Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services

I. Executive Summary

This report has been prepared to summarize the most promising preventive interventions of a behavioral nature intended to impact mental and substance use disorders, or in some cases, medical outcomes. This review focuses on prevention interventions that are primarily delivered by health care systems. Interventions provided in schools, worksites, communities, and criminal justice systems were excluded, as were population-based interventions.

The information provided here increases the rigor of a previous literature review published by SAMHSA in 2000 by Dorfman and updates it. That report was a first of its kind in that it reviewed the literature to identify preventive interventions in mental health and substance abuse that offer evidence for a positive effect on individuals, while imposing no additional cost to health plans, based on rigorous research studies. However, that report confined its discussion to only those studies with positive effects.

This newer report fills in the previous gaps by including all studies, regardless of outcome—even those with negative or no effects—and based on the literature, describes the optimal circumstances for implementing services and tracking costs. The descriptions may be most useful to health care organizations and providers in determining what preventive services to offer and how to implement them. The report may also be helpful to employee benefits designers and advisors, managed care organizations, employers, researchers, financial managers of health plans, and decisionmakers for benefit package services.

A common barrier is that although rigorous research exists, often there is a lag time in applying research findings to practice.

The literature included in this monograph was published in English between 1964 and mid-2003. More than 3,000 papers and related documents were reviewed, and of those, approximately 530 were appropriate to be included in this report. Most of the literature items reviewed are research studies summarizing randomized or other controlled trials, as well as other governmental recommendations that were based on rigorous research studies, such as the precedent-setting universal recommendation in 2002 by the Agency for Healthcare Quality Research that adults be screened for depression.

Because the field of prevention of mental or substance use disorders has not yet uncovered a “magic bullet” equivalent to a vaccine in clinical medicine, we must rely on associated indicators to identify individuals who are at risk for developing disorders. For example, we may target known risk factors, such as those associated with disadvantaged first-time young mothers, or increase protective factors that promote resilience. Based on the rigor of the research presented here, the breadth of applicability among interventions, and their potential costeffectiveness for health plans, effective behavioral preventive interventions can be classified as basic or “general,” or less widely applicable but “targeted” to certain groups at risk or within specific conditions.

The following interventions discussed here in detail have shown the greatest promise, based on the research reviewed, to diminish or prevent the development of a mental or substance use disorder. They can be categorized as “general” (universally applicable) or “targeted” to specific subgroups with certain risk factors.

Universal screening of pregnant women for use of tobacco, alcohol, and illicit drugs.
Home visitation for selected pregnant women, and some children up to age 5.
Supplemental educational services for vulnerable infants from disadvantaged families.
Screening children and adolescents for behavioral disorders.
Screening adolescents for tobacco, alcohol, depression, and anxiety.
Screening adults for depression and anxiety, and use of tobacco and/or alcohol.
Psychoeducation to increase early ambulation of surgical patients, adherence to prescribed regimens of care for patients with chronic diseases, and to decrease somatization of other patients. Psychoeducation refers to counseling integrated with health education to address emotional, perceptual, and psychological barriers to compliance with prescribed regimens of care. Somatization refers to true physical symptoms and true physical illnesses that are initially psychogenic in nature.

According to the literature, services exhibiting the greatest potential to reduce costs include screening pregnant women for use of tobacco, alcohol, or drugs, with follow-up services; screening and follow-up for depression or other major mental illnesses in persons with major, chronic medical illness; and psychoeducation for heavy users of health care services, persons with chronic diseases, or persons scheduled to undergo surgery. This publication presents an analysis of the research basis for providing these services and guidelines for implementation, data collection, and management.

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