Mental health and well-being for the prevention of substance use disorders

INTRODUCTION

Mental health is defined as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.”

Well-being is defined as “a good or satisfactory condition of existence; a state characterized by health, happiness, and prosperity; welfare.” It encompasses but is not limited to physical, emotional, social, occupational, and economic well-being.

The relationship between the use of substances and well-being is complex. Historically, the normative use of different substances has been documented in cultures across the world. Substances (such as cannabis and psychedelics) have been used as a means to heighten spiritual experiences, gain greater insight and understanding about the world, and enhance well-being. They have also been used in healing rituals by medicine men or shamans. In recent times, substance use (particularly alcohol and cannabis) in social contexts has become common. A cross-sectional study, which used data from the Danish National Youth Study 2019 (25,910 students aged 15–25 years), found that there was a U-shaped association between weekly alcohol consumption and poor well-being; for example, students who never drank, students who only drank occasionally, and students who drank a lot (22 units of alcohol or more a week) had higher odds of poor well-being, compared with the reference group (1–7 units a week).[1]

The relationship between excessive use of substances or substance use disorders (SUDs) and decreased well-being is indisputable, with the relationship appearing to be a bidirectional one. This is borne out by a study in a random national sample of 9493 adolescents aged between 12 and 18 years recruited as part of My World Survey 2-Second Level (MWS2-SL), which found that the “low” health-promoting cluster was characterized by high alcohol, cannabis, and social media use; moderate sport and hobby participation; and low sleep duration. They also demonstrated the highest levels of anxiety and depression and the lowest levels of life satisfaction, self-esteem, and daily functioning.[2]

ETIOLOGY OF SUD

There are a number of etiological factors that seem to be associated with the development of SUD. Figure 1 provides an overview of these factors and how they can contribute to the risk of developing SUD.

Figure 1.

Framework for understanding the etiology of psychiatric disorders, including SUD

It is important to recognize that a number of the factors outlined confer risk or protection for a range of mental health conditions, including psychosis, depression, anxiety, and SUD. Furthermore, they seem to operate from the antenatal period through infancy, childhood, and adolescence, long before the symptoms of mental illness become apparent. This risk or protection is likely mediated by deviations in the normative trajectories of brain structure, function, and neuropsychological functioning, which are also transdiagnostic in nature. This, in turn, leads to differences in temperament, which can increase the risk of developing psychopathology. These same factors are also likely to contribute to resilience and well-being. This framework can also be used to study the effect of preventive interventions that modify these risk and protective factors.

PREVENTIVE INTERVENTIONS FOR SUD

The Institute of Medicine (IOM) classifies preventive interventions based on the level of risk into the following:

• Universal (targeting the population in general)

• Selective (targeting those at a higher-than-average risk of substance use, e.g. children of substance users)

• Indicated (targeting those who are already using substances or engaging in high-risk behaviors)

The Centre for Substance Abuse Prevention (CSAP) further identifies six domains where risk and protective factors can operate, namely:

• Individual

• Family

• Peer

• School

• Community

• Society or environment

In this section, we will describe interventions across different developmental stages and further divide them based on the risk level and the domain of the intervention. The impact of these interventions will be described on both intermediate outcomes, such as neurodevelopment, and terminal outcomes, such as well-being and psychopathology, with a focus on substance use. We will also summarize the certainty of the evidence for each type of intervention using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) [Table 1]. We feel that this will serve as a way to both review the current evidence and highlight the gaps in the same, which can guide future studies.

Table 1.

GRADE certainty ratings

Certainty	What it means
Very low	The true effect is probably markedly different from the estimated effect
Low	The true effect might be markedly different from the estimated effect
Moderate	The authors believe that the true effect is probably close to the estimated effect
High	The authors have a lot of confidence that the true effect is similar to the estimated effect

Prenatal and antenatal interventions

There is accumulating evidence that health-related factors, such as nutritional deficiencies, obesity, substance use, infections or inflammation, and exposure to environmental toxins, and psychosocial factors, such as exposure to intimate partner violence and psychopathology, including anxiety and depression during pregnancy, can affect neurodevelopment and are associated with the development of internalizing and externalizing psychopathology in childhood.[3] Given that these factors predispose individuals to develop SUD, interventions to address them in the prenatal, antenatal, and postnatal periods may reduce the future occurrence of SUD. The interventions in this section are mostly universal and delivered to pregnant mothers, although fathers may also be involved in certain cases. The evidence for these interventions directly influencing terminal outcomes, such as well-being and substance use, is sparse, as most of the studies described have not followed up children into adolescence and adulthood.

