E10. Aliza Werner-Seidler – Preventative Mental Health Care

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Today we speak with Dr. Aliza Werner-Seidler, a Clinical Psychologist and Senior Research Fellow at the Black Dog Institute, affiliated with the University of New South Wales. Aliza works on the prevention and treatment of depression and anxiety disorders, particularly via school-based and digitally delivered, evidence-based programs. She is currently the Chief Investigator of the largest preventative program of anxiety and depression run in Australia, a randomised controlled trial involving 20,000 young people across 400 schools.

Prevention is an emerging and understudied area of mental health, but one with the potential to save huge amounts of suffering and make a significant contribution to the alleviation of the economic burden of mental health disorders facing the modern world.

In this conversation, Aliza provides outlines the work that she is leading at the Black Dog Institute and gives an overview of the field of preventative and early intervention approaches to mental health care.

Show Notes

0:55 – On the history of preventative and early intervention programs, and the reasons increasing interest in them

2:45 – Do preventative and early intervention programs actually reduce the incidence of mental health issues or reduce their severity?

5:05 – What do we know about matching people with different sorts of preventative and early intervention programs?

6:50 – Challenges that preventative programs face, beyond being a young field

7:45 – On what a typical universal prevention program looks like.

11:35 – On the relation between mental health promotion and mental disorder prevention.

13:35 – What is happening at the moment in terms of pilot programs?

18:10 – What content is typical of a universal program aimed at preventing depression and anxiety?

21:00 – What is the attitude of schools toward preventative programs?

26:05 – On the goals of the Future Proofing study Aliza is currently leading

27:45 – How do we prevent less common mental health challenges, such as psychotic disorders.

32:15 – What do the economics of preventative mental health programs look like?

39:10 – What must be considered around “critical windows”?

43:25 – Early life trauma and preventative programs

44:50 – How to learn more about the field of prevention

47:45 – Opportunities to get involved in the field, and the work at the Black Dog Institute.

50:10 – On disorders which preventative approaches don’t seem to be effective for.

0:55 – On the history of preventative and early intervention programs, and the reasons increasing interest in them

The increasing interest in preventative and early intervention programs was catalysed by a statement from a taskforce of the Institute of Medicine in 1994 on disease prevention. Additionally, interest has been fuelled by growing recognition that the high rates of common mental disorders, such as depression and anxiety, must be addressed with not only treatment but preventative efforts.

2:45 – Do preventative and early intervention programs actually reduce the incidence of mental health issues or reduce their severity?

In short, both. But it is worth differentiating between different sorts of programs.

  • Universal prevention programs are delivered to an unselected group (eg. an entire school or workforce). Universal programs have been shown to reduce the incidence of mental health problems.
  • Selective intervention programs are delivered to people on the basis of the presence of some risk factor.
  • Indicated prevention programs are delivered to people who display symptoms of a disorder but don’t yet meet clinical criteria.
  • Early intervention, which has some overlap with indicated prevention programs, but is also used to refer to programs that have experienced their first episode of a mental health disorder.

In school, universal programs, can be expected to reduce the incidence of depression by ~20% in the 2 years after the program. How this translates to later outcomes is unknown.

5:05 – What do we know about matching people with different sorts of preventative and early intervention programs?

As the field is still quite young, most meta-analyses lump all preventative and early intervention programs in together without differentiating between them. One factor to consider when comparing programs is that the very low symptom levels displayed by the recipients of universal prevention programs (ie. healthy populations) result in a floor effect, and hence indicated prevention programs typically appear more effective.

6:50 – Challenges that preventative programs face, beyond being a young field

A key challenge is motivating people to engage in preventative exercises if they don’t have any symptoms or risk factors. This is particularly challenging given the audience is children and adolescents and a challenge the field is yet to solve.

7:45 – On what a typical universal prevention program looks like.

Typically universal prevention programs will resemble a CBT course that has been adapted from being part of a treatment program. The skills taught are the same as a treatment course, and often the scenarios used in the program are the same. There are other non-CBT prevention programs, such as interpersonal psychotherapy programs, mindfulness programs, yoga and exercise programs, but CBT programs have been studies the most and (therefore?) have the most evidence to support them. Overwhelmingly, these programs are delivered to children in school. Due to cost considerations, digital programs are being increasingly explored, however engagement is even more of a challenge with digital programs.

