Prevention of mental disorders implies preventing their occurrence in non-affected individuals or reducing relapse frequency, symptom burden, and overall impact in affected patients and their families. This popular concept had its early moorings in the mental hygiene movement, called so because of its similarities with other hygienic practices that seek to establish a set of conditions or practices for good health. Specifically, it invokes the use of positive psychological interventions and cognitive training activities, such as meditation (Tremblay et al., 2021).
Subsequently, the movement lost momentum till around 1980s when develop-ment and testing of evidence-based mental health prevention strategies regained researcher attention. These approaches work on a broad range of risk and protective factors that have been shown to influence morbidity measures of mental illness. Examples of these are interventions focusing on reducing social, health, and eco-nomic inequities, improving access to health care and job market, reducing stigma and discrimination, and reducing violent conflicts in the community (Singh et al., 2022).
Based on the nature of interventions and target group, prevention activities can be organized into primary, secondary, and tertiary prevention. Primary prevention may target the general population to prevent mental illness or morbidity (universal prevention), or those who are deemed to be vulnerable to develop mental disorders or representing a “high-risk” subgroup for the same (selective prevention), or indi-viduals showing attenuated early clinical signs and symptoms thought to herald a mental illness (indicated prevention). Secondary prevention involves early diagno-sis and treatment of mental disorders, while tertiary prevention is aimed at reducing relapses and improving clinical and functional outcomes in those with mental illness.
Mental health promotion, on the other hand, is an approach that aims to improve population wellness, in terms of mental health, by promoting mental well-being, improving psychological resilience, and leveraging intersectoral collaboration to foster supportive environments. At its heart, it aims to promote positive mental health and well-being; in contrast, mental health prevention is illness-based with a focus on strategies aimed at preventing mental illness. As can be easily discerned, the scope of mental health promotion is likely to be broader and span various set-tings, life stages, and population subgroups. The focus of most of these interven-tions has been to strengthen protective factors through individual or group cognitive behavior therapy or improving self-efficacy.
Examples of mental health promotion interventions include home-based inter-ventions aimed at supporting positive parenting practices, improving family sup-port, and preventing child abuse. Promotion of healthy caregiver–child interaction can have beneficial spinoffs on psychological resilience of the child, which will improve their ability to withstand later life adversities and promote lifelong mental well-being.
School or educational institution-based interventions, rooted in ecological sys-tems theory, aim to provide an environment that promotes socioemotional develop-ment among children. Specific activities are intended to improve a broad range of outcomes such as mental health, emotional and moral literacy, emotional intelli-gence, interpersonal awareness, self-efficacy, resilience, life skills, and character development. The beneficial impact of these interventions has extended beyond reduction of anxiety, depression, and delinquency at schools to improvement in scholastic record and social and emotional competence.
Other types of mental health promotion interventions include workplace inter-ventions that have mainly focused on providing supportive workplace environments to reduce harassment and improve employee participation and job satisfaction. Finally, community-based interventions that seek to strengthen local resources for self-care and social support and improve capacity for delivering mental health first aid have seen renewed interest. Salient features of these interventions include a community-based participatory approach, use of self-help guides to empower people to offer support till professional help is available, and capacity building by partnering with the community to enhance local capacity for self-help (Sharma et al., 2017).
Risk Assessment in Suicide: An Evidence-Informed Approach
Suicide risk assessment is an important procedure employed by mental health pro-fessionals to evaluate an individual’s degree of suicide risk. Despite risk assessment being a core competency, many mental health professionals feel inadequate when performing it. The main goal of risk assessment is to provide sufficient information on risk and protective factors to feed into a risk formulation that guides clinical tri-aging, management, and prevention efforts (Menon, 2013).
Major domains of risk assessment involve evidence-based risk factors, protective factors, specific suicide inquiry, and suicide warning signs (Table 5.1). Risk factors include both static (e.g., age, gender, marital status, and past history of suicide) and dynamic risk factors (e.g., depression, hopelessness, guilt, anger, anxiety, and panic). In this context, readers may note that a past history of suicide attempt remains the most robust and well-replicated predictor of eventual suicide. Protective factors are those which, when present, decrease the risk of suicide. These include robust coping skills, good social support, a sense of overall life satisfaction, strong therapeutic relationship, and being pregnant or having children (for women). Specific suicide inquiry refers to assessment of suicidal ideation, plans, behavior, and intent. For instance, if a patient endorses the lead-in question about suicide ideation, he/she would be asked for their frequency, intensity, duration, and specific-ity. Specificity, in this context, refers to the degree to which the suicidal ideas have crystallized into a specific plan and method. For those endorsing a plan, its time frame, lethality, means, and availability of means are assessed. History of past sui-cide attempts, including aborted or interrupted attempts, rehearsal behaviors, and non-suicidal self-injurious behaviors, is important as all of them have been found to increase risk of subsequent suicidal behavior.
Suicide intent, perhaps the most important suicide construct, refers to the extent to which the suicidal person expects to carry out his/her plan and believes the plan or act to be self-injurious or lethal. A high degree of suicide intent in attempted suicide has been linked to suicide recidivism. Intent may be subjectively expressed or objectively inferred (e.g., preparing a will, giving away belongings, etc.). A range of validated measures are available to quantify intent and assist clinicians in man-agement of suicide risk. Finally, evidence-based warning signs, a collection of signs and symptoms that indicate near-term suicide risk, are an important cog in the suicide risk assessment wheel. These are summarized by the mnemonic IS PATH WARM (Table 5.1) (avail-able on American association of suicidology website). Presence of any of these warning signs should heighten risk perceptions and increase the intensity of man-agement. Most contemporary suicide risk formulation models, such as recognizing and responding to suicide risk, emphasize the distinction between chronic and acute risk; the latter is mainly judged by the presence or absence of these warning signs which indicate imminent, foreseeable risk of suicide.