Nutritional Interventions

A large longitudinal study from Central America clearly showed that nutritional interventions starting in the antenatal period till 2 years of age were associated with improved neurodevelopmental and neurocognitive outcomes starting from infancy, into early and middle childhood, adolescence, and young adulthood.[4] It was also associated with enhanced executive functioning and psychological well-being in adulthood.[5] However, as demonstrated in another study from Latin America, providing nutritional counseling alone may not be sufficient with no differences in intelligence, mental health, or alcohol use and smoking among adolescents in the treatment and control groups.[6] This underlines the role of maternal micronutrient supplementation to both treat nutritional deficiencies and, in certain cases, to mitigate the effects of environmental exposures, such as substance use or infections. This may help to prevent the future occurrence of mental illness[7] and also enhance well-being.

Prenatal and antenatal iron and folic acid (IFA) supplementation seems to have a positive impact on neurodevelopment in infancy and early childhood.[8,9] These effects also seem to persist into adolescence, as seen in a 14-year follow-up of a large randomized controlled trial (RCT) from rural China, which compared multiple micronutrient (MMN) supplementation, IFA supplementation, and folic acid supplementation alone, which found that the MMN and IFA groups showed improved measures of intellectual development[10] and also reduced levels of total and externalizing psychopathology.[11]

The evidence for B-complex vitamins is less consistent. A small RCT conducted in India found that B12 supplementation from preconception to delivery was associated with better neurodevelopmental outcomes at 2 years of age as compared to placebo.[12]

There was no association between ω-3 long-chain polyunsaturated fatty acid, docosahexaenoic acid (DHA) supplementation, and childhood behavior or cognitive development.[8,13]

A number of longitudinal studies have shown a link between lower maternal choline concentrations and poorer performance on attentional and processing speed tasks in early childhood.[14,15] A review of uncontrolled interventional studies found that higher maternal choline intakes during the second half of pregnancy and early postnatal period (550 to 1000 mg/day, apart from diet) demonstrated favorable effects on several domains of child neurocognition, such as memory, attention, and visuospatial learning versus the comparison groups.[16] A small RCT comparing choline supplementation at 480 mg/day to 930 mg/day in the third trimester of pregnancy found that mothers of children receiving 930 mg/day had improved performance on sustained attention tasks at 7 years of age.[17] In addition, maternal choline supplementation may ameliorate some of the cognitive problems seen in offspring born to alcohol-exposed pregnancies.[18,19]

Psychosocial Interventions

Evidence from longitudinal cohort studies has highlighted the association between antenatal maternal depressive and anxiety symptoms and infant and child development[20] and internalizing and externalizing psychopathology.[21,22] These are likely to be mediated by epigenetic changes,[23] which may influence brain structure and function.[24] Furthermore, exposure to stressful life events and intimate partner violence during pregnancy is also associated with child executive functioning problems and externalizing problems, a relationship that was moderated by maternal parenting quality, such that higher parenting quality is protective for the associations between stressful life events and outcomes in the child.[25] This emphasizes the importance of interventions that can reduce stress, enhance well-being, and address depression and anxiety in pregnant mothers.

