Kirkbride et al's outstanding paper¹ updates recommendations from the perspective of social determinants of health to mitigate the onset of mental disorders and lay out a roadmap for an effective prevention plan. They explain that the maldistribution of essential social determinants is not random, is shaped by policy and by those in power, and could reproduce intergenerational inequities in people's opportunities. They refer to the saliency of “a threshold moment” to actualize our response, given societal demands to tackle the global burden of psychiatric morbidity. They underline the shift of focus from the internal individual-level factors to the environmental conditions that impact mental health and well-being, particularly in children, adolescents and younger ages.

The authors’ analysis leads to several new significant insights. Their preventive framework to enhance children's mental health and prevent psychopathology offers a rich array of primary and secondary interventions with proven evidence for rapid implementation. They identify gaps and inconsistencies in intervention results that require further evaluation, and studies that lack scientific rigor. With a strong anchor on equity, their seven recommendations make a compelling claim for investing in primary prevention.

This important contribution offers a blueprint for preventive actions. However, the authors acknowledge the limitations of prevention strategies to significantly reduce the incidence and prevalence of mental disorders, since there is a shortage of population coverage and it is highly challenging to implement interventions to alter social or physical environments. Preventive interventions may fail to solve the structural problems that generate them in the first place. Some studies may not stratify the diverse groups to examine if the average effect differs by population subgroups of age, sex, region and ethnicity.

Partly missing from the review is an adequate attention to the possible unintended harmful effects of prevention interventions, some of which may have consequences that are the opposite of those desired². These unintended consequences – such as stigmatization of children or frustration of teachers who participate in a school mental health promotion program – are hard to anticipate, identify and observe³. Recent work suggests the need to consider possible physical, psychosocial, economic, cultural and environmental harms of prevention interventions, especially when they do not align with the target community's norms, values and preferences⁴. For example, work using mediation analysis⁵ found that boys in families receiving a housing voucher in the Moving to Opportunities intervention showed an elevated risk of mood and externalizing disorders. Similarly, other research points to how primary prevention interventions can aggravate disparities and social inequities, particularly when they lack cultural humility in their approaches for minoritized populations⁶. Having the perspective of those involved in the program can be critical to optimize the impacts of the prevention interventions and minimize their unintended consequences.

Specific framing is one of the tricky features of this contribution. Certain review areas may sound like putting the onus on individuals, replicating a narrative that the problems are theirs rather than at the institutional or societal levels. Subtly, this message may convey disempowerment, implying that we researchers can tell these groups how to solve their problems rather than co-create with them the solutions. Considering racial or minoritized groups as the inheritors of the problems, and framing appropriately the preventive interventions (i.e., acknowledging the role that society as a whole has had in generating the problems) can revert the liability. Sometimes we phrase race questions as biological or behavioral flaws or equate race with racism in our interpretation of findings⁷.

A more extensive review of the system- and institution-level preventive interventions would call attention to policies and regulations to prevent the onset of mental illness and psychological distress. Addressing structural determinants, as in income support provided by the Earned Income Tax Credit, and changing legislation which promotes unpredictable and precarious work schedules for parents in low-paying jobs, are examples of the broad potential impact of policy levers in reducing the adverse mental health harms to young children and decreasing the psychological distress to families. Public policies play a role in onset of and recovery from mental illness. An example is the analysis of the impact of health insurance expansions in Oregon, which demonstrated a decrease in the depression rate⁸, although physical health outcomes did not improve in the first two years.

Kirkbride et al focus on positive and enrichment approaches to the neighborhood, such as neighborhood regeneration programs. This section is one of their review's most thoughtful and provocative components. It lends itself to collaborating with the community and policy makers to co-create a program of how, given the context and resources, mental health prevention should best be prioritized. In deciding which alternatives should be selected, the community voice must be central to the discussions. This can help researchers to anticipate unintended consequences and align with what matters most to that community. On the other hand, it can avoid that policy makers view the feasibility and sustainability of such prevention programs as challenging to sell to their electorate.

The authors are practical in recommending that we give precedence to interventions that might influence multiple domains, such as intervening in the prenatal period or in childhood in order to orient mental, physical and cognitive trajectories. However, policy makers must also play a significant role, since their ranking of what needs to be prioritized and invested in might differ from our theoretical models of causation and reparation. Community-research-policy partnerships⁹ might be the best avenue to build and implement the preventive agenda. Because not all social determinants equally affect or impact onset, progression or recovery of mental health problems, which might depend on the population and its characteristics, some preliminary work and convening might be needed to bring the different partners to agree on a plan of action and on the desired outcomes.

