Introduction
Disease burden
● Burden of disease is expressed in Disability Adjusted Life Years (DALY’s) → the amount of one-year health
loss in a population
● Combines Years of Life Lost due to mortality (YLLs) and Years of healthy life Lost due to Disability (YLDs)
● 1 DALY = 1 year of healthy life lost
● 0 DALY = perfect health
Key insights of the figure of global DALYs by
mental health disorder, sex and age.
● The overall global burden of mental
health disorders increased from 1990
to 2019
● The burden is highest among
adolescents and young adults (10-24
years)
● Women tend to have a slightly higher
DALY burden than men, likely due to
greater prevalence of anxiety and
depression in females
● Depressive disorders are the largest
contributor to DALYs, significantly
impacting quality of life
There are different reasons why the global burden of disease of mental health disorders may be underestimated:
● People with personality disorders are not included
● Indirect contributions of mental health disorders to mortality
● Suicide and self-harm are grouped under injuries (in some countries)
● Overlap with other (neurological) disorders
● People with chronic pain disorders are not included
→ considering these aspects and including them would rise the proportion due to mental health disorders to 16% of
global DALYs and also cause a bigger economic burden
Mental health or well-being refers to positive emotional well-being, psychological- and social functioning
Why treatment alone is not enough:
● Treatment may only reduce a part of the burden
● Treatment is not always effective (small effect sizes are found for psychotherapy and pharmacotherapies)
● High relapse rates for some diseases;
● 70% of the people who need it do not have access to care mental health care facilities
, Key concepts in prevention
Continuum of care:
● Treatment: care give to person with illness or injury to cure, heal, or repair
● Health promotion: promoting positive health by increasing well-being, competence, resilience, and
creating supportive living conditions and environments
● Prevention: reduction of incidence, prevalence, recurrence of disorders (prevent onset of disease)
○ Preventive interventions → reducing exposure to risk factors, enhancing protective factors, and
targeting putative mediating causal mechanisms.
Classification of prevention:
● Traditional medicine (focused on disease phase):
○ Primary: prevent onset of a disorder
○ Secondary: early identification and treatment in those diagnosed
○ Tertiary: prevent recurrence, relapse, or worsening (disability)
● Mental health primary prevention (focused on groups):
○ Universal: targeting the population
○ Selective: target subgroups that are at risk
○ Indicated: target people in the early stages who experience symptoms
Target Aims Examples
Universal General Target risk and protective factors to Improving maternal nutrition (i.e. supplementation
prevention population prevent development of one or more during pregnancy or promoting effective parenting)
conditions
Restriction of access to lethal means and
school-based awareness programmes to reduce
suicidality.
Selective Subgroups at risk Target risk factors and strengthen Psychosocial interventions to prevent eating
prevention abilities to prevent development of one disorders in adolescents with body image issues
or more conditions
Prevent PTSD at people exposed to a traumatic
event
Indicated People with Treat subclinical manifestations to Mindfulness training for people with mild symptoms
prevention subthreshold prevent full-blown disorder of depression
symptoms
Target risk factors and strengthen Parent management training to prevent
abilities to promote resilience externalizing disorders in children with high
antisocial behavior scores
CBT to prevent PTSD in patients showing early
acute stress symptoms after a traumatic event
,You can divide universal, selective and indicated intervention in three different types:
● Psychological interventions → using psychological strategies such as cognitive-behavioral therapy (CBT),
aimed at restructuring cognitive patterns and behaviors.
● Educational interventions → focusing solely on providing information without cognitive restructuring
techniques, such as lectures, workshops, or pamphlets.
● Physical interventions → involving physical-based exercises, such as team sports or yoga, to promote
mental health and reduce symptoms.
Prevention strategies and challenges
Different strategies for prevention:
● Complex programs → multiple components in one intervention
● Programmatic approaches → multiple strategies at once, always connected as a whole
○ Micro (e.g. self-help interventions)
○ Meso (e.g. support groups)
○ Macro (e.g. mass media campaigns) - universal prevention
Challenges in prevention
In practice:
● Complexity: you don’t know if the disorder will occur
● Low uptake (methods to increase help-seeking rates include universal prevention or gatekeeper training)
In research:
● High numbers needed to treat: studies need a large sample size
● Prevention studies need a long follow-up: takes long time before disorder develops
● Programs and risk factors are generic: what disorder do you want to prevent?
