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ajp.psychiatryonline.org In any case, as I read chapter after chapter I began to discover a different perspective about this book. While there is no longer a need to prove that homosexuality is not a mental disorder or that Dr. Spitzer’s study of 2001 lacked scientific rigor, this compendium of papers/chapters permitted the review of this historical series of events together rather than separately. This historical and comprehensive approach has some value when seen in this context. However, for the reader who might want to examine both sides of this issue for the purpose of deciding who was right or who was wrong on this topic, reading this book will serve no purpose whatsoever, since that type of decision has no validity in the 21st century. In terms of the book itself, it has 37 chapters, divided into four sections. The first section lays out an introduction to the topic of this book and the book itself. The second section focuses on the concept of “changing sexual orientation.” The third section is comprised of a series of commentaries about Dr. Spitzer’s controversial study of the early 2000s and his response to them. Both sides attempt to explain how right or wrong Dr. Spitzer’s study was. The fourth section includes commentaries on the Spitzer study as well as an interview with Dr. Spitzer conducted by Dr. Jack Drescher. In summary, despite its shortcomings, this compendium of previously published papers offers a unique opportunity to review and understand the historical perspective of “homosexuality” as perceived by the profession and society at large during the last several decades. From this viewpoint, I strongly recommend this book to those interested in this historical perspective.

The purpose of this chapter is to discuss an additional complicating factor that impacts adolescent treatment and goes beyond the individual youth and his or her family: the service delivery system. These systems (e.g., educational institutions, health care, juvenile justice, and mental health systems) are complex environments that offer opportunities to identify, treat, and monitor adolescent substance abusers. However, the architecture and operating procedures of these systems often serve to inhibit access to needed services and to confuse or confound coordination of complementary service delivery across systems. The result can be formidable challenges to the identification and subsequent intervention and treatment of the adolescent who uses, abuses, or is dependent upon substances. In the text that follows, we identify problems within the current “standard” system of care leading to failure to identify these adolescents, inadequate access to even basic substance abuse intervention for those identified, and failure to provide adequate amounts or types of services to those who do access the care system. We also present mechanisms for enhancements and conclude with a summary of three innovative approaches targeted to systems improvement.

The prevention of an individual's first episode of depression is worthy of greater study among investigators concerned with mood disorders. Not only is the first episode devastating for individuals and those around them but it is a major burden within our health system and society. Once the first episode of major depressive disorder (MDD) occurs, the sequelae are substantial. Following an episode of MDD, the probability of subsequent episodes is significantly increased, even to the point that many now consider MDD to be a chronic disease. The sequelae to MDD are numerous and include poorer social relationships, increased substance abuse, increased use of medical services, interference with long-term cognitive functioning, significant comorbidity with major health problems, and younger ages of death (even when deaths by suicide are taken into account). Most investigators of mood disorders believe that the first episode lays down neural pathways that are difficult to overcome and, without modification via medications or psychosocial interventions or their combination, are likely to be lasting pathways that impact individuals' lives. Even though prevention of MDD is an important topic, empirical work in this area is difficult and has been slow to progress. Some recent work has been conducted on the prevention of second and subsequent episodes, but the work designed to prevent the first episode of MDD has been meager. Before addressing the empirical work on prevention of MDD, it is important to note again the conceptual and historical context in which general prevention research has been defined.

There are no scientific studies to indicate the optimal treatment of eating disorders for adolescents, in terms of when treatment should begin, where that treatment should be delivered, or who should provide the treatment. The consensus view is that therapy should begin as soon as possible after a clinically significant eating problem has been identified, with the treatment provider, parents, and patient working to individualize treatment. The setting for the treatment is partially determined by availability, but the severity and duration of illness, especially with regard to medical complications, must also be considered. The optimal professional to treat an adolescent with an eating disorder is again determined in part by availability. Eating disorders can be effectively managed by a variety of different professionals, including physicians (psychiatrists, primary care providers, or adolescent medicine specialists), psychologists, social workers, and nutritionists who are familiar with efficacious treatment of eating disorders.

The purpose of this chapter is to outline these challenges to improving delivery of effective treatments for adolescents and their families and to define a set of research and policy directions that may help improve delivery. In particular, a number of major multisite studies supported by several foundations and federal agencies are currently under way to examine contextual influences on delivery of youth mental health services. These studies will very likely lead to new ways of thinking about implementation and dissemination of effective practices.

