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The Journal of Primary Prevention, Vol 15, No. 1, 1994
The Prevention of Primary Prevention, 1960-1994: Notes Toward a Case Study
David F. Duncan
This paper discusses the barriers that have kept primary prevention from realizing its potential
KEY WORDS: Community mental health; funding; individual care; biological problems.
In the 1960's it appeared that there was a bright future for the primary prevention of mental illness. The Joint Commission on Mental Illness and Health (Appell & Bartemeier, 1961) had urged a greater emphasis on preventive efforts. President Kennedy had addressed Congress on mental health, emphasizing the possibilities for prevention. Congress had responded with passage of the Community Mental Health Centers Act. Caplan (1963) had published his Piinciples of Preventive Psychiatry. It looked as if our great national resource of the mentally ill might be seriously depleted through primary prevention. Primary prevention was threatening the job security of all of all of us who made our living caring for and treating those who suffered from mental illness, drug abuse or antisocial behavior. Today, a third of a century later, there appear to be no fewer mentally ill than in the past. While we do not have solid data on the incidence or prevalence of mental disorders in the past, the Epidemiologic Catchment Area Study shows that one out of every five noninstitutionalized adults suffers from a diagnosable mental disorder (Robins, Locke, & Regier, 1991, p. 329). Not only are the mentally ill still present in ample number but there continues to be a backlog of four untreated persons for every one under treatment (p. 341).
1Division of Biology and Medicine, Brown University, Providence, Rhode Island. 2Address correspondence to the author at Brown University, Box G-BH, Providence, RI 02912.
All of this was achieved without an organized national effort. There was no National Committee to Preserve High Rates of Mental Illness. public service announcements were prepared by the Ad Council urging mental health centers to "say no" to primary prevention. Not one political platform declared that primary prevention was un-American, inflationary, a violation of states' rights, or destructive of family values. The amazing success of this quiet movement to prevent primary prevention is worthy of study. It may well be the outstanding example of goal free policy implementation -where a policy is affected without ever being publicly stated, by policymakers who act independently toward that stated goal, which even they may be unaware of. In this paper I shall present an outline of the major intervent strategies by which primary prevention was so successfully prevented. I have identified five such strategies which can be applied wherever we are threatened by primary prevention. To prevent it:
DON'T MAKE IT A PRIORITY
When President Kennedy addressed the Congress on mental health an mental retardation in 1963 he called for "a bold new approach" which emphasized comprehensive care in the community and primary prevention. Congress responded by passing the Community Mental Health Centers Act providing construction and staffing grants. This legislation mandated five "essential services" which had to be provided by every community mental health center - 1) inpatient care, 2) outpatient care, 3) partial ho mergency care, and 5) consultation and education. The first four essential services were intended to comprise comprehensive care in the community the fifth was all that was left of the goal of prevention. The legislative process had reduced a broad goal of preventing mental illness to a narrower objective of providing consultation and education services. Symbolically, perhaps, consultation and education was listed last of the five essential services. Prevention was already being moved toward last place priority as community mental health services were still aborning.
The Prevention of Primary Prevention, 1960-1994
Federal funding under the Community Mental Health Centers Act was on a decreasing share basis with the centers becoming fully reliant on state and local funding after four years. The states did not consider indirect or general community services, such as primary prevention, to be as critical to their mission as direct services, particularly services to the chronically mentally ill (Jerrell & Larsen, 1984, 1985). They already had heavy budgetary commitments to care for chronic psychotics in state hospit and had little interest in taking on new budgetary burdens for community services unless those services directly affected a reduction in costs for state hospital operations. Primary prevention could do this, but it was a long range and untested promise. Discharging patients from the state hospitals to outpatient or day hospital care at the CMHCs was an immediate budgetary gain.
The low priority (or non-priority) given to primary prevention by state departments' of mental health has played a major role in preventing primary prevention. With its low priority, primary prevention has occupied less than 5% of CMHC staff time nationally (Klein & Goldston, 1977).
DON'T FUND IT
The priorities discussed above have largely been funding priorities. Mental health services have made "a decided effort to remain closely aligned with public funding sources and policies" (Larsen, 1987). The failure of primary prevention has in large part been due to a lack of interest in prevention on the part of funders.
This has been compounded by the lack of appropriate funding mechanisms to pay for the prevention of mental illness. You can bill an insurance company, Medicare or Medicaid for fifty minutes of psychotherapy or a group therapy session but you can't bill them for reducing the incidence of schizophrenia by 2 per 1,000. As third party payment has become more important this has increasingly become a barrier to primary prevention. With new proposals for national health care reform placing emphasis on managed care and a single payer system, primary prevention may be even more difficult to finance following reform.
