's authors called on the White House to create an entity that would coordinate multiagency efforts to implement such programs more widely.

Each year an estimated 14% to 20% of young people have mental, emotional, or behavioral disorders, with consequences that cost the United States an estimated $247 billion, according to the report. Kenneth E. Warner, PhD, chair of the panel that drafted the report and dean of the School of Public Health at the University of Michigan in Ann Arbor, explained that not only do such conditions take a tremendous emotional toll on the affected children and their families, but they also have wider societal effects on schools, the criminal justice system, and social welfare programs.

Yet there are well-validated programs targeting children that have been shown to reduce the incidence or burden of mental illness among individuals at risk, said David A. Brent, MD, a professor of psychiatry at the University of Pittsburgh Medical Center in an interview. Many of these programs have also proven to be cost-effective. For example, one meta-analysis examined 25 programs in which nurses or other professionals visited the homes of infants and young children to provide support and advice to parents. The analysis found that such programs cost about $5000 per child but produced benefits of about $11 000 per child, according to a report by the Washington State Institute for Public Policy (http://www.wsipp.wa.gov/pub.asp?docid=04-07-3901). Certain programs have demonstrated an even higher benefit-to-cost ratio. For example, the Nurse-Family Partnership program costs about $7000 per child, but yielded benefits of about $41 000 for a child at high risk of poor outcomes and $9000 for a child at lower risk, according to a 2005 report by the RAND Corporation (http://www.rand.org/pubs/monographs/2005/RAND_MG341.pdf). Brent noted that the Nurse-Family Partnership has shown positive effects on targeted children well into their adult years.

School-based programs have also demonstrated the ability to reduce problematic behaviors and improve student well-being and academic performance. One example is the Good Behavior Game, which groups first-grade students into teams that can earn rewards or privileges for good behavior. According to the IOM report, the program has been shown to reduce aggression and disruptive behavior among participating students, and in the long term, participants were less likely to abuse drugs and alcohol and had lower rates of suicidal thoughts or behaviors. Additionally, boys who participated in the program reduced their risk of being diagnosed with an antisocial personality disorder as adults.

Brent noted that effective interventions do not necessarily have to target individuals or at-risk groups but rather should be aimed at producing environments that are conducive to good mental and physical health.

“We can do prevention by strengthening the institutions we have,” he said.

In addition to calling for wider implementation of such proven interventions, the report called for more research on the underlying neurobiology of psychiatric conditions. It also said the Department of Health and Human Services should collect annual data on the prevalence of mental, emotional, and behavioral disorders in young people in order to track trends over time and identify key risk and protective factors in this group.

Warner emphasized the need to assess the effectiveness of previously validated programs after they are put into wider use in a variety of real-world settings. He explained, for example, that some programs may have been initially tested in schools where teachers were highly motivated to participate, were trained by experts, and had ample resources to implement the program. When such a program is scaled up to an entire school system, teachers may have competing demands for their time or less training. Results may also vary among different cultures or communities, and research will be necessary to identify such differences, according to the report. To ensure that such research is performed, the report recommends that the government agencies bundle together funding for program implementation and program effectiveness research.

Warner emphasized that mental disorders can be prevented, and that even primary care physicians can play a role by helping to identify patients who are at risk and suggesting to families or children that they participate in preventive interventions.

“The burden of mental, emotional, and behavioral disorders in children is enormous, and much of it is preventable,” said Warner. “Primary care physicians have an important role to play in identifying children at risk before problems arise and reducing the damage when problems do occur.”