Preventing Mood, Psychotic, Personality and Childhood Disorders and Psychosocial Deviances

1A game in Grade 1, and adults decades later

In the 1980s, first- and second-grade classrooms in Baltimore, USA, were randomly assigned to play the Good Behavior Game: teams of children earned small rewards when the whole team kept agreed classroom rules. When the children were followed into their twenties, the boys who had played it, especially those who had been most aggressive at age six, had lower rates of drug and alcohol disorders and antisocial personality disorder, and fewer young adults reported suicidal thoughts (Kellam and others, 2008). A simple classroom routine seemed to change lives two decades later. But a large trial in English primary schools (Humphrey and others, 2018) found no overall effect on behaviour, a reminder that a programme that works in one place must be tested again in another. This lesson completes the survey of prevention.

21. Mood disorders and suicide

• Universal school programmes that teach coping and problem-solving reduce depressive symptoms a little on average; effects are small but reach many students.
• Indicated prevention: a group CBT course for adolescents whose parents had depression and who already had mild symptoms reduced new episodes of depression, except when the parent was currently depressed (Garber and others, 2009), which shows why treating parents' depression also protects children.
• Depression around childbirth. In the Thinking Healthy trial in rural Pakistan, community health workers were trained to use simple CBT-based methods during home visits to pregnant women with depression. Six months after birth, 23% of these mothers still had major depression, against 53% of mothers in the control group (Figure 1). The WHO later published the method as a free manual, because it shows that health workers without a psychology degree can deliver effective help.

Figure 1. Results of the Thinking Healthy cluster-randomised trial in rural Pakistan (Rahman and others, 2008): about 900 pregnant women with depression, visited either by trained community health workers using CBT-based methods or by untrained health workers making the same number of visits.

• Bipolar disorder: regular sleep, avoiding alcohol and drugs, and group psychoeducation, in which patients learn to spot early warning signs of relapse, reduce relapses.
• Suicide prevention. The WHO's LIVE LIFE approach (2021) recommends four key actions: limit access to the means of suicide (such as highly toxic pesticides), work with the media to report suicide responsibly, build life skills in adolescents, and identify, assess and follow up anyone affected by suicidal behaviour early.

32. Schizophrenia and dissociative disorders

• Primary: good antenatal care and nutrition, safe childbirth, protecting children from abuse, and discouraging cannabis use, especially frequent, high-potency use in adolescence.
• Indicated: services for young people at clinical high risk. A meta-analysis (Fusar-Poli and others, 2012) found that about 22% of them developed psychosis within a year and 36% within three years, so most do not; support must not frighten or label them.
• Secondary and tertiary: early intervention services shorten untreated psychosis; family psychoeducation, which lowers expressed emotion, reduces relapse; continued medication, help with school and work, and community support aid recovery. The RBC lists Ndera Neuropsychiatric Hospital and all district hospitals as places where psychosis is diagnosed and treated.
• Dissociative disorders: the main prevention is protecting children from abuse and treating trauma early. Therapists must also avoid suggestive techniques, such as using hypnosis to "recover" memories, because research by Elizabeth Loftus and others shows that such methods can create false memories.

43. Personality and childhood disorders

• Parenting programmes that teach praise, clear rules, consistent non-violent consequences and warm play reduce children's conduct problems (Cochrane review: Furlong and others, 2012), one of the best-supported forms of prevention for later antisocial behaviour.
• Early intervention for emerging borderline features in adolescents, using adapted CBT or DBT skills, can reduce symptoms before they become fixed patterns.
• Before and around birth: no alcohol in pregnancy (fetal alcohol spectrum disorders are entirely preventable), iodised salt (iodine deficiency is the world's most common preventable cause of brain damage, according to the WHO), good nutrition, skilled care at birth, and vaccination against diseases such as measles and meningitis.
• Nurturing care (WHO, 2018): good health, nutrition, safety, responsive caregiving and early learning in the first years. For autism and ADHD, which are mostly genetic, early identification and support improve outcomes even if they cannot prevent the condition.

54. Psychosexual disorders

• Age-appropriate education about bodies, relationships and consent; teaching children that no one may touch them in a way that makes them uncomfortable and that they should tell a trusted adult; supervision and safe reporting systems in schools, churches, mosques and sports clubs.
• Medical care for physical causes of sexual problems, and couple or individual therapy for psychological ones.
• A few countries offer confidential treatment to people worried about a sexual interest in children before any offence occurs (for example Germany's Prevention Project Dunkelfeld, begun in 2005); evaluations are still limited. Whatever the diagnosis, any sexual contact with a child is abuse and a crime.

65. Psychosocial deviances: what works and what does not

For people who already have a substance use disorder, treatment and rehabilitation are forms of tertiary prevention; in Rwanda, the RBC lists the Huye Isange Rehabilitation Center and the Rwanda Military Hospital among the services for drug addiction.