University of Pittsburgh of School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
J Child Psychol Psychiatry. 2010 Apr;51(4):472-96. doi: 10.1111/j.1469-7610.2010.02230.x. Epub 2010 Feb 22.
Given the long-term morbidity of juvenile-onset major depressive disorder (MDD), it is timely to consider whether more effort should be dedicated to its primary and secondary prevention.
We reviewed studies of prodromal symptoms that may herald a first episode pediatric MDD and considered whether that literature has made an impact on secondary prevention (efforts to prevent progression from symptoms to full disorder). We also reviewed studies of children at familial risk for MDD that addressed atypical affectivity and the regulation of sad, dysphoric affect (mood repair) and related physiological systems, and considered whether research in those areas has made an impact on primary prevention of pediatric MDD (efforts to prevent the disorder).
A compelling body of literature indicates that depressive symptoms in youngsters predict subsequent MDD across the juvenile (and early adult) years and that any combination of several symptoms for at least one week is informative in that regard. These findings are echoed in the case selection criteria used by many secondary prevention programs. Convergent findings also indicate that (compared to typical peers) young offspring at familial risk for depression manifest low positive affectivity and compromised mood repair, along with signs of dysfunction in three intertwined physiological systems that contribute to affectivity and mood repair (the hypothalamic-pituitary-adrenal (HPA) axis, cerebral hemispheric asymmetry, and cardiac vagal control). While all these affect-related parameters are suitable for case selection and as intervention targets, they have not yet made an impact on primary prevention programs.
According to recent meta-analyses, attempts to prevent pediatric depression have not lived up to expectations. Based on our review, possible reasons for this include: (a) the use of case selection criteria that yield samples heterogeneous with regard to whether the symptoms are truly prodromal to an episode of MDD or are trait-like (which could affect response to the intervention), (b) failure to fully capitalize on the broad-ranging literature on vulnerability to pediatric MDD, as evidenced by the infrequent use of family history of depression (a robust index of vulnerability) or combined indices of vulnerability for case selection, and (c) lack of synchrony between dimensions of vulnerability and the content of the prevention program, as indicated by the overwhelming use of cognitive-behavioral interventions, irrespective of subjects' age, developmental readiness, and whether or not they evidenced the relevant cognitive vulnerability. Prevention trials of pediatric MDD could benefit from new approaches to case selection that combine various indices of vulnerability, more effective use of existing findings, and new or modified interventions that are developmentally sensitive.
鉴于青少年发病的重度抑郁症（MDD）的长期发病，现在及时考虑是否应该更多地致力于其一级和二级预防。
我们回顾了可能预示首次儿童 MDD 发作的前驱症状研究，并考虑了该文献是否对二级预防（从症状到完全障碍的进展预防）产生了影响。我们还回顾了针对 MDD 家族风险的儿童研究，探讨了非典型情感和悲伤、抑郁情绪（情绪修复）的调节以及相关生理系统，并考虑了这些领域的研究是否对儿童 MDD 的一级预防（预防障碍）产生了影响。
大量文献表明，青少年的抑郁症状预示着此后几年（包括青少年早期）的 MDD，并且任何症状持续至少一周的组合都具有信息性。这些发现与许多二级预防计划使用的病例选择标准相呼应。汇聚的发现还表明，（与典型同龄人相比）具有抑郁家族风险的年轻后代表现出低正性情绪和受损的情绪修复，以及三个相互交织的影响情绪和情绪修复的生理系统的功能障碍迹象（下丘脑-垂体-肾上腺（HPA）轴、大脑半球不对称性和心脏迷走神经控制）。虽然所有这些与情绪相关的参数都适合病例选择和作为干预靶点，但它们尚未对一级预防计划产生影响。
根据最近的荟萃分析，预防儿童抑郁症的尝试并未达到预期。根据我们的审查，造成这种情况的可能原因包括：（a）使用病例选择标准，导致样本在症状是否真正是 MDD 发作的前驱症状或特征性方面存在异质性（这可能会影响干预的反应），（b）未能充分利用广泛的儿童 MDD 易感性文献，表现为对抑郁家族史的使用频率较低（一种强大的易感性指标）或用于病例选择的易感性综合指标，以及（c）易感性维度与预防计划的内容之间缺乏同步性，表现为压倒性地使用认知行为干预，而不管对象的年龄、发育准备程度以及是否存在相关认知易感性。儿童 MDD 的预防试验可以从结合各种易感性指标的新病例选择方法、更有效地利用现有发现以及对发展敏感的新或修改的干预措施中受益。
