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

IV. Overview of Interventions

A health care system could initiate a screening program for one disorder, or for a single age cohort, or for a life cycle group, and use the policy, management, and evaluation procedures as templates for other preventive behavioral services to other age and life-cycle groups. Two tabular summaries of screening topics based on age and life cycle groups addressed in this monograph follow:

Table 1: Summary of Universal Preventive Service Guidelines

	Tobacco	Alcohol	Illicit Drugs	Child/Adolescent Behavioral Disorders	Depression
Pregnant Women	General	General	General
Children and Adolescents (5–18 years)				Targeted
All Adolescents (12–18 years)	General	General	General		Targeted
Adults (19 years and older)	General	General			General

Table 1 summarizes the screening and follow-up guidelines for all patients within the life cycle group. Those designated as “general” are intended for all patients within that group. Pregnant women and adolescents should be screened for use of tobacco, alcohol, and illicit drugs. All adults should be screened for depression, as well as selected adolescents who are at unusually high risk. The use of the term “targeted,” relative to children and adolescents, reflects literature that shows the utility of a standardized questionnaire, the Pediatric Symptom Checklist, but the absence of published studies that demonstrate improved patient outcomes. All adults aged 19 and older are grouped into a single life cycle group. For the preventive behavioral services covered in this report, the guidelines are identical for seniors.

The robust literature search supports “general” services for implementation by all health care delivery systems. “Targeted” services can be considered by health care delivery systems, but they will only be appropriate for providers serving highly vulnerable populations or those with the staff expertise to effectively use guidelines and tools. They are either less well documented or are not to be universally applied. Screening pregnant women, adolescents, and adults and providing follow-up for tobacco use, inappropriate use of alcohol, illicit drug use, and depression may be regarded as “general” services, supported by rigorous replicated research studies, as are psychoeducational services for patients with chronic diseases and those scheduled for surgical procedures.

Table 2: Summary of Selective Preventive Service Guidelines

Pregnant Women; Children to Age 5	Targeted: Intensive case management, outreach, and home visitation services for selected families handicapped by social and economic dependency
	Targeted: Supplemental educational services for selected infants and preschool children born to mothers with mental retardation or selected other problems
Adults (19 years and older)	General: Psychoeducation and related services for patients with chronic disease
	General: Psychoeducation for patients scheduled for surgical procedures
	Targeted: Psychoeducation for patients with somatization

Table 2 summarizes the preventive behavioral interventions suggested for specific groups of patients. The first service with home visitation is targeted to high-risk pregnant women and their children through age 5. The second service is for children born to mothers with mental retardation or other limitation. The last three interventions on psychoeducation are for adults who fall into one of three categories.

The following are exceptions to the general guidance above:

There is no evidence that screening pregnant women for depression will reduce the prevalence or severity of postpartum depression, and the research is not yet sufficient to demonstrate that all adolescents and children should be screened for depression.
Community programs that address tobacco, alcohol, illicit drugs, behavioral disorders, and depression are all important preventive measures. In clinical settings, there appears to be no specific need for physicians and nurses to screen children for these disorders, as is suggested for adolescents and adults. Screening children and adults for other behavioral disorders may be considered a “targeted” service, as noted below.
Depression is a common and serious problem in adolescence. The screening modalities used in adults appear somewhat less specific for adolescents, and too few substantive studies exist on screening adolescents for depression to assert a robust evidence base. The USPSTF found insufficient evidence in 2002 to make a recommendation for universal depression screening of adolescents, similar to the one they made for adults.
Adults using illicit drugs should be treated vigorously for both the physical and psychological aspects of their addiction. That having been noted, the literature does not support screening all adults for use of illicit drugs.

Screening for child and adolescent behavioral disorders using the Pediatric Symptom Checklist (PSC) is widely used in many medical practices and Medicaid programs. The current literature documents the ability of this brief, one-page instrument to identify children in need of further behavioral evaluation. Unfortunately, there are no randomized controlled studies that compare outcomes on screened individuals with unscreened populations. Despite the fact that no randomized, controlled trials have been conducted, PSC screening is still classified here as “general” because of its low burden, ease of use, wide applicability, and potential cost-effectiveness.

The “targeted” services for pregnant women and infants handicapped by social and economic disadvantage can be considered under the general category for health care delivery systems serving Medicaid and “safety net” populations, but this designation may not be appropriate for other systems.

The supplemental educational services for infants and preschool children born to mothers with mental retardation or selected other problems are nonmedical services needed by infants and preschool children whose risk profiles are most obvious to their primary care providers. Health care delivery systems can identify the infants and children in need of these supplemental services and either provide the services or otherwise connect these infants and children to needed educational programming.

When dealing with patients who have heart disease, asthma, diabetes, or other major chronic illnesses, the term psychoeducation, as defined earlier, refers to counseling integrated with health education to address emotional, perceptual, and psychological barriers to compliance with prescribed regimens of care. The value and efficacy of psychoeducation for chronic disease patients is well established in the published literature (Spiegel, Kraemer, Bloom, & Gottheil, 1989; Roter et al., 1998; Hammerlid, Persson, Sullivan, & Westin, 1999; Dusseldorp, van Elderen, Maes, Meulman, & Kraaij, 1999; Von Korff et al., 1998; Winkler et al., 1989; Parcel et al., 1994; Mishel et al., 2002). Similar psychoeducational services have been shown to be of substantial value for both children and adults scheduled to undergo surgical procedures (Egbert et al., 1964; Mumford et al., 1982; Devine & Cook, 1983; Devine et al., 1988; Jay, Elliott, Fitzgibbons, Woody, & Siegel, 1995).

As previously defined, somatization describes true physical symptoms and true physical illnesses that are initially psychogenic in nature. Those who experience somatization use substantial medical resources but do not display physical illness adequate to explain their high use. Recent reviews have estimated the prevalence of somatoform disorders in the range of 10–15 percent of primary care patients (Kroenke, Spitzer, deGruy, & Swindle, 1998; Kirmayer & Robbins, 1991; Spitzer, Williams, et al., 1994; Kellner, Lin, Von Korff, et al., 1985) and documented the impact of these disorders on both quality of life and health care utilization (Kroenke et al., 1998; Katon, Lin, Von Korff, et al., 1991; Smith, Monson, & Ray, 1986; Swartz, Landerman, George, et al., 1991; Kroenke, Spitzer, deGruy, et al., 1997; Smith, 1994; Escobar, Rubio-Stipec, Canino, et al., 1989; Deighton & Nicol, 1985; Hiller, Rief, & Fichter, 1995). Although there are several studies suggesting that screening for somatization, followed by psychoeducational interventions is of value (Smith, Rost, & Kashner, 1995; Fifer et al., 2003), specification of exact screening and follow-up procedures is insufficient to suggest implementing psychoeducational services for somatization as a general clinical preventive service.

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