Child and adolescent psychiatry in the context of disease prevention

Psychiatry stands out as the only medical specialty, other than paediatrics, where over 50% of cases originate before the age of 18. The average onset age for all disorders in our field is notably 14.5 years.¹ Despite this, child and adolescent psychiatry have traditionally received inadequate attention within the broader field, raising concerns in the context of a crucial paradigm shift towards disease prevention and health promotion.^2,3

This Journal issue features several compelling papers addressing key priorities in child and adolescent mental health. Among them is the escalating concern of adolescent suicide, with rising numbers observed globally in younger adolescents over recent decades. Suicide has become the leading cause of death among adolescents in certain Western countries, resulting in significant years of life lost due to premature death. Fonseca-Pedrero et al delve into the psychological network structure of suicidal behavior, examining risk and protective factors in adolescence.⁴ Despite limitations in sampling and a lack of longitudinal or biomarker data, the study reveals that nodes with the highest strength in the network include depressive symptomatology, positive affect, and empathic concern, with the most influential nodes linked to emotional intelligence abilities. Employing network analysis in large populations can aid in identifying dynamic areas for intervention in preventive approaches to suicide. Similarly, childhood adversities, a well-established risk factor for future mental disorders, emerge as a clear target for suicide prevention, as emphasized by Navarro-Mateu in this issue.⁵ Accumulating evidence supports the declaration of childhood adversities as a public health priority.

Selective primary prevention, centered on identifiable risk factors, is crucial for identifying very high-risk subgroups in very young population. Few medical risk factors predict a disorder's lifetime incidence above 50%. It is noteworthy that despite the awareness that 50 to 70% of extremely preterm newborns will develop a neurodevelopmental disorder, there is a lack of effective early prevention strategies. Collaborative studies, such as PeriSTRESS-PremTEA presented in this journal, offer insights into early detection through biomarkers for high-risk groups of neurodevelopmental disorders in newborns.⁶

Advanced parental age at conception is a well-established risk factor for neurodevelopmental disorders, including autism spectrum disorders. García-Alcón et al ⁷ explore in an elegant study the correlation between autistic traits in parents and parental age at conception. Their study investigates whether delayed father/motherhood results from autistic traits or if advanced age contributes to a higher rate of de novo mutations. The findings reveal a connection between autistic traits and advanced age at conception only in mothers, where parental age correlates with an Asperger Syndrome (AS) diagnosis. Polygenic Risk Scores are associated with autistic traits in mothers of subjects with AS, indicating a higher polygenic maternal contribution as a risk factor for an Asperger phenotype in offspring.

The necessity for multidisciplinary perinatal mental health programs is underscored in Roca-Lecumberri's paper, describing the first 150 mother-baby dyads attended to in their program in Barcelona.⁸ Notably, over 30% required psychiatric inpatient admission, with almost half diagnosed with a major depressive episode, accompanied by other psychiatric comorbidities. These programs mitigate the need to separate mother and baby during psychiatric hospitalization, enabling the observation of mother-baby interaction and early positive parenting training.

Continuing the focus on identifying high-risk groups, Buesa et al highlight threatened preterm labor (TPL) as a risk factor for postpartum depression, an underdiagnosed condition impacting mother-infant interaction and increasing the risk of neurodevelopmental disorders in offspring.⁹ The study reveals that factors such as higher maternal age, lower educational level, history of trauma, and higher trait anxiety scores predict postpartum depression after TPL.

As numerous papers in this issue emphasize, there is a pressing need to invest in very early primary prevention in mental health. Many well-established risk and protective factors for mental disorders are potentially modifiable through cost-effective preventive interventions.¹⁰ The question remains: What are we waiting for?

Conflicts of Interest

Celso Arango has been a consultant to or has received honoraria or grants from Acadia, Angelini, Biogen, Boehringer, Gedeon Richter, Janssen Cilag, Lundbeck, Medscape, Menarini, Minerva, Otsuka, Pfizer, Roche, Sage, Servier, Shire, Schering Plough, Sumitomo Dainippon Pharma, Sunovion and Takeda.

Acknowledgements

Celso Arango has been supported by the Spanish Ministry of Science and Innovation, Instituto de Salud Carlos III (ISCIII), co-financed by the European Union, ERDF Funds from the European Commission, “A way of making Europe”, financed by the European Union - NextGenerationEU (PMP21/00051), PI19/01024. CIBERSAM, Madrid Regional Government (B2017/BMD-3740 AGES-CM-2), European Union Structural Funds, European Union Seventh Framework Program, European Union H2020 Program under the Innovative Medicines Initiative 2 Joint Undertaking: Project PRISM-2 (Grant agreement No.101034377), Project AIMS-2-TRIALS (Grant agreement No 777394), Horizon Europe, the National Institute of Mental Health of the National Institutes of Health under Award Number 1U01MH124639-01 (Project ProNET) and Award Number 5P50MH115846-03 (project FEP-CAUSAL), Fundación Familia Alonso, and Fundación Alicia Koplowitz.