This chapter on the research agenda for depression and bipolar disorders consists of a summary of what is currently known, what is currently not known and what further research is needed on the subject of major depressive disorder (MDD) and bipolar disorder, including how they can be treated, and how they can be prevented.

Our primary goal in this section of the book is to examine youth suicide prevention strategies and interventions with an eye toward identifying what works, what does not appear to work, and what research needs to be undertaken to move the field forward. We begin with a review of the multiple factors that have been suggested to put youth at risk for suicide.

This chapter reviews the epidemiology and definitions of mood disorders in children and adolescence. The psychological, social, and biological factors that have been shown to increase the risk of mood disorders in children and adolescents are also discussed.

In this chapter, we focus on suicide prevention programs that have taken a universal approach, targeting youth in specific settings regardless of individual risk factors. One particularly widespread approach targets youth where they are most accessible–in the schools. Although the ultimate goal of all suicide prevention programs is to reduce death by suicide, school-based programs typically focus on more proximal outcomes. Two broad types of universal prevention programs have been especially common. The first includes educational programs that aim to increase students' knowledge and awareness about suicidal behavior, encourage troubled students to seek help, and improve recognition of at-risk students by teachers, counselors, and other “gatekeepers” within the school or community settings. In the second category are screening programs that seek to identify and refer to treatment youth who are at risk for suicidal behavior. In each category, suicide prevention efforts have been separately designed for high school and college students. In the following pages, we summarize these universal programs, identifying for each broad type the underlying assumptions and specific program examples, and providing a summary critique of the approach.

There are currently recognized precursors of schizophrenia that are apparent during adolescence. A wide variety of early-intervention techniques have been developed that draw on the knowledge of these precursors to identify individuals at risk for the illness and to prevent the predisposition toward schizophrenia from developing into the full disorder. Unfortunately, most of the research that has enabled the identification of these precursors and the development of these intervention techniques has been performed retrospectively in adults with schizophrenia, with little specific research attention directed toward forms of schizophrenia that manifest during adolescence. In addition, prevention efforts have necessarily lagged behind studies of the risk factors, detection, and early intervention of the disease. Yet, a great deal has already been learned about risk-profiling and early intervention in schizophrenia generally, and those aspects that may be useful in understanding the adolescent forms of the illness are discussed below.

This chapter on the prevention of anxiety disorders in adolescents considers intervention studies, but before this it is important to briefly consider what is known about risk and protective factors at the individual, familial, and societal level, because it is knowledge of these factors and their interrelations that should inform the development of specific intervention strategies. Unfortunately, knowledge of such factors is limited, and perhaps the paucity of prevention studies in anxiety disorders is a direct result of this limited knowledge. Of particular concern is the absence of evidence about protective factors that are specific to anxiety disorders. That is, although the youth resilience literature has generally underscored the importance of factors such as high IQ, selfesteem, social support, and positive coping in serving to protect young people from the development of psychopathology in general, there is a paucity of literature regarding whether any protective factor(s) may serve to protect against anxiety disorders in particular. Certainly, development of effective prevention programs will continue to be hampered until evidence-based knowledge has accumulated in this area. The summary below is thus reflective of this in proportion to the literature; that is, considerable more coverage is paid to risk factors than to protective factors.

We have learned a great deal about the early course of schizophrenia during the past two decades, leading to therapeutic optimism. However, several key areas of research continue to be a priority. First, we need to identify specific clinical characteristics in the premorbid and prodromal phases that can help us predict the individuals at a high risk for developing psychosis. Second, we do not know how to prospectively identify the early beginnings of the psychotic illness with an adequate degree of reliability to be able to intervene early. We also need to better understand the pathways to care for these patients. Educating the public and health care providers in early signs and symptoms can reduce the delay in care. Third, we need to further clarify the clinical features in the first psychotic episode that can help us predict subsequent illness course. Finally, we need to better understand the neurodevelopmental and neurodeteriorative processes that may underlie both the emergence and the subsequent course of the first psychotic episode.

Concurrent with the emergence of a growing psychopathology literature, child and adolescent clinical psychology and psychiatry have moved away from nonspecific interventions toward problem-focused treatments keyed to specific diagnoses and, within diagnoses, targets. The past 40 years have seen the emergence of diverse, sophisticated, empirically supported, cognitivebehavioral and pharmacological therapies that cover the range of childhood-onset anxiety disorders). Before reviewing what is known about the treatment of anxiety disorders in adolescence, we first provide a brief overview of the history and rationale for cognitive-behavioral therapy (CBT), for pharmacotherapy, and for the combination of the two in the treatment of youth with anxiety disorders. Because of increasing emphasis in the field on evidence-based approaches, those interventions that have not been subjected to treatment outcome study by means of accepted research methodology, such as psychodynamic approaches, “play therapy,” and other approaches, are not reviewed in this chapter.