11:35 – On the relation between mental health promotion and mental disorder prevention.

Mental health promotion often aims to increase help-seeking behaviours and increase people’s knowledge about mental health problems. Preventative programs tend to be more skills-based. So the two are distinct, but with significant overlap.

13:35 – What is happening at the moment in terms of pilot programs?

At the moment, the program designers are focused on building engagement by learning from the gaming community and increasingly involving young people. There is also room for improvement with selling these programs in to schools: stigma and a preference for a positive-focus continue to be challenges. Consequently, Aliza is; (a) targeting the angle of poor sleep, as a risk factor and an angle to increase engagement, and (b) seeking to understand how psychological skills can be incorporated into PDHPE classes.

18:10 – What content is typical of a universal program aimed at preventing depression and anxiety?

Most programs are based on a modified CBT approach. They contain psycho-education, relaxation techniques, thought challenging and restructuring, behavioural activation and for anxiety, some sort of exposure therapy. Aliza would ideally like to see modules on interpersonal relationships, sleep, well-being promoting practices (such as exercise and time outdoors) and also something on less-common psychotic disorders.

21:00 – What is the attitude of schools toward preventative programs?

The state government’s education department and other peak bodies are very much on board with preventative programs. And although individual schools are varied in their enthusiasm for preventative programs, there is enough support that the largest digital mental health prevention trial ever attempted is underway. 

26:05 – On the goals of the Future Proofing study Aliza is currently leading

The Future Proofing study is looking at how to scale up and implement digital preventative programs. In part this involves looking for patterns in how engagement and outcomes vary, with a focus at school-level differences and how to increase student engagement.

27:45 – How do we prevent less common mental health challenges, such as psychotic disorders.

Screening is a key approach to helping prevent less common mental health challenges, and Aliza sees a place for universal screening. Alternatively, it might be considered that less common disorders are better suited to an early intervention approach rather than a preventative approach. This second position, is supported by the difficulty in predicting who will suffer a mental health disorder even if we can screen for risk factors. In other instances, we can sensibly target high risk groups, such as those with particular personality traits or adults who have recently been diagnosed with cancer or other serious illnesses associated with risk of depression and anxiety. Ultimately, it depends…

32:15 – What do the economics of preventative mental health programs look like?

Prevention programs, and especially digitally-delivered prevention programs, are likely to have very favourable economics, especially once lost productivity, the recurrent nature of common mental health disorders and other social outcomes are considered. This is evidenced by, for example, the work of Pim Cuijpers in the Netherlands But at this stage, a lack of long-term follow up studies in Australia, limits what we can say with precision and confidence. Hence, vision is required at a policy level.

39:10 – What must be considered around “critical windows”?

This is still being teased apart, but the jump in mental health difficulties seen among 16-17 year olds, compared to 11-15 year olds, suggest a critical window during adolescence. There is also demand from schools for programs for younger children.

43:25 – Early life trauma and preventative programs

Preventative programs aren’t intended to treat the effects of early life trauma. Preventative programs could be an adjunct to but not a replacement for other therapy for trauma.

44:50 – How to learn more about the field of prevention

Some papers shared by Aliza:

47:45 – Opportunities to get involved in the field, and the work at the Black Dog Institute.

The Future Proofing Study will be supported by a team of volunteer research assistants who will support school visits. The next wave of volunteer research assistants will be recruited our next year. If this is something you are interested in, please keep an eye on the Black Dog website closer to the end of the year. Also, the Black Dog Institute, in association with the University of New South Wales, offers a number of PhD scholarships.

50:10 – On disorders which preventative approaches don’t seem to be effective for.

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Episode References

The 1994 report from the Institute of Medicine’s Committee on Prevention of Mental Disorders

Blackdog’s preventative, digitally-delivered Future Proofing Study, involving 20,000 high school students.

A seminal meta-analysis on the prevention of depression by Pim Cuijpers’ group at the Vrije Universiteit Amsterdam (The Netherlands).

World Health Organization pages on the prevention of Mental Health disorders and Suicide.

Aliza’s profile at the Black Dog Institute.

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