Parenting or Family interventions

A meta-analysis evaluating the effect of universal prevention interventions among 2559 pregnant women found that there was a moderate effect of preventive interventions implemented during pregnancy on maternal distress, depressive symptoms, and stress. The effects were not associated with intervention timing, intervention type, intervention delivery mode, timing of posttest, and methodological quality.[26]

Another meta-analysis on the impact of parenting interventions on symptoms of perinatal depression and infant outcomes found significant reductions in maternal depressive symptoms at postintervention for mothers allocated to receive parenting interventions. For both studies, data on infant development outcomes were scarce and therefore not analyzed.[27]

Summary and recommendations

Nature of the intervention	Outcome	Recommendation
Nutritional interventions
Iron supplementation (maintaining serum (Sr) ferritin above 30 mcg/L, Complete Blood Count (CBC) at first antenatal checkup (ANC), 24 and 36 weeks)	Cognitive performance	High certainty
Choline at 500 mg/day during the second and third trimesters of pregnancy	Cognitive performance	Moderate certainty
ω-3 long-chain polyunsaturated fatty acid (DHA) at 400 mg/day during the second and third trimesters of pregnancy	Cognitive performance and childhood behavior	Very low certainty
Parenting or family interventions
Mindfulness or relaxation; cognitive behavioral therapy (CBT)-based interventions	Maternal depressive symptoms and stress	High certainty
Mother–infant interactions, attachment and relationships and parenting competency using diverse approaches	Infant neurodevelopment	No evidence

Interventions during early (birth to 6 years) and middle (6 to 12 years) childhood

Childhood nutritional deficiencies, obesity, parenting, and home, school, and community environment have been strongly associated with cognitive development, child well-being, and the development of psychopathology in early and middle childhood. As in the previous section, the direct evidence of these interventions influencing terminal outcomes, such as the risk of developing substance use-related problems, is limited, but encouraging.

Nutritional Interventions

The use of micronutrient supplementation for improving cognitive outcomes in early childhood has shown promise. Among them, iron and multi-micronutrient supplementation have been shown to be most effective in improving cognitive abilities, particularly in undernourished children.[28] A meta-analysis of iron supplementation in schoolchildren (aged between 6 and 12 years) has shown significant improvements in intelligence, attention and concentration, and memory, although there was no impact on overall school performance. The improvements were more in children who were anemic at baseline.[29] These findings were also partly replicated in another meta-analysis, including studies from only low and middle income countries.[30]

Psychosocial Interventions

Psychosocial interventions in early and middle childhood may be universal, selective, or indicated. The domain of interventions is usually parents or families and schools.

Parenting or family interventions

Universal parenting interventions may have a positive impact on childhood development and lead to better emotional and behavioral adjustment of children. This, in turn, may be associated with a decreased likelihood of developing substance use later in life. These interventions, in most cases, focus on providing feedback either in-person or through recorded videos on parenting practices to improve parent–child interactions.

The Family Check-Up (FCU) is one such well-researched family intervention. It is a brief intervention that is based on motivational interviewing principles and consists of a broad assessment of the family context and parenting practices, an initial “get-to-know-you” meeting with the family, and a formal feedback session. It includes a menu of empirically supported child and family interventions that reduce problem behavior and promote emotional well-being in children and families. There is also a mechanism for periodic contact (at least once a year) with families.[31] The FCU has been used to intervene with families across age groups from early childhood to adolescence[32] and also in diverse ethnic and cultural settings.[33] It has been seen to reduce externalizing and internalizing psychopathology in adolescence[34,35] and reduce the likelihood of getting into high-risk trajectories of alcohol, tobacco, and cannabis use.[36,37]

The Attachment and Biobehavioural Catch-Up (ABC) is another 10-session home-visiting program developed to enhance parental sensitivity. The intervention provides parents practice and feedback in interacting sensitively with their children. It has been used in a number of different settings across the world and has also adapted for specific situations. The ABC has been shown to be effective in enhancing parental sensitivity and children's attachment security and regulatory capabilities.[38] It has also been associated with greater high-frequency power (beta, 12–20 Hz) on electroencephalogram (EEG)[39] and increased activation in the amygdala–prefrontal cortex (PFC) circuitry in response to faces in functional magnetic resonance imaging (fMRI).[40]

Tuning in to Toddlers (TOTS) is another universal intervention that aims to improve parent emotion socialization, reduce parent and toddler stress, and improve social, emotional, and behavioral functioning in toddlers using a 2-hour/week, 6-week program. An RCT found reductions in difficulties in parental emotion regulation and greater increases in parental empathy and competence. There were also significantly greater reductions in systemic cortisol among intervention but not control group children.[41]

The Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) is another program that used six sessions of video-feedback intervention instead of home visits and was found to have a positive effect on behavioral problems, with particular improvements in conduct symptoms, and was also found to be cost-effective compared with usual care at 24 months postintervention.[42]

A large meta-analysis, which included 102 unique RCTs, reported positive benefits of parenting interventions on child cognitive development, language development, motor development, socioemotional development, and attachment and reductions in behavior problems. Positive benefits were also found in parenting knowledge, parenting practices, and parent–child interactions. There was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias.[43] Another meta-analysis, which included 22 RCTs and two quasi-RCTs evaluating the effectiveness of group-based parenting programs, found that they reduced overall emotional and behavioral problems and total externalizing problems but had no effect on total internalizing problems; however, the quality of evidence was considered low.[44]

In addition to the universal interventions described above, selective or indicated interventions may be required among families at higher risk of substance use. These interventions are typically longer and more intensive, but they focus on imparting skills and mentoring with a view to improve the quality of interactions and well-being in families.

The Strengthening Families Program (SFP) is an evidence-based prevention program for parents and children between the ages of 3–5, 6–11, and 12–16 in higher-risk families. It consists of parenting skills, children's life skills, and family skills training courses taught together in fourteen 2-hour group sessions preceded by a meal that includes informal family practice time and group leader coaching, to promote behavior change in high-risk families [Table 2]. It has been tested extensively and found to lead to significant improvements in youth behavioral health, including reductions in substance misuse, depression or anxiety, and child maltreatment. It has also been adapted to different cultural and socioeconomic backgrounds and in a less intensive format as a universal prevention intervention.[45]

Table 2.

Key components of the strengthening families program

Domain	Skills
Parenting skills	Review appropriate developmental expectations Interacting positively with children including showing enthusiasm and attention for good behavior and letting the child take the lead in play activities Positive family communication, including active listening and reducing criticism and sarcasm Family meetings to improve order and organization Effective, consistent, and effective discipline, including reasonable and logical consequences and time-outs
Children’s life skills	Communication skills (parents, peers, and teachers) Resilience skills Problem-solving Peer resistance Feeling identification Dealing with criticism Anger management Coping skills
Family skills	Practice what is learned in individual sessions using experiential exercises

The Building Healthy Children (BHC) home-visiting preventive intervention was designed to provide concrete support and evidence-based intervention to young mothers and their infants who were at heightened risk of child maltreatment and poor developmental outcomes. Mothers who received BHC evidenced significant reductions in depressive symptoms at mid-intervention, which was associated with improvements in parenting self-efficacy and stress and decreased child internalizing and externalizing symptoms at postintervention. The follow-up study found that BHC mothers exhibited less harsh and inconsistent parenting and marginally less psychological aggression. BHC children also exhibited less externalizing behavior and self-regulatory difficulties across parent and teacher report.[46]

Nature of the intervention	Outcome	Recommendation
Nutritional interventions
Iron and multi-micronutrient supplementation	Cognitive performance	High certainty
Parenting or family interventions
Improving parenting skills through corrective feedback	Parenting Cognitive development Externalizing and internalizing behaviors	Moderate certainty Moderate certainty Low certainty
School-based interventions
Improving children’s behavioral control using contingency management—Good Behaviour Game Improving children’s socioemotional skills through training—Michigan Model of Health	Disruptive behaviors Substance use and risk behaviors Healthy lifestyle Disruptive behaviors Substance use and risk behaviors	Moderate certainty Low certainty Low certainty Low certainty Low certainty

SafeCare is an 18-session behavioral parenting program for child welfare-referred caregivers that teaches skills in positive parent–child interactions, home safety, and child health. It has shown preliminary evidence of effectiveness in improving several parenting outcomes, including supporting positive child behaviors, proactive parenting, and aspects of parenting stress. However, the impact of these changes on child well-being was not clear.[47] There were also improvements in parental support and depressive symptoms.[48]

School-based interventions

The Good Behaviour Game (GBG) is a universal prevention intervention implemented among preschool and elementary school students based on the principles of group contingency management. The classroom is typically divided into teams, and rewards are provided for good behavior during the game.[49] It has empirical support for an increase in prosocial behavior over time[50] and a decrease in aggression and disruptive behaviors, although the effects may be smaller than previously estimated.[51] It has also been seen to lead to reductions in substance use and other risk behaviors during adolescence.[52]