● Reaching people who are not integrated into an existing system such as schools,workplace, hospitals etc.
Risk and protective factors
Diathesis-stress model → a psychological framework that explains how mental health disorders or childhood
problems develop as a result of the interaction between genetic predispositions (diathesis) and environmental
stressors (stressful life events), problems arise when a predisposition is "activated" by stressors. Both are needed
for the development of a disorder:
● Diathesis → predisposition or vulnerability to a disorder
● Stress → the occurrence of severe environmental stressor or life event
Facilitation effect → once vulnerable or already exposed to risk factors, make it more likely that further risk factors
may lead to a vicious cycle.
Risk factors (direct or indirect effect) Protective factors
- Genetic (e.g., family history of mental health - Resilience
disorders) - Social support
○ Biological mechanisms can help refine - Good interpersonal
interventions and understand their impact on relationships
brain plasticity and recovery - High self-esteem
○ Biological systems play a role in resilience - Good physical health
and long-term psychological adaptation
○ Genetic variations may impact intervention
efficacy
- Biological (e.g., brain trauma of physical health)
- Family related (e.g., parental neglect)
- Socio-Environmental (e.g., housing quality,
inequality)
- Societal (e.g., social adversity, stigma)
- Life-events
, Investigation of early stages of mental disorders integrating different dimensions
● Genetic → having a parent or sibling with depression increases your chances of developing it too.
● Transcriptomic (gene activity) → stress can change activity in genes related to inflammation and stress
response, long term stress can cause problems in mood and behavior.
● Neurobiological → examining reduced hippocampal volume in individuals with a family history of major
depressive disorder (MDD)
● Psychological → assessing early signs of cognitive distortions or maladaptive coping mechanisms in
adolescents with subclinical anxiety symptoms.
● Socio-economic → growing up in a neighborhood with high unemployment or unsafe conditions can
increase the risk of depression.
Opportunities for prevention during development
● Enhancing protective factors to prevent multiple-hit → the cumulative effect of risk and lack of protective
factors during development can lead to a transition from mental health to mental illness.
○ Even if early risk factors are present, in the absence of additional “hits”, a disorder may not
develop by enhancing protective factors like resilience.
● Intervene in the (subtle) developmental process of any mental condition (indicated prevention)
○ Offering CBT to subjects at clinical high risk (CHR) for psychosis may lead to a reduction in
transition rates to psychosis or a delay of onset
○ ADHD treatment for kids may improve or stabilize social functioning and academic performance.
The rate of conduct disorders and social problems may decrease in adolescence and adulthood,
stopping a potential downward spiral.
● Active prevention during sensitive periods (e.g. prenatal period, childhood, puberty)
Other types of intervention
Target population Aims Examples
Health General public or Promote psychological wellbeing and School-based programmes to foster healthy
promotion whole population increase the ability to achieve eating or positive coping skills
developmental milestones
Strengthen abilities to adapt to adversity
and build resilience and competence
Secondary Individuals meeting Early intervention in patients already Interventions to improve early detection
prevention diagnostic criteria in meeting diagnostic criteria for a specific and access to services in patients with
the early stages of mental disorder depression to reduce duration of untreated
illness depression
Provide adequate treatment, improve
satisfaction with treatment, reduce
substance use and prevent relapses
Tertiary Individuals with Treat established disease to prevent Interventions for quitting smoking in
prevention established illness deterioration, disability, and secondary patients with schizophrenia
conditions
Prevention of suicide with lithium in
patients with bipolar disorder
Indirect Individuals Focuses on less stigmatising problems that Preventing onset of depression by
prevention experiencing are related to the bigger mental illness, but intervening insomnia
/treatment different symptoms not directly on the illness itself
of a certain mental Preventing the onset of depression or
disorder but are anxiety at perinatal women scoring high on
unwilling to seek help perfectionism.
