Prevention of depression will only succeed when it is structurally embedded and targets big determinants
Prevention of depression will only succeed when it is structurally embedded and targets big determinants
复制标题
抑郁症的预防只有在结构上根深蒂固并针对重大决定因素时才能成功
作者：
J. Ormel;P. Cuijpers;Anthony F Jorm;R. Schoevers
全球约有1.5亿人随时受到重度抑郁症（进一步抑郁）的影响，每5名女性中就有1名，每8名男性中就有1名在其一生中经历过一次重度抑郁症。尽管自20世纪70年代以来，西方国家越来越多的人接受了精神卫生保健，尤其是药物治疗，但流行病学数据并未表明抑郁症的人口患病率有所下降。很明显，与安慰剂相比，目前的治疗方法的有效性是适度的，并且仍然存在实质性的治疗质量差距。然而，即使提供最佳治疗，也需要其他方法来解决抑郁症和其他常见疾病的公共卫生负担。预防是一个在很大程度上被忽视的选择，但有其自身的复杂性。最近对旨在减少抑郁症发病率的预防性干预措施的随机对照试验的荟萃分析一致报告了小到偶尔中等的效果，需要治疗的人数（NNT）约为22人。值得注意的是，这些效果与使用他汀类药物预防5年期间急性心肌梗死的效果相似。然而，绝大多数的预防试验都是针对有亚阈值症状的人进行心理治疗。此外，研究仅限于短期结果，影响随着时间的推移而降低，这表明重复的年龄适应暴露是必不可少的。很少使用主动比较器，高质量的研究报告的影响也小得多。此外，依从性远不是最佳的。风险最高的人群往往最不愿意参加心理治疗。目前预防的最大问题是，它没有针对风险的最强烈决定因素，也没有从结构上嵌入主要的社会制度。较强的近端决定因素包括受到不良的养育（危险的产前行为、情感忽视、拒绝、缺乏结构、过度控制和过度参与、父母之间的冲突、家庭不稳定），以及儿童适应不良的人格特征（消极情感、低自我控制）和较差的社交和解决问题的能力。这些都对一系列广泛的结果产生了公认的长期影响。当不良的养育和孩子的风险都存在时，不适应的人与环境的交易可能会发展，往往导致难以解决的人格问题，这些问题是抵制改变的。因此，必须同时针对与父母和儿童有关的风险决定因素。因此，预防需要在生命早期开始，同时针对儿童和父母，是长期的和结构性的，并提高养育技能和儿童的自我控制，消极情绪和生活技能，部分通过更好的养育，部分通过更好的教育。鉴于早发性恐惧症、多动和对立违抗行为的潜在意义，消极情感和自我控制尤为重要。同样令人感兴趣但调查较少的是远端社会经济和文化因素对心理健康的影响，如社会地位低下、收入不平等、移民及其影响中介。当前预防的第二个问题是，它没有在结构上和社会上根深蒂固。只有在地方、地区/州和国家各级落实预防措施，大规模、长期实施和利用预防措施才能取得成功。有两种形式的嵌入很重要。第一，“社会政治形式”，地方行政当局和国家政府将预防（方案/活动）纳入教育、怀孕和儿童保健、保健和社会工作领域的现有机构。第二，“社会心理形式”，心理健康价值观和行为发展成为广泛接受的社会规范（就像吸烟一样）。第一种嵌入形式可能是保证结构性资金、政治合作以及长期实施的最佳方式。第二种形式很重要，因为它奖励（心理）健康行为。例如，如果生活技能成为学校常规课程的一部分（在小班！），那么反复接受适合年龄的普遍“预防”就会成为为成年生活做准备的正常组成部分。精神卫生专业人员和组织无法单独实现这一目标。正如世界卫生组织所倡导的那样，它需要多个组织（社区、市、区、州）的多方共同协作。嵌入式普遍规划的主要优点是：a)可以使预防活动正常化，因为它们扎根于（实际上）强制性的系统（教育、产科、儿童保健）；B)减少污名化的风险；C)改善养育方式，孩子的特点和生活技能（以及生活方式），这将使生活的多个领域受益。这可能包括从精神和身体健康到教育程度、职业和收入，甚至包括关系、社会嵌入和犯罪率。虽然天花板效应确实存在，但即使是在各方面都做得相对较好的父母和孩子也可能从普及计划中受益。尽管预计人口效应将是巨大的，但普遍计划不会使每个人都达到预期的水平。有些人将需要额外的投入：补救预防，类似于对学习成绩不理想的学生进行补救教学。通过这种方式，选择性/指示性预防补充了普遍预防。我们正面临着一个引人注目的悖论。一方面，利益相关者(政策制定者、消费者、保险公司、
About 150million people worldwide are affected withmajor depressive disorder (further depression) at any moment, and one in every five women and one in every eight men experience an episode of major depression over the course of their life. Although, since the 1970s, more and more people in Western countries have received mental health care, most notably pharmacotherapy, epidemiological data do not indicate a drop in the population prevalence of depression. It is clear that the effectiveness of current therapies relative to placebo is modest, and substantial treatment quality gaps still exist. However, even with optimal treatment delivery, other approaches are necessary to address the public health burden of depression and other commonmental disorders. Prevention is a largely neglected option, but has its own complexities. Recent meta-analyses of randomized controlled trials of preventive interventions that seek to reduce the incidence of depression consistently report small to occasionally moderate effectiveness, with numbers needed to treat (NNT) around 22. Notably, these effects sizes are similar to those for the use of statins to prevent an acute myocardial infarction during a 5 year period. However, the large majority of prevention trials concern psychological therapies administered to motivated people with sub-threshold symptoms. In addition, studies are limited to short-term outcomes and effects decrease over time, suggesting that repeated age-adapted exposures are essential. Active comparators are rarely used, and higher quality studies report substantially smaller effects. In addition, adherence is far from optimal. Populations at the highest risk are often the least motivated to participate in psychological therapies. The biggest problems of current prevention are that it does not target the strongest determinants of risk and is not structurally embedded inmajor social systems. Strong proximal determinants include exposure to poor parenting (risky prenatal behavior, emotional neglect, rejection, lack of structure, over-control and over-involvement, inter-parental conflict, family instability), as well as children’s maladaptive personality traits (negative affectivity, low selfcontrol) and poor social and problem-solving skills. These have well-established long-term effects on a broad range of outcomes. When both poor parenting and child risks are present, maladaptive person-environment transactions may develop that often result in intractable personality problems which are resistant to change. It is therefore essential to target simultaneously both parentand child-related determinants of risk. Thus, prevention needs to start early in life, address both child and parent, be long-term and structural, and improve parenting skills and children’s self-control, negative affectivity and life skills, partly through better parenting and partly through better education. Negative affectivity and self-control are especially important, given the prospective significance of early-onset phobia, hyperactivity and oppositional-defiant behavior. Also of interest, but less thoroughly investigated, are the mental health effects of distal socio-economic and cultural factors, such as inferior social status, income inequality, migration, and their effect mediators. The second problem of current prevention is that it is not structurally and socially embedded. Large-scale, long-term implementation and utilization of prevention can only be successful if prevention is embedded at local, district/state, and national levels. Two forms of embedment are important. First, the “socio-political form”, in which local administrations and national governments embed prevention (programs/activities) in existing institutions in the domains of education, pregnancy and child care, health and social work. Second, the “social-psychological form”, in which mental health values and behaviors develop into widely accepted social norms (as is happening with smoking). The first form of embedding is probably the best way to guarantee structural funding, political collaboration and thus long-term implementation. The second form is important as it rewards (mental) health behaviors. For instance, if life skills become part of the regular curriculum of schools (in smaller classes!), repeated age-adapted exposure to universal “prevention” becomes a normal component of preparation for adult life. Mental health professionals and organizations cannot achieve this alone. As advocated by the World Health Organization, it requires the joint collaboration of multiple parties at multiple levels of organization (community, municipality, district, state). The major advantages of embedded universal programs are that they: a) may normalize prevention activities because they are anchored in systems that are (virtually) mandatory (education, obstetric, child care); b) reduce risk of stigma; c) improve parenting, child characteristics and life skills (and hence lifestyles), which d) will benefit multiple domains of life. This may range from mental and physical health to educational attainment, occupation and income, but even relationships, social embeddedness and crime rates. Although ceiling effects certainly exist, even parents and children who do relatively well on all fronts may benefit from universal programs. Despite the expectation that population effects will be substantial, universal programs will not involve everybody at the desired level. Some people will need additional input: remedial prevention, analogous to remedial teaching for pupils with unsatisfactory academic progress. In this way, selective/ indicated prevention supplements universal prevention. We are facing a remarkable paradox. On the one hand, stakeholders (policy makers, consumers, insurance companies,
影响因子：
--
作者：
Kessler, Ronald C.;Ormel, Johan;Petukhova, Maria;McLaughlin, Katie A.;Green, Jennifer Greif;Russo, Leo J.;Stein, Dan J.;Zaslavsky, Alan M.;Aguilar-Gaxiola, Sergio;Alonso, Jordi;Andrade, Laura;Benjet, Corina;de Girolamo, Giovanni;de Graaf, Ron;Demyttenaere, Koen;Fayyad, John;Haro, Josep Maria;Hu, Chi Yi;Karam, Aimee;Lee, Sing;Lepine, Jean-Pierre;Matchsinger, Herbert;Mihaescu-Pintia, Constanta;Posada-Villa, Jose;Sagar, Rajesh;Uestuen, T. Bedirhan
通讯作者：
Uestuen, T. Bedirhan