The concept of tertiary prevention arises from the public health preventive services model (Commission on Chronic Illness, 1957; Last, 1992). In this model, preventive services are categorized into primary, secondary, or tertiary interventions. The goal of primary prevention is to decrease the prevalence of disease via reduction in its rate of occurrence.
Primary prevention is therefore directed at eliminating eti-ologic factors, thereby reducing the incidence of the disease or eradicating it entirely (Greenfield & Shore, 1995). Aclas-sic example of primary prevention is the use of immunization against measles and rubella to eliminate neonatal neurological impairment caused by these diseases. Secondary prevention works to reduce prevalence (a function of both duration and rate of occurrence of the illness) by decreasing the illness's duration through early intervention and effective treatment. Tertiary prevention refers to interventions that aim to reduce the severity, discomfort, or disability associated with a disorder through rehabilitation or through the reduction of the acute and chronic complications of the disorder (Fletcher, Fletcher, & Wagner, 1988; Mrazek & Haggerty, 1994).
Certain interventions may be considered to be either secondary or tertiary prevention. For example, the use of psy-chotropic medications and psychotherapies may serve at different times as secondary or tertiary preventive measures. Early intervention and use of these as effective treatments can decrease the duration of the illness and may represent secondary prevention. However, in individuals with a chronic relapsing illness, the use of psychotherapy and psychotropic medications to prevent relapse to a symptomatic stage of the illness would constitute tertiary prevention. For example, maintenance antidepressant medication to prevent relapse to a symptomatic stage of mood disorder can be viewed as tertiary prevention. Another example would be the use of group psychotherapy to prevent relapse in currently abstinent individuals with substance use disorders. Other interventions that diminish social impairment or disability among those with chronic conditions also represent tertiary prevention—for example, vocational rehabilitation or social skills training for those with chronic psychotic disorders. Overall, most tertiary preventive interventions for psychiatric disorders fall into the category of maintenance treatments for chronic conditions. Such maintenance interventions include (1) interventions that are aimed at increasing compliance with long-term treatment and whose goal is to reduce relapse and recurrence and (2) aftercare treatments, such as rehabilitation, whose goal is to improve social and occupational function (Mrazek & Haggerty, 1994).
Most examples of tertiary prevention within mental health are found in the maintenance, treatment, and rehabilitation of individuals with chronic mental disorders. Schizophrenia is a chronic psychotic disorder with onset usually in late adolescence and an overall prevalence in the United States of approximately 1%. The combination of relatively high prevalence and early onset imposes a large burden of personal suffering and need for treatment and rehabilitative services due to the morbidity and chronic disability the disorder engenders. Tertiary preventive interventions are, therefore, quite important in this population in the form of rehabilitation and prevention of relapse (Preventing schizophrenic relapse, 1995). Medication nonadherence may be responsible for 40% of all exacerbations of schizophrenia that result in hospitalization. In addition, the illness generally interferes with a number of areas of functioning.
Anumber of tertiary preventive interventions have been designed to improve functioning, increase medication adherence, and reduce relapse, and thereby decrease overall disability due to the illness. Comprehensive psychosocial treatments such as those involving Assertive Continuous Care (Stein, 1990) and behavioral rehabilitation (Anthony & Liberman, 1986; Liberman, Falloon, & Wallace, 1984) can improve patients' medication adherence and help with a number of psychosocial aspects of life, including vocational and recreational activities. For example, behavioral rehabilitation uses a multidisciplinary team to provide services that can help increase adherence to medication and provide support and direction in other areas of the patients' lives, including work, family, and social interactions (Kopelowicz & Liberman, 1995).
Depressive disorders are among the most common psychiatric disorders. For example, the prevalence of major depressive disorder at any one time is estimated to be 2% to 4% in the community, 5% to 10% among primary care outpatients, and 10% to 14% among medical inpatients (Katon & Schulberg, 1992). Depressive illness is generally chronic and relapsing and can have significant social and economic consequences for the affected individual (Montgomery, Green, Baldwin, & Montgomery, 1989). Tertiary prevention of depressive disorders, therefore, usually focuses on decreasing the likelihood of relapse and recurrence. At least 50% of recurrent episodes of depression are preventable by adequate prophylaxis with antidepressant medication (Montgomery et al., 1989). For major depression, anti-depressant treatment for a minimum period of 6 to 9 months following the resolution of symptoms is indicated to decrease the risk of recurrence. In addition, a common tertiary preventive intervention for bipolar disorder is maintenance medication with a mood stabilizer with or without an antidepressant to minimize the risk of another manic or depressive episode (Goodwin & Jamison, 1990).
Tertiary prevention of substance use disorders involves relapse prevention and rehabilitation. Considerable evidence suggests that patient involvement in ongoing treatment is helpful in maintaining abstinence, limiting the total duration of relapses, and improving overall long-term outcome (Greenfield & Shore, 1995; Higgins et al., 1994; McLellan, Luborsky, Woody, O'Brien, & Druley, 1983; O'Malley, Jaffe, & Chang, 1992). Programs that help individuals maintain abstinence from substances or limit the duration of relapse are effective tertiary preventions; they include aftercare participation such as training in relapse prevention or coping skills, behavioral treatment, involve ment in Alcoholics Anonymous, and methadone maintenance (Galanter & Kleber, 1999).
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Shelly F. Greenfield McLean Hospital
See also: Drug Rehabilitation
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