Institute of Medicine Classification System

Classification systems are tools to help researchers, practitioners, and others think about large-scale problems. To avoid misuse of these tools, and to get the maximum benefit, a classification system's nature, strengths, and weaknesses must be understood. The Institute of Medicine's (IOM) classification of preventive interventions is important to the practice of substance abuse prevention.

Prior to 1994, substance abuse prevention used a public health classification system that designated "primary prevention" as stopping a problem before it starts, "secondary prevention" as stopping a problem early in its course, and "tertiary prevention" as minimizing further injury, disease, or disability among those with a problem. This system was originally designed to apply to physical illness. This system was helpful in some ways, but not easy to apply, especially to substance abuse prevention. For example, "tertiary prevention" fits into treatment systems but is not congruent with abstinence-based substance abuse prevention.

In 1994, the IOM issued a report called "Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research." As part of its analysis, IOM proposed the use of a newer classification system, based on the work of R. Gordon. This new system divided mental disorder prevention into three categories: universal, selective, and indicated. The categories were based partly on the nature of the services provided rather than just the status of the service recipients.

Universal preventive interventions were defined as those for the general public or a population group (i.e., community, school, or neighborhood) with no screening to assess the risk for substance abuse of the participants. An example for substance abuse prevention would be a parenting program designed to be offered to all parents of teens in a community, irrespective of whether alcohol or other drug use by their teen had been an issue. The IOM made a cost-benefit argument for universal prevention because these interventions generally have a low cost per individual. If the interventions are perceived as effective and acceptable to the population and there is a low risk of undesirable unintended effects from the interventions, then universal prevention is worthwhile.

Selective preventive interventions are designed for groups with risk factors that indicate increased chance of developing a mental disorder. An example for substance abuse prevention would be a parenting program targeted toward parents of children experiencing academic failure. Because academic failure is a known risk factor for substance abuse (and vice versa), a prevention program that focused on this group might be appropriate, even if the cost per individual was higher than it would be for a universal population.

The IOM's report was created very specifically for the purpose of reviewing research about prevention of mental disorders, rather than substance abuse prevention. The IOM's definition of indicated preventive [Page 493]interventions was especially focused toward this purpose. The definition targeted people with signs of a mental disorder whose symptoms were not yet severe enough to allow the application of a diagnosis. As applied to substance abuse prevention, this has often been taken to mean youth who have "experimented" with some substance use but have not experienced sufficient problems to be diagnosed with a substance use disorder. A wide range of interpretations have been applied to the meaning of indicated, including use of the term whenever individual case management services are involved.

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