The Evolution of the Approach to Mental Health: Towards a More Preventive Strategy

Mental wellbeing is one of the most overlooked parameters contributing to an individual’s overall health and wellness. According to the World Health Organization, depression is considered one of the leading causes of disability worldwide. Death by suicide is the second most common cause in youngsters, from fifteen to twenty-nine. Moreover, mental health conditions reduce two decades of an individual’s lifespan, causing premature death.

The World Health Organization (WHO) considers mental illness the pandemic of the 21st century – with an estimated 350 million individuals experiencing depressive symptoms annually. The COVID-19 pandemic has made matters worse with an estimated 3-fold increase in the rate of depressive symptoms (Ettman, 2020). The social isolation measures, compounded by the fear of the pandemic, exposed critical weaknesses in the healthcare system and how it addresses people in need of mental health care. Additionally, individuals recovering from COVID-19 had almost a 50% higher likelihood of a mental health concern. All of these occur when there are large gaps in access to mental health care providers. The mental health fallout from the pandemic will likely reverberate for years to come.

A Brief History of Psychiatry

Healthcare has a sordid past in how it addressed mental health. During the Middle Ages, mental health issues were believed to be a result of possession, witchcraft, or punishment from an angry god. An individual with a mental illness would be subjected to trephining, creating a small hole in an individual’s skull to allow evil spirits an exit, exorcisms, imprisonment, or even execution (Ref).

Later in the 18th century, individuals with mental health conditions were kept in asylums, isolated, and ostracized from society. Reforms calling for more humane treatment of mental health patients gradually supplanted the prior practices. However, even into the 1990s, some asylums remained open.

In the 1930s two main treatments arose: frontal lobotomy and electro-convulsive therapy (ECT). The leucotomy, or lobotomy, was developed in 1935 by Portuguese neurologists Drs. Moniz and Lima – a procedure which earned Moniz a Nobel prize. A decade later, a new technique was developed to access the brain through the orbits, called a Transorbital lobotomy. The surgery was a blind procedure using a tool similar to an ice pick and was ineffective if not deadly. Ultimately, the procedure was deemed inhumane and banned in the US by the 1970s.

In 1938, ECT began to be used for patients with more serious disorders. Although the mechanism is not completely clear, ECT induces seizures to “reset” the brain and can be effective for some after several sessions. It was conceived after observations that patients with psychosis and epilepsy generally improved following a seizure. Even today, an estimated one million people receive ECT every year (Prudic, 2001).

A growing trend in deinstitutionalization and community-based treatment was ushered in by the development of medications for mental health. Pharmacologic therapies beginning with chlorpromazine in 1954 offered less invasive options for psychosis. Today there are many medications for anxiety, depression, bipolar disorder, and schizophrenia. In 2019, about 15.8% of the US population received a medication for a mental health condition.

Unfortunately, there are significant associations between severe mental illness, homelessness, and incarceration. The prevalence of persons with psychotic disorders in the prison is approximately 15-22% compared with 3.1% in the general population. Whether it is a question of access to care or efficacy, there are large hurdles yet to cross in mental health care.

Are Medications Efficacious?

Do medications work for psychiatric disorders? The Sequenced Treatment Alternative to Relieve Depression (STAR*D) study showed a 47% response rate in patients with chronic or major depression on a first line therapy with the selective serotonin reuptake inhibitor (SSRI) citalopram (Trivedi, 2006). The most successful patients were Caucasian, females, with a higher level of education, or higher income. A further analysis suggested that only about 30% of patients met criteria for remission – meaning for 70% of patients, a medication is not sufficient to treat depression (Insel, 2006).

Get ready for a hard pill to swallow. The STAR*D trial was not a placebo-controlled trial. Interestingly, placebo response rates for depression fall between 30 and 40 percent efficacy – and in the shorter duration and less severe depressed patients up to 50% (Brown, 1994). However, a Cochrane review did favor treatment over placebo, particularly with tricyclic antidepressant and SSRIs (RR 1.24; CI 1.11-1.38; RR 1.28, CI 1.15 to 1.43, respectively) (Arroll, 2009). The results still leave many wondering whether medications can ever be enough; and whether more precision diagnostic and therapeutic testing will provide a greater efficacy.

Studies support that psychotherapy is as effective, or even more effective than medication. Within the setting of therapy, the therapist and patient form a therapeutic alliance which enhances care. An estimated 37% of the US population live in areas, predominantly rural, where mental health workers are lacking.

The ACEs Study

A past history of a significant traumatic event or chronic trauma can predict mental illness as well as a risk for chronic diseases.

