Relationship Between Etiology Knowledge and Prevention Efforts?

What is the relationship between etiology knowledge and prevention efforts? Some people think that to prevent an illness, you must know what causes it. Causation, or etiology, is very useful. We know the causes of a number of mental disorders, particularly those associated with structural alterations in the brain, e.g., general paresis induced by syphilitic infection, pellagra psychosis caused by a vitamin deficiency, and dementia triggered by arteriosclerosis of the brain.

Mental disorders affected by chronic alcoholism, psychiatric deficiency, and endemic cretinism affected by iodine deficiency mental disorders due to lead poisoning, etc. In some of these cases, this knowledge allows us to prevent mental disorders by removing the causes before they affect mental health.

The pellagra has been prevented by ensuring an adequate vitamin-containing diet in the southern areas of the United States. It was once quite common, but the incidence of general paresis has been dramatically reduced by the successful treatment of early syphilitic infections with antibiotics.

The mental disorders lead poisoning have been reduced by controlling the mercury content of paints used on baby equipment and by protective measures for workers in lead industries; endemic cretinism has been prevented by putting iodide in the table salt in areas where it is missing in the drinking water, etc. Unfortunately, it is not always easy to use etiological knowledge to combat causative factors and prevent illness. For instance, we know that the ingestion of a certain quantity of potassium bromide will usually lead to a toxic illness with psychotic symptoms.

We have known this for years, but bromide psychosis still occurs regularly in our communities. True, the rate has apparently decreased since many doctors have stopped prescribing bromides as sedatives now that they have better drugs available, such as barbiturates and tranquilizers. But bromides are freely available to the general public as proprietary medicines that can be bought at any drugstore without a prescription.

The Food and Drug Act allows such medicines to contain only small quantities of bromide. However, this drug is very slowly excreted and, therefore, can accumulate in the body until it reaches toxic proportions. The result is that a mental disorder of no known etiology is not prevented. An analysis of the reasons would involve a host of considerations ranging from physicians’ apathy to a lack of knowledge and interest from the general population.

It would also involve the complications of the legislative process and the vested interests of proprietary medicine manufacturers. It is possible to illustrate the same point by using examples from more general physical experience. Such as our lack of success in preventing traffic deaths due to speeding and alcohol intoxication, our inability to reduce heart disease associated with overeating, and lung cancer associated with cigarette smoking.

True, our etiological knowledge in these cases is not as certain as in bromide psychosis. However, even if it were, the problem of treating it preventively would still not be simple. When we turn our attention to the other side of the question and ask whether it is possible to prevent the many illnesses whose cause is not known, we find that the answer is not straightforward. Public health history affords many examples of effective illness prevention at a time when their etiology was unknown.

Prior to the discovery that scurvy was caused by vitamin deficiency, the sailors consumed limes to prevent it. The smallpox vaccinations were introduced before the causative agent was discovered, and improvements in drinking water and sewage disposal prevented many infectious diseases before the germs responsible for them were identified. Some of these programs were empirical, which is based on the effective exploitation of chance findings. Certain measures seemed beneficial, but many of them were more scientifically based upon the observation that a population with a high rate of the disease differed in certain respects from a population with a lower rate of the disease.

The difference often appeared to be related to certain aspects of the community’s living situation, such as the nature of its food, water, or housing. The prevention program then attempted to alter the environmental situation to correct the supposedly unhealthy influence. This was sometimes successful, even though the nature of this influence was unknown or incorrectly explained. The use of personal isolation for the interruption of epidemics of infectious illness was originally based upon the theory that such illness was due to pestilential odors. Prevention of mental disorders cannot wait, therefore, until we know their exact etiology.

This knowledge would undoubtedly be helpful. There is plenty of progress to be made by capitalizing on observations like those made by pioneers in public health. Such observations aim to identify pathogenic factors or situations that appear to be associated with an increased risk of mental disorders in one population. This is compared with another without the factors. In this endeavor, pure guesswork is likely to be wasteful. However, an inspired guess based upon a chance empirical observation might be as valuable as the one that produced the lime diet to prevent scurvy among sailors.

What is needed as a basis for a preventative program is a reasonable conceptual framework that is buttressed and progressively refined by clinical studies and also by systematic epidemiological research consisting of careful comparisons of the characteristics of populations with differing rates of mental disorders or exposed to different environments.

Since we must recognize the uncertain basis for most preventive programs because of our current lack of scientifically tested knowledge of the causation of mental disorders, it is important that programs be constantly evaluated so that waste of money and effort is kept to a minimum by discarding those procedures that are found in practice to be ineffective.

Of course, we must also press forward with basic research on etiology. We expect that additions to this knowledge will provide a more secure foundation for our preventive programs. Considerations such as these have, during the last five to ten years, governed the thinking of pioneers in the field of preventing mental disorders. Some of their exploratory efforts will now be discussed.

Although these efforts will be described here as separate programs under the headings of “primary” and “secondary” prevention, it is to be emphasized that in practice they should optimally be coordinated and integrated within a comprehensive community program.

A systematic and planned attempt is made to appraise the range of local needs and problems and to prevent, treat, control, and rehabilitate all types of mental disorders within a logical system of priorities consonant with the traditions and resources of the community.

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