edited by Dwight L. Evans, Edna B. Foa, Raquel E. Gur, Herbert Hendin, Charles P. O’Brien, Martin E. P. Seligman, and B. Timothy Walsh. New York, Oxford University Press, 2005, 864 pp., $59.50.
This is a big and ambitious book. I was interested in reviewing it to compare what it has to say with my experience as a consultant in child and adolescent psychiatry at a federally funded community health center, located in the middle of a dilapidated, crime-ridden, Puerto Rican Hispanic neighborhood in one of the largest cities of the wealthiest state in the Union. Most Americans don’t even know such places exist. The chair of the pediatric department, where I consulted, remarked to me one day how upset she was to have followed children from babyhood to adolescence only to hear they have died from a drug overdose or in a shootout. “I see some of my kids on the street corners and know that sooner or later they will be dead.”
While this may be the picture of the lowest end of our child and adolescent psychiatry population, even children and adolescents of middle class families with respectable insurance coverage face insuperable difficulties in receiving psychiatric treatment. Try to have an insurance company pay for the appropriate, prolonged, outpatient treatment of a depressed adolescent with a narcissistic or borderline personality disorder!
Before opening the book, I wondered: How much of this reality will find its way inside the covers?
The publication of this volume was sponsored by the Annenberg Public Policy Center of the University of Pennsylvania through the Annenberg Foundation Trust at Sunnylands. Each of the eight parts of this book was conceived by a separate commission on depression and bipolar disorder; schizophrenia; anxiety disorders; eating disorders; substance and alcohol abuse; suicide prevention; positive youth development; and summary of conclusions, recommendations, and priorities. There are 164 pages of references, none after 2004. The commissions had a total of 134 members; 53 were physicians, mostly psychiatrists, and 65 were Ph.D.-level scholars in psychology, psychopharmacology, epidemiology, statistics, and various related fields. There are very big guns here—truly outstanding people—many are luminaries in our field, but with 7 editors it is not clear at all who were the prime shapers of this document and its message.
So, how well did these researchers and clinicians do in responding to the subtitle of the book: “What We Know and What We Don’t Know—A Research Agenda for Improving the Mental Health of Our Youth”? On the level of research, very well. I can only applaud the conclusion that “the disorders as presently conceived may not ‘cut nature at the joints’ … what is most relevant … is not the DSM disorders themselves but common pathways to these disorders” (p. xxxix).
Each chapter reviews the definition, epidemiology, etiology and risk factors (personality and temperament, genetics, gender, stress, trauma, interpersonal relationships), comorbidities, psychosocial and pharmacological treatment, followed by recommendations summarized with respect to three questions: “What do we know? What do we not know? What do we need to urgently know?” (p. xxxix).
Unfortunately, the most difficult and most urgent question, a vital clinical question, was not asked: “What do we need to do, urgently do?” Nevertheless, some issues on service delivery systems as well as policy changes are addressed in the concluding chapters.
Another hard issue that was not addressed is the plight of children and adolescents with conduct disturbances who are in the process of developing severe personality disorders. Adolescents with antisocial, narcissistic, or borderline personality disorders, among the most difficult to treat, are not discussed. Conduct disorders and attention-deficit/hyperactivity disorder, the most common childhood psychiatric disorder, are only mentioned peripherally in conjunction with bipolar disorder.
On the level of psychosocial treatment, the discourse leaves something to be desired. The index has 33 separate entries for cognitive behavior therapy, six for behavior therapy, eight for family therapy, six for interpersonal therapy, five for problem-solving therapy, but only one for psychodynamic therapy, and even that one only with the added qualification of “brief.” Brief therapies, preferred by insurance companies, and symptomatic improvement are emphasized, to the exclusion of even a discussion of broader, longer-term developmental psychosocial goals. There are no index entries for such subjects as affect regulation, developmental psychology, identification, individuation, object relations, oedipal, preoedipal, self, or transference, issues that are paramount in the psychotherapeutic treatment of developing adolescents. That which can be measured gets attention. That which cannot be measured, the conundrum of a human relationship in the service of psychotherapeutic purposes, at times perhaps to save the life of a child or adolescent, is not attended to and does not get written about. Clinical observations not made within the framework of a randomized controlled trial are not significant or scientific or important enough to merit attention. There is no acknowledgment that “not everything that counts can be counted, and not everything that can be counted counts” (1). This is a highly idiosyncratic use of evidence-based medicine. Ralph Horwitz, chairman of Internal Medicine, Stanford University School of Medicine, had this to say about this “dark side of evidence-based medicine”:
The art of medicine will flourish where data are incomplete and blurred, which is much of medicine. It will flourish whenever caring doctors strive to meet the needs of their individual patients. Care of patients is an act, not an application of guidelines, but of interpretation of information. Physicians will be returned to grace because of this act of interpretation. Scientific evidence must be blended with a physician’s experience, reasoning and knowledge (2, p. 323).
Of course, we should continue to stay in the forefront of research on adolescent mental health disorders. But in caring for our adolescents, our fundamental problem very definitely is not lack of knowledge; we know quite a lot about the treatment of these disorders. Yet we have not been able to put our knowledge to best use. What do we need to urgently know? We need to acknowledge that a very disquieting and unbridgeable moat separates the one in five youths in this country suffering currently from psychiatric problems from the resources necessary for their successful treatment. Our society has made the anachronistic decisions to provide vigorous financial support for research on neuroscience and psychiatric illnesses, but to withhold, by default, the funds necessary for the everyday implementation of the practical findings of these projects for the treatment of mentally ill people, including adolescents with developmental, emotional, and behavioral problems—thus abandoning them. This is the problem we need to acknowledge and do something about urgently. It would be a most helpful and significant initiative for the Annenberg Foundation Trust at Sunnylands to convene commissions, similar to those whose work is summarized in this volume, to investigate and summarize what public policy, legal, and diverse other issues need to be addressed, and how to address them urgently, and to make available the extensive theoretical knowledge and clinical expertise we already have for the treatment of current developmental, emotional, and behavioral problems of all American youths.
In conclusion then, this volume well summarizes the basic knowledge we have on the definitions, epidemiology, risk factors, comorbidities, and pharmacological treatment of depression, bipolar disorder, schizophrenia, anxiety disorders, eating disorders, substance use disorders, and suicide in adolescents. For an unbiased review of psychosocial treatments of these disorders in adolescents, the reader will have to look elsewhere.
1.Kobelinski T as quoted in: In Minnesota, Voters Tune Out Scandals and Infighting to Focus on Issues. By Lynette Clemetson, The New York Times 2006; 156: No. 53,724, October 6, p A242.Horwitz RI: The dark side of evidence-based medicine. Cleve Clin J Med 1996; 63:320–323