Disease burden
● Burden of disease is expressed in Disability Adjusted Life Years (DALY’s) → the amount of one-year health
loss in a population
● Combines Years of Life Lost due to mortality (YLLs) and Years of healthy life Lost due to Disability (YLDs)
● 1 DALY = 1 year of healthy life lost
● 0 DALY = perfect health
Key insights of the figure of global DALYs by
mental health disorder, sex and age.
● The overall global burden of mental
health disorders increased from 1990
to 2019
● The burden is highest among
adolescents and young adults (10-24
years)
● Women tend to have a slightly higher
DALY burden than men, likely due to
greater prevalence of anxiety and
depression in females
● Depressive disorders are the largest
contributor to DALYs, significantly
impacting quality of life
There are different reasons why the global burden of disease of mental health disorders may be underestimated:
● People with personality disorders are not included
● Indirect contributions of mental health disorders to mortality
● Suicide and self-harm are grouped under injuries (in some countries)
● Overlap with other (neurological) disorders
● People with chronic pain disorders are not included
→ considering these aspects and including them would rise the proportion due to mental health disorders to 16% of
global DALYs and also cause a bigger economic burden
Mental health or well-being refers to positive emotional well-being, psychological- and social functioning
Why treatment alone is not enough:
● Treatment may only reduce a part of the burden
● Treatment is not always effective (small effect sizes are found for psychotherapy and pharmacotherapies)
● High relapse rates for some diseases;
● 70% of the people who need it do not have access to care mental health care facilities
, Key concepts in prevention
Continuum of care:
● Treatment: care give to person with illness or injury to cure, heal, or repair
● Health promotion: promoting positive health by increasing well-being, competence, resilience, and
creating supportive living conditions and environments
● Prevention: reduction of incidence, prevalence, recurrence of disorders (prevent onset of disease)
○ Preventive interventions → reducing exposure to risk factors, enhancing protective factors, and
targeting putative mediating causal mechanisms.
Classification of prevention:
● Traditional medicine (focused on disease phase):
○ Primary: prevent onset of a disorder
○ Secondary: early identification and treatment in those diagnosed
○ Tertiary: prevent recurrence, relapse, or worsening (disability)
● Mental health primary prevention (focused on groups):
○ Universal: targeting the population
○ Selective: target subgroups that are at risk
○ Indicated: target people in the early stages who experience symptoms
Target Aims Examples
Universal General Target risk and protective factors to Improving maternal nutrition (i.e. supplementation
prevention population prevent development of one or more during pregnancy or promoting effective parenting)
conditions
Restriction of access to lethal means and
school-based awareness programmes to reduce
suicidality.
Selective Subgroups at risk Target risk factors and strengthen Psychosocial interventions to prevent eating
prevention abilities to prevent development of one disorders in adolescents with body image issues
or more conditions
Prevent PTSD at people exposed to a traumatic
event
Indicated People with Treat subclinical manifestations to Mindfulness training for people with mild symptoms
prevention subthreshold prevent full-blown disorder of depression
symptoms
Target risk factors and strengthen Parent management training to prevent
abilities to promote resilience externalizing disorders in children with high
antisocial behavior scores
CBT to prevent PTSD in patients showing early
acute stress symptoms after a traumatic event
,You can divide universal, selective and indicated intervention in three different types:
● Psychological interventions → using psychological strategies such as cognitive-behavioral therapy (CBT),
aimed at restructuring cognitive patterns and behaviors.
● Educational interventions → focusing solely on providing information without cognitive restructuring
techniques, such as lectures, workshops, or pamphlets.
● Physical interventions → involving physical-based exercises, such as team sports or yoga, to promote
mental health and reduce symptoms.
Prevention strategies and challenges
Different strategies for prevention:
● Complex programs → multiple components in one intervention
● Programmatic approaches → multiple strategies at once, always connected as a whole
○ Micro (e.g. self-help interventions)
○ Meso (e.g. support groups)
○ Macro (e.g. mass media campaigns) - universal prevention
Challenges in prevention
In practice:
● Complexity: you don’t know if the disorder will occur
● Low uptake (methods to increase help-seeking rates include universal prevention or gatekeeper training)
In research:
● High numbers needed to treat: studies need a large sample size
● Prevention studies need a long follow-up: takes long time before disorder develops
● Programs and risk factors are generic: what disorder do you want to prevent?