In 1998, a pivotal study the ACEs study factored the influence of environmental exposure to trauma on the incidence of chronic diseases and mental health. Adverse Childhood Experiences (ACEs) are traumatic experiences that occur from birth to up to seventeen years of age. Examples of ACEs include physical abuse, sexual abuse, neglect, living with someone who abused drugs or alcohol, and losing a parent through divorce, death, or abandonment. Environmental risk factors include communities with few activities for young people, poverty, food insecurity, and easy access to drugs or alcohol in a community.

ACEs are common. In a 2014 UK retrospective study, almost 50% of the population had at least one ACE and 9% had 4 or more ACEs (Bellis, 2014). Those with 4+ ACEs had increased odds for smoking (4-fold), heavy drinking (3.7-fold), incarceration (9-fold), and morbid obesity (3-fold). The ACEs study reveals in its correlations a way to envision mental and physical illness as a behavioral adaptation to trauma.


The diagnosis of mental health conditions uses a syndromic understanding of an illness without the same objective criteria of chronic diseases, such as diabetes mellitus, high blood pressure, and congestive heart failure. For instance, psychiatrists listen to patients closely in the interviews and order bloodwork to screen for infrequent laboratory test abnormalities that suggest a systemic process, such as syphilis, hypothyroidism or B12 deficiency.

Psychiatrists use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to provide the foundation to diagnose mental health conditions. The first manual was published in 1952, as an attempt to develop a classification system nationwide in the US. It relies on a clinical basis to observe behavior and record thought as it fits a syndrome list. The most recent iteration the DSM-5 was released in 2013.

There exists debate as to the validity of the DSM-5 in light of neuroscience findings, which offer a more accurate view of behavior. Additionally, the DSM-5 has an inherent risk of labeling, stigmatizing, and removing an individual’s agency. The inclusion of bereavement disorder was a contested topic, because it suggested that grieving was a dysfunction rather than a normal process.

The National Institute of Mental Health (NIMH) initiated the Research Domain Criteria (RDoC) in 2009 as a process to identify a mental health condition through the basis of genetics, imagining, cognitive science, along with other tools to develop a new classification system (Pidoux, 2015).

The search leads to discovering genetic and epigenetic changes that contribute to these syndromes and their phenotypes. Some evidence Understanding psychopathology at the molecular level may usher in a new era of precision psychiatry (Maj, 2020). Soon will be a time when we understand mental illness as a physical disorder of the brain as it adapts to trauma.

Neuroscience researchers strive to identify the biological underpinnings that contribute to the development of mental health disorders. Imaging studies such as resting-state functional MRIs support that mental illness is associated with physical changes of the brain. For instance, someone who has Post-traumatic Stress Disorder has an increased amygdala and a decreased hippocampus, corresponding to increases and decreases in blood flow in these areas, respectively.

mental health issues can have a devastating impact on quality of life, employment, and physical health.
Photo by Kat Smith on Pexels.com

Soon will be a time when we understand mental illness more accurately as a physical condition of the brain as it adapts to trauma.

The Future of Mental Health Care: Start before Birth?

The link between mental health, physical health and the environment is logical yet riveting. Although our nervous systems develop through our lives, the seed is planted at an early age – even before birth. And just like a tree, the environment plays a crucial role on the development of stable and resilient mental health.

The rates of major depressive episode are on the rise, sparked by the COVID-19 outbreak. In 2020, 1 million youth ages 11-17 tested their level of depression and anxiety online with Mental Health America (MHA) screening program, an increase of over 600% from 2019. Access to care has also been limited with only 43% of youths with major depressive episodes receiving any treatment in 2019. The projections are worse over the two years of the pandemic with a fall-out that may take many years to recover (Santomauro, 2021). The breakdown in care that COVID precipitated accentuated the already challenging field of mental health.

Given the increased need and limited benefit of therapy, should not our mission in addressing mental health begin as early as possible? The following are a few suggestions to addressing mental health within a public health framework: Obstetrical care during pregnancy; Parenting programs; and youth activities.

Obstetrical care during pregnancy

Stress contributes a significant amount to one’s health and the impact can be seen during pregnancy. When a woman is depressed during pregnancy, there are greater rates of preterm birth, stillbirths, small for gestational age, need for operative delivery, complications like preeclampsia, and low birth weights (Jahan, 2021; Coussons-Read, 2013).

The term fetal programming refers to the effects of maternal stress on the children. The development of the infant’s hypothalamic pituitary adrenal (HPA) axis may alter because of exposure to maternal distress. The ramifications extend to the child’s learning, motor development, health, and behavior (Schetter, 2015).

