Preventive Medicine: Preventive Medicine 3

Disease, Illness, and Disability

• Disease is defined as a medical condition or diagnosis, e.g., diabetes, heart disease, chronic obstructive lung disease.
• Disability is the adverse impact of a disease on objective physical, psychological, and social functioning.
• Illness is the adverse impact of a disease or disability on how the patient feels.
• Illness perceptions strongly predict recovery, loss of workdays, adherence, and healthcare utilization.

Opportunities for Tertiary Prevention

• The first sign of an illness provides an excellent opportunity to initiate tertiary prevention methods.
• Early treatment of infectious diseases can prevent their transmission to others.
• Early treatment of alcoholism or drug addiction can prevent social and emotional problems in family members.
• Symptomatic illness can identify individuals most in need of preventive efforts.
• The onset of symptoms can provide a "teachable moment" for health promotion aimed at preventing disease progression.

Disability Limitation

• Disability limitation includes therapy and attempts to halt or limit future progression of the disease.
• Most medical or surgical therapy of symptomatic disease is directed at preventing or minimizing impairment.
• Strategies of symptomatic stage prevention include modifying diet, behavior, and environment, screening frequently for incipient complications, and treating any complication that is discovered.

Cardiovascular Disease

• Cardiovascular disease encompasses coronary artery disease, cerebrovascular accident (stroke), heart failure, and peripheral artery disease.
• The clinician's immediate goal is to prevent death and permanent damage, and then to slow, stop, or even reverse the progression of the disease process.
• Risk factors to be addressed to slow or reverse disease progression include hypertension, smoking, dyslipidemia, diabetes, diet, and exercise.

Risk Factor Modification

• Modifiable risk factors to address in cardiovascular disease include hypertension, smoking, dyslipidemia, diabetes, diet, and exercise.
• Smoking cessation is probably the most effective behavioral change a patient can make when cardiovascular disease is present.
• Diabetes mellitus increases the risk of repeat MI or restenosis of coronary arteries.
• Hypertension increases the risk of cardiovascular disease, and severe hypertension approximately quadruples the risk.

Rehabilitation

• Rehabilitation occurs after disease has already caused damage, and aims to reduce the social disability produced by a given level of impairment.
• Rehabilitation must begin in the early phases of treatment to be maximally effective.
• A rehabilitation program is tailored to meet the physical, emotional, psychological, and occupational needs of the individual.
• Rehabilitation specialists can contribute to a patient's progress back from an illness.

Categories of Disability

• Disability is a socially defined concept with practical implications for financial support.
• Most states delineate several categories for reimbursement of workers who have job-related injuries or illnesses, including permanent total disability, permanent partial disability, temporary total disability, temporary partial disability, and death.

Risk and Protective Factors for Mental Health and Behavioral Disorders

Biologic Risk Factors

• Genetics account for 30-40% of risk for anxiety and depression, and 50-60% of risk for substance dependence
• Endophenotypes are inherited traits that increase risk of disorder and are present before disorder is expressed
• Other biologic factors associated with dysphoric mood:
  • Hormonal changes (e.g., postpartum onset)
  • Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)
  • Amount of daylight (e.g., seasonal pattern)
  • Disturbances of circadian rhythm

Psychological Risk Factors

• Maladaptive thought patterns contribute to anxiety and depression
• Negative expectancies do not deter substance use, while positive expectancies increase use
• Perceived burden and thwarted belongingness increase risk of suicidal ideation
• Past suicidal behavior is a strong predictor of future attempts

Social Risk Factors

• Exposure to anxious parents increases risk of anxiety disorder
• Exposure to substance-using peers increases risk of substance use disorder
• Parental depression increases risk of depression in offspring
• Direct exposure to threatening stimuli (e.g., trauma, social evaluation) increases risk of anxiety and depression
• Poverty, social isolation, and inadequate access to health services increase risk of mental health and behavioral problems

Cultural/Diversity Factors

• Women are more likely to experience anxiety and mood disorders, while men are more likely to experience substance use disorders
• Racial and ethnic minorities are at higher risk for mental health and behavioral problems due to social and economic disparities
• Age is a risk factor for mental health and behavioral problems, with some research suggesting older adults are at higher risk, while others suggest young adults are at higher risk

Protective Factors

• Achieving developmental milestones, being physically healthy, and being physically active are associated with good mental health
• Possessing at least average cognitive ability is associated with lower rates of anxiety and depression
• Cognitive, social, environmental, and cultural factors contribute to good mental and behavioral health outcomes, including:
  • Secure attachment during infancy
  • Strong attachments to family, school, and community among adolescents
  • Social support and positive parenting practices
  • Adequate coping skills for managing stress
  • High self-esteem
  • Strong religious beliefs### Prevention and Intervention Strategies
• DARE program has been shown to be ineffective in preventing drug use among youth
• School-based interventions that teach drug refusal skills and address outcome expectancies can be effective in decreasing substance use
• Gatekeeper training improves knowledge, skills, and attitudes toward intervening and can reduce suicidal ideation and attempts

Brief Interventions

• Motivational interviewing (MI) is a brief intervention that can enhance treatment retention and reduce substance use and related negative consequences
• MI can also be effective in increasing motivation to engage in treatment for mental health disorders
• The five "A" program is a brief intervention designed to assist physicians in encouraging patients to quit smoking
  • Ask about smoking status
  • Advise patients to quit and provide feedback on health risks
  • Assess smoking status and health risks
  • Assist patients in quitting
  • Arrange a follow-up appointment

Longer-Term Interventions

• Early home-based interventions that facilitate maternal responsiveness and teach effective parenting skills can enhance resilience in at-risk children
• School-based and community-based programs that encourage prosocial behavior and teach empathy and cognitive skills can improve mental health and substance use outcomes
• Cognitive-behavioral therapy (CBT) is effective in treating anxiety, depression, and substance use disorders
  • Focuses on restructuring maladaptive cognition and teaching effective coping strategies
  • Can also be used to prevent a first depressive episode and promote sustained abstinence

Treatment of Substance Dependence

• Contingency management (CM) models can increase motivation for abstinence and improve treatment compliance
  • Use reinforcements such as vouchers and retail items to encourage abstinence and participation in non-drug-related activities
• Social network and family models can increase social support and improve treatment outcomes
  • Involving drug-free family members and significant others in treatment can improve substance use outcomes

Medical/Pharmacologic Interventions

• Pharmacotherapies such as SSRIs and SNRIs can be effective for treating anxiety and depression, but may have limited effectiveness after medication discontinuation
• Cognitive therapy is more effective than pharmacotherapy for preventing relapse after medication discontinuation
• Pharmacologic interventions for substance use can encourage abstinence initiation or prevent relapse
  • Antagonists block the effects of drugs and induce withdrawal symptoms
  • Agonists mimic the effects of drugs and prevent withdrawal
  • Vaccines prevent drugs from entering the brain and reduce euphoric effects