Our findings indicate that this objective is attainable in the nations' schools if we are willing to make the needed investments.

The good news in the commission reports is that the most common disorders (anxiety and depression) have effective treatments that can help more than 70% of those who are afflicted. Those who do not respond to particular treatments can be given alternative therapies that can raise the success rate even higher. Although combination treatments involving both drugs and psychotherapy are often most effective, it is also the case that psychotherapy, in particular cognitive-behavior (CBT) or interpersonal (IPT) approaches, can reduce symptoms and lead to improvement without the use of medication.

There is also progress in the treatment of the less prevalent conditions. Treatments for bipolar disorder have a high success rate, and therapeutic interventions for anorexia nervosa can lead to recovery from this illness. Early intervention can also benefit those with schizophrenia, reducing the severity of the illness and leading to better adaptation to the disorder. Since many with severe mental disorders are at risk for suicide, these interventions can be not only life altering but also life saving.

As discussed below, the findings also have important implications for the reduction of stigma associated with mental illness. Public awareness of the effectiveness of treatment for mental disorders should increase the willingness of parents and youth to seek treatment before illness pro gresses. Stigma reduction throughout society should also increase the likelihood that those who have been successfully treated will lead productive and satisfying lives.

As this book goes to press, there is vigorous discussion about the safety and efficacy of antidepressants in particular, selective serotonin reuptake inhibitors (SSRIs), for treatment of adolescent depression. Many clinical trials supported by the pharmaceutical industry suggest the potential for adverse events in the use of SSRIs, including increased suicidal ideation and suicide attempts (Harris, 2004a, b). Unfortunately, these trials were often kept from public view. This has led to increased pressure to make all clinical trials involving drugs available for public inspection. In addition, an FDA panel has determined that these trials support the conclusion that SSRIs may carry an increased risk for suicidal ideation or behavior for a small proportion of users (perhaps 2 or 3%) and as a result labels warning of these effects will now be placed on all antidepressants (FDA, 2004).

A recent trial with adolescents suffering from major depression (Glass, 2004; March et al., 2004) indicated that treatment with a particular SSRI (Prozac) was less likely to produce adverse events when combined with CBT. Based on this evidence as well as considerable research suggesting the effectiveness of CBT as well as IPT with adolescents (reviewed by the depression-bipolar commission), it may be that combined treatment is the best approach for adolescents who present with depression and suicidal thoughts or behaviors. Since many physicians and mental health providers may not be trained to deliver CBT or IPT, there is a clear need to increase the number of practitioners who can provide these alternatives. Use of CBT or IPT may be the preferred alternative for less severe cases, since it has proven efficacy and does not run the risk of increased suicidal behavior.

It is encouraging to note the appearance of several initiatives designed to increase public ac

cess to the results of clinical trials evaluating the effects of therapeutic interventions. Eleven major medical journals have established a policy requiring the registration of such trials at inception before findings can be considered for publication (DeAngelis, Drazen, Frizelle, Haug, Hoey, Horton, et al., 2004). The American Medical Association has endorsed the concept of a federally mandated registry of clinical trials (Council of Scientific Affairs, 2004). Legislation mandating registration has been introduced in both the House and Senate (Fair Access to Clinical Trials Act, 2004). All of these efforts encourage greater use of the existing federally-sponsored but voluntary repository of clinical trails, www.clinicaltrials.gov . We look forward to the eventual open access to all results regarding the efficacy of medication and other therapies as well as reports of adverse reactions experienced following regulatory approval.

Treatment for drug dependence in adolescents raises a host of issues because some drugs of dependence (e.g., marijuana) are banned by law and their use is treated as criminal behavior. This is unfortunate because dependence on most drugs can be successfully treated if the family is involved in the therapy (see Chapter 18). Furthermore, drug dependence is often comorbid with other mental conditions that would benefit from treatment as a medical problem rather than as criminal behavior. Because the treatment system for substance abuse is not integrated with treatment for mental conditions (see below), those with both suffer needlessly.

It is now clear that most cases of adult mental disorders make their first appearance prior to or during adolescence (Kim-Cohen, et al., 2003; Roza, Hofstra, van der Ende, & Verhulst, 2003). This reality makes the early detection and treatment of mental disorders even more critical (see also The President's New Freedom Commission on Mental Health, 2003). The earlier a condition is identified and treatment begun, the less serious the course of illness and the lower the likelihood that it will disrupt healthy adolescent development. This is particularly important for substance dependence, including smoking, because there is evidence of nervous system plasticity during adolescence. A drug habit learned early produces brain changes that may be lifelong. If early detection and treatment of mental disorders were the norm, the possibility of reducing subsequent disorder would be increased. Furthermore, given the high rates of mental disorders as precursors to suicide, their early treatment would boost our chances of preventing this fatal outcome in youth.

Because it is clear that early detection and referral for treatment should be a high national priority, it is disappointing to learn from research conducted as part of the commissions (Chapters 30 and 31) that the primary care system and schools are inadequately prepared to meet this challenge. Primary care physicians are not trained to detect mental disorders or substance abuse problems, and most do not employ screening programs to identify youth at risk for these conditions. A similar situation exists in the schools where mental health professionals do not have the resources to identify youth at risk for problems. As a result, schools do not intervene until illnesses progress and come to the attention of staff. Unfortunately, the most common disorders in adolescence (depression, anxiety, and substance abuse) are not as easily recognized as conduct disorder and attention-deficit hyperactivity disorder (ADHD), conditions that make their first appearance in the elementary years. Waiting until adolescent conditions seriously interfere with school performance forestalls treatment and reduces the odds of successful recovery.

Treatment systems also are poorly designed for delivering care to adolescents. The most glaring example of this, treatment for substance abuse, is a case study of inadequate response to a large but potentially manageable problem (Chapter 29). The long-standing dichotomy between treatment for drug dependence and other mental conditions creates a barrier that prevents comprehensive treatment. Since substance abuse