This chapter presents research conducted as part of the Sunnylands Adolescent Mental Health Initiative (SAMHI) to determine primary care provider practices in identifying and referring adolescents for treatment of mental health problems.

Although it is clear that adolescent mood disorders exist and lead to significant immediate and lifelong impairment for the child, there exists limited treatment research in this special population. This has led clinicians to consult with the adult literature to provide guidance in their treatment approaches. In fact, the adult research studies have provided the template for the present interventions being explored in adolescent treatment studies. To appreciate how the adult literature informs the field of adolescent mood disorder treatments, the current status of the adult literature for both psychosocial and psychopharmacologic treatments will be reviewed. This will be followed by an appraisal of the same treatment areas for adolescents.

The effective prevention and treatment of adolescent substance abuse, like that for any public health problem, require a clear understanding of causes and the context in which these causes operate. Research on the origins of adolescent substance abuse is asking many important questions: How do different drugs affect the brains of different adolescents at different stages of maturation? How do environmental conditions increase or decrease the probability of substance abuse? Are there individual sensitivities to drugs of abuse that increase the risk of a substance use disorder? How do social factors produce contagion of drug abuse among adolescents? Are there specific treatments or prevention interventions for specific types of adolescent substance abuse? How do biological, psychological, and social factors account for failed prevention efforts or drug treatment relapse, and how common is it? This promising body of research carries with it the potential to create more effective approaches to the prevention of adolescent substance abuse as well as guiding treatment efforts.

In this chapter we review examples of selective suicide prevention programs that have been developed for youth identified or presumed to be at increased risk for suicidal behavior. Although the youth targeted by such programs are considered to be particularly vulnerable to suicide, in most cases they have not yet exhibited specific signs of suicidality. Discussed here are programs for three specific groups, each of which has shown elevated rates of suicidal behavior: Native American youth, youth with recent exposure to a suicide in the school or community, and youth who have access to firearms in the home. While there has been considerable research suggesting that adolescents and young adults in these groups are at greater risk for suicide, relatively few intervention programs for these populations have been developed to date.

An occasion of drug taking may be a passing indulgence of an adolescent, perhaps initiated in a moment of immature judgment. All too often, the drug taking can become repetitive and may lead to a syndrome of abuse or addiction, possibly in an interaction of inherited vulnerability traits with environmental conditions and processes. The development of addiction and the dependence syndrome in adolescents are emotion-laden, controversial, and often misunderstood topics. Public opinion leaders often do not appreciate the scientific evidence that tends to favor a disease concept of addiction or dependence on alcohol, tobacco, and other drugs such as cocaine or cannabis. This evidence includes a neuronal basis for many of the prominent clinical features of dependence, genetic vulnerability, and a characteristic chronic, relapsing course that resembles that of many medical illnesses. Unfortunately, these biological bases of addiction are often forgotten or misunderstood by a nonetheless opinionated American public that can view adolescent drug problems as purely behavioral and morally objectionable. Consequently, many affected adolescents end up being managed by their parents, school authorities, or the judicial system rather than being treated in specialized adolescent treatment programs. Even those seeking treatment often discover that appropriate programs do not exist in their geographic region or are difficult to access because of low capacity or managed care policies. While there would be a public uproar if treatment were not available to adolescents with head injuries, diabetes, or cancer, obvious disparities in addiction treatment have been tolerated for decades and may well reflect public skepticism about the biological bases of drug dependence and addiction. Unfortunately,we have much to learn about the onset, nature, and treatment of these conditions in adolescents. It is our contention that gaps in our knowledge should be addressed with research and clinical experience, and not cited to justify an inadequate treatment infrastructure.

This chapter on the research agenda for anxiety disorders in adolescents consists of a summary of what is currently known, what is currently not known and what further research is needed on the subject, including how they can be treated, and how they can be prevented.