Kirkbride 等人的杰出论文¹从健康的社会决定因素的角度更新了建议，以减轻精神障碍的发作，并为有效的预防计划制定了路线图。他们解释说，基本社会决定因素的分配不均不是随机的，而是由政策和当权者决定的，并且可能会重现人们机会方面的代际不平等。鉴于社会要求解决全球精神疾病发病率负担，他们提到了实现我们的应对措施的“阈值时刻”的重要性。他们强调重点从个人内部因素转向影响心理健康和福祉的环境条件，特别是在儿童、青少年和更年轻的年龄段。

作者的分析得出了一些新的重要见解。他们旨在增强儿童心理健康和预防精神病理学的预防框架提供了丰富的初级和次级干预措施，并提供了快速实施的经过证实的证据。他们发现干预结果中需要进一步评估的差距和不一致，以及缺乏科学严谨性的研究。他们的七项建议以公平为基础，对初级预防的投资提出了令人信服的主张。

这一重要贡献为预防行动提供了蓝图。然而，作者承认，显着降低精神障碍发病率和患病率的预防策略存在局限性，因为人口覆盖范围不足，而且实施干预措施来改变社会或物理环境非常具有挑战性。预防性干预措施可能无法从一开始就解决产生这些问题的结构性问题。一些研究可能不会对不同群体进行分层，以检查平均效应是否因年龄、性别、地区和种族的人口亚组而异。

审查中部分遗漏的是对预防干预措施可能产生的意外有害影响的充分关注，其中一些可能产生与预期相反的后果² 。这些意想不到的后果——例如儿童的耻辱或参与学校心理健康促进计划的教师的沮丧——很难预测、识别和观察³ 。最近的工作表明，有必要考虑预防干预措施可能对身体、社会心理、经济、文化和环境造成的危害，特别是当它们不符合目标社区的规范、价值观和偏好时⁴ 。例如，使用中介分析^{5 的}研究发现，在“转向机会”干预措施中获得住房券的家庭中的男孩表现出情绪和外化障碍的风险较高。同样，其他研究指出初级预防干预措施可能会加剧差距和社会不平等，特别是当它们在针对少数群体的方法中缺乏文化谦逊时⁶ 。获得参与该计划的人员的观点对于优化预防干预措施的影响并最大程度地减少其意外后果至关重要。

具体的框架是这篇文章的棘手特征之一。某些审查领域可能听起来像是将责任归咎于个人，重复了这样一种说法：问题是他们的，而不是在机构或社会层面。巧妙地，这一信息可能传达了一种剥夺权力的感觉，这意味着我们研究人员可以告诉这些群体如何解决他们的问题，而不是与他们共同创造解决方案。将种族或少数群体视为问题的继承者，并适当制定预防性干预措施（即承认整个社会在产生问题中所扮演的角色）可以扭转责任。有时，我们在解释调查结果时将种族问题表述为生物学或行为缺陷，或将种族与种族主义等同起来⁷ 。

对系统和机构层面的预防干预措施进行更广泛的审查将引起人们对预防精神疾病和心理困扰发作的政策和法规的关注。解决结对幼儿造成伤害，减少家庭的心理困扰。公共政策在精神疾病的发病和康复中发挥着作用。一个例子是对俄勒冈州健康保险扩张的影响的分析，结果表明抑郁症发病率有所下降⁸ ，尽管身体健康结果在头两年没有改善。

Kirkbride 等人关注积极和丰富社区的方法，例如社区再生计划。这一部分是他们的评论中最深思熟虑和最具争议性的部分之一。它有助于与社区和政策制定者合作，共同制定一项计划，根据背景和资源，最好优先考虑心理健康预防。在决定选择哪些替代方案时，社区的声音必须成为讨论的核心。这可以帮助研究人员预测意想不到的后果，并与对该社区最重要的事情保持一致。另一方面，它可以避免政策制定者认为此类预防计划的可行性和可持续性难以向选民推销。

作者务实地建议我们优先考虑可能影响多个领域的干预措施，例如在产前或儿童时期进行干预，以调整心理、身体和认知轨迹。然而，政策制定者也必须发挥重要作用，因为他们对需要优先考虑和投资的项目的排序可能与我们的因果关系和赔偿理论模型不同。社区-研究-政策伙伴关系⁹可能是制定和实施预防议程的最佳途径。由于并非所有社会决定因素都会同样影响精神健康问题的发生、进展或恢复，这可能取决于人口及其特征，因此可能需要开展一些初步工作和召集会议，以使不同的伙伴就行动计划达成一致，关于期望的结果。