Address the Role of Parents in Adolescent Depression and Anxiety

Since parenting can have a direct impact on a child’s mental health, efforts to address parenting skills and mental health can influence a child’s outcomes. In an intervention involving 318 parents and 308 adolescents, a web-based parenting intervention demonstrated potential, albeit follow-up studies will be needed (Yap, 2018). A meta-analysis of 37 studies did show a benefit of parenting programs to parental depression and child maltreatment (Chen, 2015). Any public health approach to reducing depression and childhood trauma would benefit from a parental initiative.

Youth Programs and Community Outreach

The benefits to mental health of group sports have been well established. An analysis of multiple studies show improvement in physical self-perception and self-esteem (Lubans, 2016). Self-esteem has a small, but significant protective effect against violence and criminality (Mier, 2017).

In a pilot study of junior sports for 12- to 15-year-olds (n=74), there were significant improvements in children’s level of anxiety, grit, ability to manage negative emotions, and prosocial behavior (Dowell, 2021). The mental health aspect of the program included assessments and outcomes measures of anxiety, depression and anger, feedback, online resources, along with referral for tailored care if needed.

sports can help to improve self-esteem and prosocial behavior. Some benefits for mental health issues exist.
Photo by Kampus Production on Pexels.com

Summary: Embrace Mental Health for All

We have now arrived at a place where we can embrace mental health care and prevention for everyone. The US has large gaps in access to care. Thirty-seven percent of Americans live in areas where there is a gap to access to mental health care providers. Medications aren’t going to solve the US’s mental health care crisis. We have to move past paternalism and putting out fires. Even though medications are (modestly) effective, we must address ways to develop systems that empower individuals to develop resilience strategies before they have mental health issues, nurture those being treated, and improve access to mental healthcare.

Public health strategies for mental health can start as early as the obstetrician’s office. School-based programs and parenting classes can equally be effective. A shift from reactive measures, some of which begin in the emergency room, to proactive measures requires policy that begins outside of the therapist’s office. It starts in the community centers, playgrounds, schools, and churches.

The image of pulling people out of a river is an old public health lesson, relating to identifying the upstream issues that are causing people to fall in. Reactive mental healthcare is the least effective care, akin to pulling a person out of a river. Aside from rescuing people from drowning or being incarcerated, a greater emphasis should be placed in understanding and intervening in the environmental forces that contribute to mental health issues, including abuse, neglect, substance use, and harmful parenting practices.

Thereby, not only have we identified the broken dock where people are falling in, but we have instructed them on how they can learn to swim.

Our calling is not only to pull people out of the river, but to go upstream to find out what or who is pushing them in.

Jim Wallis, Theologian and Activist

Bibliography

Included in the article as links, additionally:

Arroll, B, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev. 2009; 3: CD007954.

Brown W. Placebo as a treatment for depression. Neuropsychopharmacology. 1994; 10(4): 265-9.

Coussons-Read M. Effects of prenatal stress on pregnancy and human development: mechanisms and pathways. Obstet Med. 2013; 6(2): 52-57.

Dowell T, et al. Tackling Mental Health in Youth Sporting Programs: A Pilot Study of a Holistic Program. Child Psychiatry Hum Dev. 2021; 51(1): 15-29.

Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry. 2012; 25(2): 141-148.

Insel T. Beyond Efficacy: The STAR*D Trial. Am J Psychiatry. 2006; 163(1): 5-7.

Jahan N, et al. Untreated Depression During Pregnancy and Its Effect on Pregnancy Outcomes: A Systemic Review. Cureus. 2021; 13(8): e17251.

Lubans D. Physical Activity for Cognitive and Mental Health in Youth: A Systematic Review of Mechanisms. Pediatrics. 2016; 138(3): e20161642.

Mier C, Ladny R. Does Self-esteem Negatively Impact Crime and Delinquency: A Meta-analytic Review of 25 Years of Evidence. Deviant Behavior. 2017; (online).

Santomauro et al. “COVID-19 Mental Disorders Collaborators.” Global prevalence and burden of depressive and anxiety disorders in 203 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet. 2021; 398(10312): 1700-1712.

Trivedi M, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006; 163(1): 28-40.

Yap MBH, et al. A Tailored Web-Based Intervention to Improve Parenting Risk and Protective Factors for Adolescent Depression and Anxiety Problems: Postintervention Findings from a Randomized Controlled Trial. J Med Internet Res. 2018; 20(1):e17.

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