The Michigan Model for Health is another universal prevention intervention for elementary school students that includes 52 lessons in grades 4 and 5, focusing on nutrition, physical fitness, safety attitudes and skills, social and emotional health, interpersonal communication, social pressure resistance skills, drug use prevention, and conflict resolution skills. It has been associated with improved dietary patterns,[53] lower intentions to use alcohol and tobacco, less alcohol and tobacco use initiated, and reduced levels of aggression.[54]

Summary and recommendations

Interventions during adolescence (13 to 19 years)

There are a number of interventions that have been tested for the prevention of substance use among adolescents. These include nutritional interventions, exercise-based interventions, and psychosocial interventions. Psychosocial interventions incorporate both general aspects of well-being, such as building life skills and personality development, and more substance-specific aspects, such as substance use education and resistance skills. The interventions cover different domains, such as individual, peer, school, family, and community. In this section, we will review some of the key interventions and the evidence in support of the same. In most cases, studies directly measure outcomes related to substance use.

Nutritional interventions

There appears to be a co-occurrence of problematic substance use and poor nutritional patterns, such as irregular meal patterns, high intake of sugar-sweetened beverages, diet beverages, and energy drinks, and low intake of vegetables, fruits, and fish in adolescents, often related to poor parental supervision and parental conflict.[55] Therefore, interventions that address multiple modifiable health behaviors, such as under and overnutrition and substance use in the same program, hold promise in improving diet, substance use,[56] and mental health outcomes.[57]

Exercise-based interventions

There is clear literature to support the relationship between physical activity and well-being. Furthermore, there is also emerging evidence from cross-sectional studies to suggest that engagement in physical activity[58] and sports participation, specifically noncompetitive sports, may help to prevent the development of SUD.[59] This was also supported by a longitudinal study, which found that walking for exercise lowered the odds of current and prospective daily cannabis and cigarette use by 20–40%, while strength training, team sports, and individual sport participation were associated with 20–30% reduced risks of future daily cigarette use.[60] However, the impact of structured exercise programs on mental health and substance use among adolescents and young adults is limited. Promoting participation and engagement in such programs, determining the intensity of such programs, and integrating such programs into existing systems in schools and colleges are important considerations that need further evaluation.[61]

Psychosocial interventions

School-based interventions

In the area of universal interventions, life skills training [Table 3] developed by Botvin has been most extensively studied. It consists of 30 classes, taught in sequence over three years, with each session lasting between 45 and 50 minutes. It can be taught on an intensive schedule (2 to 3 sessions/week) or an extended schedule (1 session/week). It has been tested in numerous RCTs and found to be effective in preventing the use or misuse of alcohol, tobacco, and illicit drugs. It has also been implemented across different ages, from elementary to high school, and varied economic and cultural settings.[62]

Table 3.

Key components of life skills training

Domain	Skills
Personal self-management skills	Enhance self-esteem Develop problem-solving abilities Reduce stress and anxiety Manage anger
General social skills	Overcoming shyness Communicating clearly Building relationships Avoiding violence
Drug resistance skills	Develop skills to resist pressures to use tobacco, alcohol, and other drugs

The Ad-Venture trial, a selective personality-targeted prevention program delivered over eight sessions by trained school staff and incorporating elements of motivation enhancement and CBT, was another program that was found to be effective in reducing harmful alcohol use over 24 months.[63] The Co-Venture trial, a follow-up program, which was tested in a sample of 31 schools, where high-risk youth (N = 3826) were identified and randomized to the intervention or control groups and found the delayed onset of substance use in the intervention group[64]

