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

XI. Conclusions

This report summarizes the literature on preventive behavioral services to be delivered by health care systems to improve both medical and mental health outcomes. Some of the interventions covered in this report demonstrate potential to reduce health care expenditures within 12 months of program initiation, thus providing a “return on investment” in terms of short-term health care costs. Because of the enormity of the literature, not all potential behavioral preventive services that might be considered for implementation in health care settings have been covered. This report updates a previous SAMHSA literature revew on this topic published in 2000 (Dorfman, 2000).

This updated analysis of the literature suggests the following clinical preventive behavioral services as worthy of consideration for implementation in all health care settings:

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, use of illicit drugs, depression, and anxiety
Screening adults for use of tobacco, excessive use of alcohol, depression, and anxiety
Psychoeducation for persons scheduled for major surgical procedures, persons with major chronic diseases, and selected other heavy users of health care services

Of these, the following have the potential to reduce overall health care costs within 12 months of initiation of new or expanded preventive services:

Screening pregnant women for use of tobacco, alcohol, and illicit drugs
Screening for depression in persons with major chronic medical disease
Psychoeducation for persons scheduled for major surgical procedures, persons with major chronic diseases, and selected other heavy users of health care services

For many of these clinical preventive behavioral services, the effect size in randomized controlled trials is in the range of 5–30 percent. Therefore, the preventive interventions can be expected to reduce the burden of behavioral illnesses and substance use disorders, but not totally prevent them. Some of the reduction in burden will be the result of eliminating the problem entirely for some patients—usually those with mild or moderate risk of illness or substance use. The preventive services may also reduce the severity of illness in those more severely affected. Even with such seemingly modest effect sizes, the adverse consequences of the underlying disorders are such that the preventive services can be expected to pay for themselves in reduced health care costs and improved clinical and/or social outcomes.

Because of these seemingly modest effect sizes, health care systems are urged to track risk factors, process indicators, outcomes, and costs to document the efficacy and costefficiency of each of the suggested preventive interventions. These data will also be of value in securing the support of health care managers and fiscal officers for these preventive services. This monograph includes suggestions and guidelines for tracking these measures in a practical and cost-efficient manner.

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