The research of the past few decades has expanded our understanding of the phenomena linked to the concepts of anxiety and anxiety disorder. A comparison of contemporary reports with those of the last half century provides reason for optimism, for we have learned several important facts. First, the state we call anxiety in humans is not unitary in origin or consequence and can be the result of living with realistic threat, past history, conditioning, or a temperamental bias for unexpected somatic sensations that are interpreted as meaning one is anxious. Second, epidemiological and genetic data imply distinct biological profiles for the varied anxiety disorders, many of which implicate neurochemical processes. Finally, clinicians and investigators now have an initial set of cognitive and biological procedures that promise to aid differential diagnosis of individuals who report anxiety. Major advances will occur when investigators and clinicians add these procedures to their interview data. The results of this work will permit the parsing of individuals who have a particular diagnosis into subgroups with more homogeneous biological and psychological features. This knowledge should lead to a more fruitful set of psychiatric classifications.

Interest in psychological treatments for schizophrenia has increased in recent years, particularly in Europe and Australia, driven by understandable patient dissatisfaction with purely pharmacological approaches. The recognition that 40% of patients do not achieve symptom resolution with drug treatment has added impetus to the search for alternatives and adjuncts. Unfortunately, the paucity of data concerning the application of such approaches to adolescents suffering from schizophrenia means that, at least for the time being, inferences have to be drawn mainly from studies of adult populations. Nevertheless, the similar lack of data regarding efficacy and safety of antipsychotic drug treatment in adolescents and the observation that adolescents may be especially sensitive to the adverse effects of typical antipsychotics (e.g., extrapyramidal side effects) and clozapine (e.g., neutropenia and seizures) mean that there is a real need for alternative or supplementary interventions. Indeed, one could hypothesize that psychological treatments might be more effective in adolescents than in adults. This is a group with a greater degree of neural plasticity and a still evolving personality, and who are especially likely to have an ongoing system of support in the form of family and educational input. Furthermore, the latter presents opportunities for early detection. Alongside early treatment with antipsychotics, there is potential for psychotherapeutic interventions to lessen the impact of positive symptoms, improve coping strategies, and potentially to reduce the cognitive deficits, which so impair psychosocial function.

For any disorder, understanding the risk factors, or variables that predict the development of the disorder, is vital to prevention efforts. In eating disorders, considerable progress has been made in identifying risk factors for the development of the syndrome of bulimia nervosa and for a number of the behavioral and psychological symptoms of eating disorders; however, much less is know about risk factors for anorexia nervosa. Through recent efforts we have begun to identify risk factors and to examine how they increase the probability that an eating disorder will develop. This information is being used to inform rational prevention efforts.

For a variety of reasons, little research has been conducted among adolescents with substance abuse problems. We operate as though data obtained from studies in adults applies to adolescents, but we know that there are critical differences. Thus assumptions about adolescents must be empirically tested. The following are a series of questions compiled by the Commission on Abuse of Alcohol and Other Drugs that we believe should be given high priority.

The high rate of adolescent substance abuse in the United States makes the identification of effective treatment approaches a significant priority. Effective early intervention is crucial. Adolescents who initiate alcohol use by age 14 are significantly more likely to develop alcohol dependence as adults than those who initiate use by age 20, with significant reductions in the odds of developing dependence for each year of delayed initiation. Effective early intervention is also crucial with substance-abusing adolescents because it can play a preventive role in later years. Treatment of substance-abusing adolescents is complicated by a number of factors that appear to be particularly prevalent or problematic among adolescents. First, adolescents in treatment samples usually use multiple substances. Second, substance-using adolescents have very high rates of comorbid psychiatric disorders, which can greatly complicate treatment delivery and outcome. Treatment of substance-abusing adolescents is also complicated by high rates of substance abuse in their immediate families. Another obstacle to treatment for adolescents is that adolescents rarely seek treatment voluntarily but are usually coerced at some level after experiencing school, legal, or medical problems. Treatment is also complicated by their involvement in the multiple systems in which their legal, school, and medical problems are being addressed, as these problems may be identified prior to recognition of the presence of a substance use disorder. Finally, high attrition from treatment is a particular problem among adolescents, with treatment completion rates for adolescents in therapeutic communities estimated at less than 20%. Completion rates for outpatient programs are generally estimated at 50%.

This third and last category of youth suicide prevention efforts includes indicated interventions and treatments that target those who have already shown signs of suicidality. Such efforts seek essentially to reduce and prevent subsequent suicidal ideation and suicide attempts and prevent suicide completion. The interventions and treatments described in this chapter differ widely in the groups they target, the methods they use, and the settings in which they have been implemented.