In the area of specific interventions, the Drug Abuse Resistance Education (D.A.R.E.) program, which was designed to help elementary and junior high school students resist the peer pressure of experimenting with drugs, tobacco, and alcohol, is the most well-known. Its focus was providing children with information about drug use that encouraged them to make healthy decisions. The program was normally taught by a police officer; the core curriculum has 17 lessons, usually offered once a week for 45 to 60 minutes. Despite its widespread implementation, a large meta-analysis found that it was not effective in the prevention of substance use or attitudes and behavior toward substance use.[65] This led to a change in the name (keepin' it REAL), and the content and delivery, with the focus shifting to imparting fundamental, basic skills needed for healthy development, including self-awareness and management, responsible decision-making, understanding others, relationship and communication skills, and handling responsibilities and challenges, using interactive sessions. This has been found to be more effective in the prevention of substance use[66] and has also been tested in different populations with positive outcomes.[67,68]

Life skills training programs have also been found to be effective when delivered digitally and may be an easy-to-implement alternative to training conducted within a school curriculum. A school-based intervention consisting of online feedback and individually tailored text messages provided over 22 weeks and addressing self-management, social, and substance use resistance skills was tested in 1,473 students from 89 schools in Switzerland and showed long-term effectiveness in preventing tobacco smoking and cannabis use.[69]

Individual interventions

In addition to life skills training programs, there are also a number of other universal SUD prevention interventions in adolescents and young adults, which focus on providing feedback about substance use, risk behaviors, health, and well-being.

One such intervention, the E-health4Uth intervention, a tailored web-based feedback based on the adolescent's responses to a questionnaire assessing alcohol consumption, smoking, drug use, condom use, and mental health, showed positive results in terms of improvement of health-related quality of life and mental health status over 4 months, in a cluster RCT conducted among 1256 adolescents from the Netherlands.[70]

A Personalized Feedback Program (PFP) for college students targeting genetically influenced risk pathways for substance use and providing feedback on four risk domains (sensation seeking, impulsivity, extraversion, and neuroticism), along with individualized recommendations and campus resources, was found to lead to reductions in alcohol and cannabis use, in a pilot RCT.[71]

There is also preliminary evidence for the effectiveness of interventions based on well-being therapy in preventing substance use-related problems. A three-arm cluster RCT conducted in Italy to test the efficacy of a well-being intervention compared with lifestyle intervention or no intervention found decreases in at-risk drinking, cannabis use, and internet addiction, which were most prominent in the wellbeing intervention group.[72]

For adolescents, who are already at high risk of developing problems with substance use, the use of more intensive, selective, or indicated interventions has been found to be required.

A longitudinal evaluation of enhanced mentoring for children of incarcerated parents found improvements in positive self-cognitions, reduced internalizing psychopathology, and decreased intentions to use substances and substance use among those receiving enhanced mentoring compared with regular mentoring.[73]

A systematic review that evaluated interventions for substance use and co-occurring problems among youth with a history of trauma found that interventions with exposure-based components had robust results and minimal adverse outcomes.[74]

A large systematic review and meta-analysis found that available evidence is strongest for universal school-based interventions that target multiple-risk behaviors, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behavior and in improving physical activity among young people, but not in preventing other risk behaviors. The evidence of benefit for family- or individual-level interventions in reducing substance use and risk behaviors was not strong.[75]

Community interventions

Prevention research over the years has emphasized that working in an isolated fashion with individuals, families, or schools is insufficient to make meaningful reductions in adverse mental health outcomes, such as substance use at the population level. This has led to the adoption of community-based prevention models in many parts of the world, which focus not only on reducing problem behaviors but also enhance a sense of well-being and ownership among communities.

One of the most impactful models demonstrating effectiveness in preventing substance use among adolescents is the Icelandic Prevention Model (IPM). This model operates within the community, concentrating on tackling the underlying environmental and social factors that contribute to substance use [Figure 2]. These factors include a lack of consequences and supervision within the social environment (stemming from parents and other adults), limited personal and communal commitment to traditional, positive values (including ambitious educational aspirations), and a dearth of opportunities for engagement in constructive and prosocial growth (such as organized recreational and extracurricular activities, such as sports, music, drama, and after-school clubs).

Figure 2.

Domains of community risk and protective factors in the Icelandic Prevention Model

The primary objective of this approach is to rally society collectively against problematic substance use, prioritizing community involvement and cooperation to facilitate enduring gradual transformations in the environmental and social landscape.[76,77,78] The five guiding principles of the IPM are listed in Table 4.

Table 4.

