Lessons from Iceland: Developing scalable and sustainable community approaches for the prevention of mental disorders in young Australians
Introduction
It is widely acknowledged that common mental disorders impose a large and devastating burden on individuals, families and communities (Whiteford et al., 2013). Epidemiological data from Australia and abroad demonstrate that the age of onset for most common mental disorders is during childhood, adolescence or early adulthood (Steel et al., 2014). Because half of all mental disorders will have occurred by the age of 14 years, and it is widely accepted that mental health is closely connected to social and emotional development and early life experiences during this life phase, prevention efforts need to align with the period of risk. There are further vulnerabilities facing this age group – although adolescence is a time during which many mental disorders will first appear, treatment is often not accessed until many years after disorder onset. This age period thus presents a key window of opportunity for primary prevention, early identification of individuals at-risk, and providing treatment of those living with mental disorders (Steel et al., 2014).
National and international pressure on governments to prioritise the prevention of mental disorders is growing (Funk, 2016, Jorm and Reavley, 2013). In Australia, the federal government has responded to these demands by recognizing the importance of a coordinated, national prevention effort within the Fifth National Mental Health and Suicide Prevention Plan (Department of Health, 2017). However, to date there is no articulated blueprint or national strategy for the prevention of mental disorders in Australia.
Some of the underlying determinants of common mental disorders overlap with established risk factors for other non-communicable diseases, such as pre-conception and perinatal parental health, early life nutrition, and socioeconomic disadvantage, which are challenging to address. Risk factors that are strongly associated with mental disorders also include family history, early life trauma, life stress, and bullying (Cairns et al., 2014, Kendler et al., 1995, Saha et al., 2013, Uher, 2014). The challenges of addressing such risk factors have limited the development and implementation of universal prevention strategies for mental disorders to date. Despite these complexities, universal strategies remain the preferred approach, whereby interventions target entire populations as opposed to specific at-risk groups, as they offer greater impact at the population level and are less stigmatising for individuals (Cairns et al., 2014, Nehmy, 2010, Offord, 2000, Pössel, 2005). Such approaches also target other non-communicable disorders, which share common risk determinants, enhancing the denominator of the cost/benefit ratio. Further, such strategies are more likely to become socially embedded, therefore normalising protective and risk reduction practices (Ormel et al., 2019).
Primary prevention aims to reduce the underlying risks and promote protective factors prior to onset of illness or disease (Bonita, Beaglehole, & Kjellström, 2006). Among young people, prevention interventions often occur in school settings and these are often universal in nature. Such school-based programs have generally targeted single or few risk factors at a time and have primarily focused on Cognitive Behavioural Therapy techniques and/or social and emotional learning. A systematic review published in 2017 concluded that school-based prevention programs targeting anxiety and depression through psycho-education offered modest, short-term positive effects (Werner-Seidler et al., 2017). Similarly, a meta-analysis of 146 depression and anxiety prevention programs for young people suggested that most programs were psychoeducational, school-based, and reported effect sizes that were small in magnitude and short-lived (Stockings et al., 2016). Whilst comprehensive, this review did not evaluate interventions other than psychoeducation programs. These do not target many of the potentially modifiable risk factors known to precede mental disorders and there are a number of other prevention pathways that could offer benefits for young people's mental health. A meta-analysis of 213 school-based social and emotional learning (SEL) programs showed improved social and emotional skills, attitudes, behaviour and academic outcomes (Durlak et al., 2011). SEL programs aimed to build competencies and skills such as managing emotions and interpersonal relationships, goal setting, and respecting others perspectives. Prevention strategies targeting settings outside of schools have included internet based programs, parenting programs, mental health based service provision, and programs in sporting and other community health based settings (Burns and Birrell, 2014, Pierce et al., 2010, Stewart-Brown and Schrader-Mcmillan, 2011). Despite observable benefits, these programs focus predominately on building individual-level competencies and fail to capture the breadth of risk factors for mental disorders. It is conceivable that combining individual-level interventions with those targeted to family, school and community settings could greatly improve adolescent mental health outcomes. Such approaches are also more likely to be sustained and structurally embedded in social systems (Ormel et al., 2019).
It is now widely acknowledged that the determinants of common mental disorders extend beyond psychosocial risk factors. For example, there is evidence that lifestyle and substance use behaviours are modifiable determinants of common mental and other non-communicable disorders and are therefore key prevention targets (Cairns et al., 2014). Ebert and Cuijpers (2018) recently highlighted that collaborations across subfields of prevention, targeting underlying determinants of mental disorders including health behaviours, social isolation, adverse childhood experiences, and poor physical health, will offer the greatest potential for the prevention of anxiety or depression. While there are risk factors that are clearly specific to mental disorders, such as bullying, it is important to emphasise that many of the identified modifiable risk factors are shared with other non-communicable diseases; this means that the preventive benefits are likely to extend beyond mental health. Given the current burden attributed to common mental disorders, there is a clear need for further implementation and evaluation of universal preventive interventions that extend beyond psychoeducation.
In this viewpoint article, we argue that to maximise primary prevention of common mental disorders among young Australians, a comprehensive community-based approach that aims to strengthen underlying protective factors and reduce known risk factors is needed. Such an approach would assume complexity in underlying determinants, be adaptive to context, engage and utilise existing structures and systems and afford a common framework to which researchers, community leaders, government personnel, policy makers, parents, health services and clinicians could refer. We present recommendations for the development of a conceptual model informed by successes observed in a multi-component, community-wide prevention framework, the Icelandic Prevention Model.
Section snippets
Icelandic Prevention Model
The Icelandic Prevention Model is a pioneering, nation-wide program aimed at preventing the onset of adolescent alcohol, tobacco and other drug use (Sigfúsdóttir et al., 2008). Initiated in 1998, the approach has successfully led to a range of positive outcomes, including a reduction of teenage alcohol use; e.g. in 1998, 42% of 15–16 year-olds reported being intoxicated in the previous 30 days, while in 2017, this fell to 5%. Other findings included substantial increases in levels of parental
Conclusion
The Icelandic Model is pioneering in that it has successfully reduced adolescent substance abuse through coordinating local action, utilising real-time data driven evidence, and through focusing on the myriad of factors known to promote and protect engagement in risk behaviour. Given limitations of sustained and effective preventive efforts in Australian communities to date, we propose there are promising and novel insights to be gained from the application of this model in Australian context.
Acknowledgements
EH is supported by an Australian Rotary Health Postdoctoral Fellowship. SA is supported by funding from an Australian National Health and Medical Research Council/Australian National Heart Foundation Career Development Fellowship (APP1045836). FNJ is supported by an NHMRC Career Development Fellowship (2) (#1108125). MB is supported by a NHMRC Senior Principal Research Fellowship (1059660).
Conflict of interest
None to declare.
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