● Reaching people who are not integrated into an existing system such as schools,workplace, hospitals etc.
Risk and protective factors
Diathesis-stress model → a psychological framework that explains how mental health disorders or childhood
problems develop as a result of the interaction between genetic predispositions (diathesis) and environmental
stressors (stressful life events), problems arise when a predisposition is "activated" by stressors. Both are needed
for the development of a disorder:
● Diathesis → predisposition or vulnerability to a disorder
● Stress → the occurrence of severe environmental stressor or life event
Facilitation effect → once vulnerable or already exposed to risk factors, make it more likely that further risk factors
may lead to a vicious cycle.
Risk factors (direct or indirect effect) Protective factors
- Genetic (e.g., family history of mental health - Resilience
disorders) - Social support
○ Biological mechanisms can help refine - Good interpersonal
interventions and understand their impact on relationships
brain plasticity and recovery - High self-esteem
○ Biological systems play a role in resilience - Good physical health
and long-term psychological adaptation
○ Genetic variations may impact intervention
efficacy
- Biological (e.g., brain trauma of physical health)
- Family related (e.g., parental neglect)
- Socio-Environmental (e.g., housing quality,
inequality)
- Societal (e.g., social adversity, stigma)
- Life-events
, Investigation of early stages of mental disorders integrating different dimensions
● Genetic → having a parent or sibling with depression increases your chances of developing it too.
● Transcriptomic (gene activity) → stress can change activity in genes related to inflammation and stress
response, long term stress can cause problems in mood and behavior.
● Neurobiological → examining reduced hippocampal volume in individuals with a family history of major
depressive disorder (MDD)
● Psychological → assessing early signs of cognitive distortions or maladaptive coping mechanisms in
adolescents with subclinical anxiety symptoms.
● Socio-economic → growing up in a neighborhood with high unemployment or unsafe conditions can
increase the risk of depression.
Opportunities for prevention during development
● Enhancing protective factors to prevent multiple-hit → the cumulative effect of risk and lack of protective
factors during development can lead to a transition from mental health to mental illness.
○ Even if early risk factors are present, in the absence of additional “hits”, a disorder may not
develop by enhancing protective factors like resilience.
● Intervene in the (subtle) developmental process of any mental condition (indicated prevention)
○ Offering CBT to subjects at clinical high risk (CHR) for psychosis may lead to a reduction in
transition rates to psychosis or a delay of onset
○ ADHD treatment for kids may improve or stabilize social functioning and academic performance.
The rate of conduct disorders and social problems may decrease in adolescence and adulthood,
stopping a potential downward spiral.
● Active prevention during sensitive periods (e.g. prenatal period, childhood, puberty)
Other types of intervention
Target population Aims Examples
Health General public or Promote psychological wellbeing and School-based programmes to foster healthy
promotion whole population increase the ability to achieve eating or positive coping skills
developmental milestones
Strengthen abilities to adapt to adversity
and build resilience and competence
Secondary Individuals meeting Early intervention in patients already Interventions to improve early detection
prevention diagnostic criteria in meeting diagnostic criteria for a specific and access to services in patients with
the early stages of mental disorder depression to reduce duration of untreated
illness depression
Provide adequate treatment, improve
satisfaction with treatment, reduce
substance use and prevent relapses
Tertiary Individuals with Treat established disease to prevent Interventions for quitting smoking in
prevention established illness deterioration, disability, and secondary patients with schizophrenia
conditions
Prevention of suicide with lithium in
patients with bipolar disorder
Indirect Individuals Focuses on less stigmatising problems that Preventing onset of depression by
prevention experiencing are related to the bigger mental illness, but intervening insomnia
/treatment different symptoms not directly on the illness itself
of a certain mental Preventing the onset of depression or
disorder but are anxiety at perinatal women scoring high on
unwilling to seek help perfectionism.
