Fueled in part by national healthcare reform, a quiet revolution is taking place in how the federal government conceives of prevention and funds preventive services, and the upshot could mean more money for programs that take a public-health approach to addiction and mental health problems and less for standalone programs that focus solely on alcohol and other drugs.

The healthcare reform bill passed by Congress includes a plan to spend $15 billion on disease prevention, and while many advocacy groups want that money to be spent on disease-specific interventions targeting problems like smoking and diabetes, others have called for using the money on broader community health initiatives.

"This is the first time in all of the debates over healthcare reform that prevention is being taken somewhat seriously," said Kenneth Warner, Ph.D., dean of the School of Public Health at the University of Michigan, who chaired an Institute of Medicine (IOM) panel that released a landmark report on prevention in 2009.

The report, Prevention of Mental, Emotional and Behavioral Disorders Among Young People, concluded that prevention of addiction and mental illness has been proven to be scientifically feasible, but said that only public-health approaches are demonstrably effective.

"Currently, treatment interventions tend to isolate single problems, but there is growing evidence that well-designed prevention interventions reduce a range of problems and disorders and that these efforts are sustained over the long term," the report noted. "These programs often help children, families, and schools build strengths that support well-being. A focus on prevention and wellness can have multiple benefits that extend beyond a single disorder."

The report identified five proven approaches to prevention, including:

• Strengthening families by targeting problems such as substance use or aggressive behavior; teaching effective parenting skills; improving communication; and helping families deal with disruptions (such as divorce) or adversities (such as parental mental illness or poverty).
  
  
• Strengthening individuals by building resilience and skills and improving cognitive processes and behaviors.
  
  
• Preventing specific disorders, such as anxiety or depression, by screening individuals at risk and offering cognitive training or other preventive interventions.
  
  
• Promoting mental health in schools by offering support to children encountering serious stresses; modifying the school environment to promote prosocial behavior; developing students' skills at decision making, self-awareness, and conducting relationships; and targeting violence, aggressive behavior, and substance use.
  
  
• Promoting mental health through health care and community programs by promoting and support- ing prosocial behavior, teaching coping skills, and targeting modifiable life-style factors that can affect behavior and emotional health, such as sleep, diet, activity and physical fitness, sun- shine and light, and television viewing.

"The key to most of these approaches is to identify risks—biological, psychological, and social factors—that may increase a child's risk of MEB disorders," the report noted. "Some of these risks reside in specific characteristics of the individual or family environment (such as parental mental illness or substance abuse or serious family disruptions), but they also include social stresses such as poverty, violence, lack of safe schools, and lack of access to health care."

It all sounds fairly innocuous, but researcher Dennis Embry, Ph.D., president and CEO of the Paxis Institute, says the report is a "sleeping giant that will sweep through U.S. prevention," in part because the report concludes that most addiction problems can be prevented in early childhood.

"So much for having all those lessons about the harms of drugs or having a drug prevention program for every drug," said Embry.

Relatively few federal prevention dollars go to programs with proven outcomes, or to those that step outside their silos to address a broad range of behavioral problems, but that may be changing. The Obama administration's new Successful, Safe and Healthy Students program -- slated to replace the Safe and Drug-Free Schools grants -- is a good example, with its broad focus on creating "an improved school climate that reduces drug use, violence, and harassment and improves school safety and students' physical and mental well-being." The Substance Abuse and Mental Health Services Administration's strategic goal of creating "prevention prepared communities" by addressing addiction, mental health and other issues to improve "emotional health," is another.

Warner told Join Together that the report's call for funding evidence-based "holistic, population-based interventions" will inevitably spark turf battles. Notably, the first reaction to the Successful, Safe and Healthy Students program included concerns that funding might be diverted away from anti-drug programs.

The report's recomendations seem to have been well-received by policymakers, however. The just-released National Drug Control Strategy from the Obama administration emphasizes that drug abuse needs to be addressed as a public-health issue, with a focus on early interventions and a national community-oriented prevention system.

"It's getting some traction, and people are paying attention to it," Warner said. "There's certainly a lot of discussion of the report, but whether that translates to any policy changes remains to be seen."

"Organizational barriers are being challenged; cherished boundaries are going to get weaker," predicted Embry. "State governments will get whacked by this, because they often follow federal guidelines, and rarely read ahead of what is clearly in the literature."

On the other hand, said Embry, "Our kids might just possibly benefit, because we could have a prevention policy that is both scientifically informed and grounded in common sense that almost every preventionist in the field knows: problems we want to prevent run in packs. We need community strategies and government policies that enable preventionists to work across the artificial boundaries to help make America's future safer, saner, more sober and less stoned."