Guiding principles of Icelandic Prevention Model

Guiding Principle 1	Apply a primary prevention approach that is designed to enhance the social environment
Guiding Principle 2	Emphasize community action and embrace public schools as the natural hub of neighborhood or area efforts to support child and adolescent health, learning, and life success
Guiding Principle 3	Engage and empower community members to make practical decisions using local, high-quality, accessible data, and diagnostics
Guiding Principle 4	Integrate researchers, policymakers, practitioners, and community members into a unified team dedicated to solving complex, real-world problems
Guiding Principle 5	Match the scope of the solution to the scope of the problem, including emphasizing long-term intervention and efforts to marshal adequate community resources

The model has been successfully implemented among rural communities[79,80] and across diverse geographical settings,[81] including in lower- and middle-income countries, such as Chile.[82]

Promoting School-community-university Partnerships to Enhance Resilience (PROSPER) is a program-delivery system in which universities partner with community teams to implement evidence-based programs for preventing youth substance abuse and other problem behaviors. A 15-year follow-up of the original PROSPER RCT suggested that there were some indications of better adjustment of PROSPER intervention compared with control participants during the early phase of the pandemic (less increase in alcohol use and less decrease in parenting warmth) and their children (lower levels of externalizing and internalizing problems) but several null results as well (no differences in other substance use behaviors, other parenting measures, or parent depression).[83]

The Street University program from Australia provides a space for young people to socialize away from the street and police attention. Its design has two main components: a comprehensive engagement program aimed to attract and retain young people in the service over the long term and a therapeutic program available for those clients who need or want alcohol and other drugs and/or mental health support. It was found to be associated with good retention and improvements in parameters related to substance use, psychological distress, and well-being.[84]

Summary and recommendations

Interventions during adulthood

Interventions in adulthood for the prevention of SUD focus on screening, early detection of problematic patterns of substance use, and brief interventions for the same and referral to specialist treatment where indicated.

Nature of the intervention	Outcome	Recommendation
Nutritional interventions
Dietary advice along with substance use interventions	Substance use	Low certainty
Exercise-based interventions
Structured exercise programs	Substance use	Low certainty
School-based interventions
Life skills training	Externalizing and internalizing psychopathology Substance use	Moderate certainty Moderate certainty
Individual interventions
Personalized feedback Well-being therapy	Substance use Substance use	Low certainty Low certainty
Community interventions
Addressing environmental and social factors that contribute to substance use—IPM	Substance use	Moderate certainty

There is extensive support for the use of such an approach for reducing the hazardous and harmful use of alcohol in primary care settings[85,86] and emergency settings.[87]

There is also promising evidence for the use of personalized digital interventions to reduce hazardous and harmful alcohol use in community settings. These interventions typically involve the person entering information about alcohol use, which is followed by personalized feedback and suggestions about how to cut down on drinking.[88]

Interventions during old age

Prevention interventions specifically designed for older people are not common, and those designed for mixed-age groups often fail to address the unique and sometimes complex needs of aging communities. A systematic review of the empirical evidence from studies (N = 19) found that most studies (N = 8) utilized different types of screening, brief advice, and education. The remaining drew on behavioral, narrative, and integrated or multidisciplinary approaches, which aimed to meet older people's needs holistically.[89,90,91] Interventions need to align with other areas of health and well-being and should be delivered in locations where older people normally seek or receive help.

CONCLUSIONS

• There is a clear relationship between problematic substance use and poor well-being across different age groups.

• The pathways that influence the risk of developing mental health issues, such as problematic substance use, overlap with those that build resilience and well-being.

• Interventions that reduce risk or increase protective factors can lead to greater well-being and reduced mental morbidity, including problematic substance use.

• Universal interventions, which include multiple components, such as nutrition, physical exercise, and self-regulation beginning from the antenatal period, infancy, and early childhood are likely to have greater effects on well-being and mental morbidity, but direct evidence for the same remains scant.

• Universal school-based interventions seem to have a greater effect on the prevention of substance use among children and adolescents when compared to universal individual or family-based interventions.

• The involvement of the community in participatory interventions, which address the social and environmental determinants of substance use, seems to improve the well-being of the community and reduce substance use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.