Applied public mental health: bridging the gap between evidence and clinical practice

摘要: Wahlbeck (1) describes a public mental health approach at population level. His proposal is far reaching, including not only the reduction of illness or specific psychiatric disorders, but promotion wellbeing, positive and happiness. The targets vary widely, parenting, education, housing, employment, justice, etc. interventions include relaxation, meditation, mindfulness training, job stress management, cognitive behavioral therapy, biofeedback, exercise, social networking, strategies promotion, improvement services, stigma, fight for human rights, author concludes that challenges remain in identifying risk, protective resilience factors problems across lifespan, developing effective evidence-based interventions. One cannot disagree with mandate. However, breadth overwhelming. Many actions described require partnerships well beyond health, psychiatry even medicine, fall domain policy, government, will people functioning democracy. impinge upon values limits governmental reach, which considerably by culture country. Consider violence, are often related to firearms. Prevention may engage issues such as enforcement gun control legislation, raising minimum age requirements ownership, reforming licensing, imposing restrictions on purchases. Identifying risk education alone be insufficient. Safe food practices, immunization, improved sanitation have been successful over past century increasing life expectancy improving quality (2). Parallel initiatives wellness similar mobilization government business efforts based known risks. Although change itself improve there need confluence common good this happen. Even then, little guarantee programs resources sufficient sustain them (3). Challenges exist several levels. Governments move slowly, individuals seldom agree priorities fiscal considerations, large corporations resist increased taxation. How do you implement policy bridges gap between evidence clinical practice? Studies community rates risks disorders now available many parts world, epidemiology has linked global study disability. While country, reasonably consistent countries cultures. phrase “no without health” merely slogan; linkages physical strong bidirectional. Therefore, reducing especially intervening early can widespread beneficial effects. Defining challenge one field struggled. I would begin focusing applied manifestations disorders. Cross-national epidemiologic research documents long delays disorder onset first treatment contact. wellbeing happiness does easily fit detection model (2). In all levels economic development, much occurs within primary care. With Affordable Care Act U.S., role care providers likely expand. We combine models brief psychosocial practice patients signs disorder. Why recommend intervention psychotherapy? reasons obscure. Patients distress overwhelmingly express preference talking someone counseling (4). Controlled trials convincingly demonstrate efficacy psychotherapies. These defined manuals adapted different ages cultures (5,6). Let me propose new profession subspeciality older ones. call it health. Applied link training profession, professions. Social work might natural partner, others. The focus symptoms rather than wellness, although “wellness” an important by-product. This grounded understanding factors, skills psychotherapies adaptation treatments contexts, amalgamating old Traditional roles providing direct assistance access services other would, course, included. There urgent calls change. An editorial appeared September 2012 Nature was entitled “Therapy deficit: studies enhance scandalously under-supported” (7). World Health Organization already incorporating into its portfolio issued guidelines managing settings (8). psychotherapy fading from consciousness some developed countries, being enthusiastically embraced hurt HIV, disasters, wars, political strife (9). model, victim disaster helped deal psychologically loss grief receive emergency provisions application housing. Persons serious, recurrent triaged psychiatrists physicians (10,11). Brief situations world problem these cottage industry ad hoc manner each situation. very high quality, inefficient, insufficient, sustainable. In exception therapy residency programs, courses accreditation requirement (12). Certification standards either absent hoc. could essential. Rates particularly depression anxiety, patients, among victims civil sexual abuse, chronic medical illness, unemployed, mothers, recently divorced, etc.. frequently social, legal services. order effective, however, distressed also therapeutic alliance talk sort out their history, concerns. am advocating long-term except where indicated small number severe enduring disorders. In context Wahlbeck's comprehensive proposal, short-term implemented guidance specialists modest. broader goals should lost, recognizing they advocacy will. meantime, dedicated delivery cost-effective sought. guiding principles intervention, integration possible, patient centered orientation, perspectives. It more efficient taught formal educational grass roots courses. At present, identify teach applications, while rarely required. disciplines offer bridging gap.