Fostering an Ounce of Prevention, Many People at a Time

Already, it is very clear from national meetings held since October 1 that we have much work to do to adapt behavioral healthcare to the changes being introduced through the Affordable Care Act (ACA). Several major undertakings have very high priority for us: Helping uninsured persons with behavioral health conditions enroll in health insurance; helping them access care in a new way through medical and health homes; helping them access necessary wrap-around benefits, such as job and housing supports. Fortunately, each of these things is a logical extension of activities we already are doing. Hence, the transition should be relatively easy and seamless.

Much less clear is how we are going to reform behavioral healthcare so that it is not only a clinical discipline, but also a public health one. Here, I would like to begin to explore  the major features of this transformation.

Public health has three principal dimensions we will need to adapt to behavioral healthcare:

Intervention Target: Public health interventions address population and community health, rather than the health of a single person or family. This means that the intervention target is everyone in a population or community.

Intervention Type: Public health interventions may be directed at one person at a time, or simultaneously at all persons in a population or community. This means that the intervention type will vary, depending upon the problem being addressed.

Intervention Focus: Public health interventions frequently address disease prevention or health promotion, rather than disease treatment. This intervention focus is a hallmark of public health; disease prevention always trumps disease treatment.

In each of the following public health examples, the intervention target is a population or community, and the intervention focus is disease prevention. What varies is the intervention type. For a public water fluoridation program or an anti-smoking campaign, the intervention type is an entire population or community simultaneously, and for an influenza vaccination program and a blood pressure check program, the intervention type is a single person, one at a time.

As will become obvious to you with just a moment’s reflection, a single person is both the intervention target and the intervention type for most behavioral health interventions. Further, the intervention focus of most behavioral health work is disease treatment rather than disease prevention.

The ACA places great emphasis on disease prevention and health promotion. The Essential Health Benefit for the Qualified Health Plans in the state Marketplaces and the Alternative Benefit in the Medicaid Expansions include prevention and promotion as a mandatory benefit. Also, the Prevention and Wellness Fund provides resources for population and community interventions designed to prevent disease or to promote positive health.

In recent years, the substance use field has made considerable progress in developing, testing, and implementing interventions that target an entire population or community, that are directed simultaneously at all persons in a population or community or at single individuals in a community, and that focus on prevention, The Drug Free Communities Program is a good example of an intervention directed simultaneously at all persons in a community.. Similarly, Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a good example of an intervention directed toward one person at a time.

In mental health, considerable progress has been made in screening for depression, anxiety, and suicidal tendency through interventions directed toward one person at a time and in public ad campaigns directed simultaneously at an entire population or community. However, to my knowledge, no population or community interventions exist that focus on mental health disease prevention or health promotion.

Going forward, it will be very important for us to ask how we can amplify the progress that has been made and to begin to fill in obvious gaps with new interventions. New collaborations between public health and behavioral healthcare will be key to accelerating progress. New potential partners will include the American Public Health Association (APHA), the Association of State and Territorial Health Officers (ASTHO), and the National Association of City and County Health Officers (NACCHO), all of which employ a public health approach.

The adage remains true: An ounce of prevention is worth a pound of cure. Now we need to execute.