It is worth noting that the fifth "essential service" of consultation and education is perhaps the most billable of all primary prevention activities. The institution or person which receives the consultation can be billed for the service. Education in the form of continuing education workshops or lectures can charge tuition. Community organization, advocacy services or mass media campaigns are hard to bill either individuals or insurers for. Thus the failure to provide dedicated funding for primary prevention has served to channel preventionist's efforts into the most narrowly focused and clinically oriented form of prevention activities.
EMPHASIZE INDIVIDUAL CHANGE
Primary prevention programs have largely attempted to reach their goals by influencing individuals to change their behavior. This flies in the face of the well established public health maxim that the most effective programs are those which do not rely on voluntary behavior change. Instead of chlorinating public water supplies, we could urge everyone to boil their water or use water purification tablets before drinking any water. We could, but many people would get sick if we did. We see that whenever there is a temporary breakdown in a civic water supply and a "boil water order" is issued -people get sick because they forgot or simply can't be bothered to boil water before using it.
It might be argued that there is no alternative to focusing on individual behavior change in preventing mental illness. Whether this is so or not is really an unanswered question. Since little else has been tried, no one really knows what else might work.
While behavior change may be an essential element in the prevention of mental disorders, it doesn't have to be approached on a one-to-one basis. As has been demonstrated by the Stanford Heart Disease Prevention Project (Maccoby, Farquhar, Wood, & Alexander, 1977), significant behavior change in community populations can be brought about through mass media campaigns. That study also suggested that the addition of intensive educational and support services aimed at individuals produced only marginal increases over the effects of mass media alone.
STAFF IT WITH CLINICIANS
The prevention of mental illness has largely been placed in the hands of professionals who have been trained primarily in the treatment of mental illness. In large part this has been due to the first two strategies above. Since primary prevention had a low priority and was largely unfunded, it was not often possible to employ staff specifically as preventionists. Instead clinicians were expected to devote a part of their time to consultation and education. This added to the focus of prevention on relatively narrow approaches to individual behavior change.
Putting clinicians in charge placed primary prevention in the hands of professionals who had no training in prevention and usually little interest in it. Clinicians obviously were oriented toward clinical methods, not social action or mass education. They were accustomed to pursuing individual rather than community goals.
SET UNREALISTIC OR IMPOSSIBLE GOALS
One way that primary prevention has been successfully sabotaged has been by setting unattainable goals for prevention. Then when the program falls short of its goal it can be cancelled as a failure. With enough such preordained failures the very concept of prevention can be discredited.
One of the more absurd instances of this which I have encountered several times involves the use of repeated student drug surveys in evaluating drug abuse prevention. Frequently these surveys measure lifetime prevalence by asking, "have you ever used...... When a goal of reducing that prevalence is set, the program is doomed to failure. You can't reduce the lifetime prevalence of drug use in a group. Whatever drugs the targets of a program have used in the past, no program can reach back into thei past and make them unuse those drugs.
In many ways the field of drug abuse prevention has been particularly plagued by this problem. Drug abuse prevention has often been confused with drug use prevention. Instead of focusing on the minority whose use of a drug is pathological, drug abuse preventionists have attempted to eliminate all use of illicit drugs. History suggests that this is an impossible goal. Once a drug has become widely used, no society has ever succeeded in eliminating use of the drug.
BIOLOGIZE THE PROBLEM
The fifth strategy, which has seen increasing use in recent years, is to depict mental illness as a purely biological problem and thus unamenable to the largely psychosocial methods of primary prevention. More and more, it has been asserted that schizophrenia is genetic. There is a gene for manic depression. Heroin addiction is a metabolic disorder. Alcoholism is hereditary. Violence is the product of an abnormal brain structure.
Such ideas tend to support the view that mental illness is inevitable. If the causes of mental illness lie in our genes, then it is argued that there is nothing we can do to prevent mental illness. Someday, it is asserted, we may be able to identify those genetically predisposed to mental illness and to apply some form of gene therapy to prevent the onset of the disorder.
This is not unlike the period when, in the wake of Pasteur's advances in germ theory, it was decided that mental illness too must be due to infection with some germ. It was concluded that it was pointless to try to treat the mentally ill until the causative germ could be identified. Thus began the long era of warehousing the mentally ill in massive hospitals. While promising approaches to treatment were abandoned as being "unscientific," the microscope became a fixture in mental hospital labs- examine the brains of patients when they died, in search of the germ of madness.
In summary, the threat that primary prevention seemed to present in the 1960's-that the incidence of mental illness might be drastically reduced - has been effectively forestalled. Examining this successful example of public policy nonimplementation I have identified six strategies by which primary prevention has been prevented. Policymakers wishing to prevent similar innovations in the future would be well advised to adopt these same strategies: first, don't assign it a high priority; second, don't fund it; third, focus implementation on individual behavior change; fourth, staff it with clinicians; fifth, set unrealistic or impossible goals; sixth, biologize the problem as far as possible.
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