S P E C I A L C O M M U N I C A T I O N

Depression and Bipolar Support Alliance ConsensusStatement on the Unmet Needs in Diagnosis and

Treatment of Mood Disorders in Childrenand Adolescents

JOSEPH T. COYLE, M.D., DANIEL S. PINE, M.D., DENNIS S. CHARNEY, M.D., LYDIA LEWIS,

CHARLES B. NEMEROFF, M.D., GABRIELLE A. CARLSON, M.D., PARAMJIT TOOR JOSHI, M.D.,

DAVID REISS, M.D., RICHARD D. TODD, M.D., PH.D., MARTHA HELLANDER, J.D., AND THE DEPRESSION

AND BIPOLAR SUPPORT ALLIANCE CONSENSUS DEVELOPMENT PANEL

ABSTRACT

Objective: To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make

recommendations for future research and allocation of healthcare resources. Method: The 36-member Consensus

Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental

health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk

factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advo-

cates were obtained. Results: The Consensus Development Panel listened to presentations and participated in dis-

cussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and

prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development

Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants.

Conclusions: Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar

disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other

primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that

are not validated for youths. Effective treatments have been identified and some preliminary prevention models have

been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately

trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder.

National efforts are required to restructure healthcare delivery and provider training and to immediately develop more

advanced research on pathophysiology, prevention, and services delivery effectiveness. J. Am. Acad. Child Adolesc.

Psychiatry, 2003;42(12):1494–1503. Key Words: mood disorders, major depression, bipolar disorder.

Major depression is a common, serious psychiatric dis-order in the United States, with prevalence rates of upto 2% for prepubertal children (Bird et al., 1988; Co-hen et al., 1993; Costello et al., 1996; Fleming et al.,McGee et al., 1990; Shaffer et al., 1996). The preva-lence of bipolar disorder in children and adolescents isnot known with precision because of the lack of large-scale epidemiological studies. The lifetime prevalenceof bipolar disorder could be as high as 1% (Lewinsohnet al., 1995) by adolescence, although rates in child-hood are likely to be lower (Costello et al., 2002,1996). Early-onset mood disorders are associated withturbulent, dysfunctional lives, poor school perfor-mance, impaired peer and family relationships, alcoholand substance abuse, and other psychiatric comorbidity.

Accepted July 29, 2003.The roles of DBSA Consensus Development Panel members and their affili-

ations appear at the end of this article. This DBSA Consensus Conference washeld October 17-18, 2000, in Washington, DC. Drs. Coyle, Pine, and Charneyprovided equal input to this document.

Conference underwriters: Abbott Laboratories; AstraZeneca; Bristol-MyersSquibb Company; Forest Laboratories, Inc; GlaxoSmithKline; Janssen Pharma-ceutica; Eli Lilly and Company; Merck & Co., Inc.; National Institute ofMental Health; Pfizer Inc.; Pharmacia & Upjohn; Solvay Pharmaceuticals,Inc.; The Henry Foundation; Wyeth-Ayerst Laboratories. Dr. David Shafferacknowledges Ted Greenberg, M.P.H., Division of Child and Adolescent Psy-chiatry, Columbia University, New York State Psychiatric Institute, for hisconsiderable assistance in contributing to this consensus statement.

Correspondence to Ms. Lewis, Executive Director, Depression and BipolarSupport Alliance, 730 North Franklin Street, Suite 501, Chicago, IL 60610;e-mail: llewis@DBSAlliance.org.

0890-8567/03/4212–1494©2003 by the American Academy of Childand Adolescent Psychiatry.

DOI: 10.1097/01.chi.0000091945.28938.8f

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 20031494

Nearly one out of five high school students seriouslyconsiders taking his or her own life (Kann et al., 2000),and suicide is the third leading cause of death in thisage group (Brent, 2001; Murphy, 2000; Shaffer andCraft, 1999). Children and adolescents with major de-pression or bipolar disorder are at greatly increased riskfor suicidal behavior and completed suicide (Pfeffer,2001; Pfeffer et al., 1993). Prepubertal suicidal behav-ior predicts adolescent suicide attempts, and mood dis-orders increase the risk of repeated suicide attempts(Pfeffer et al., 1993).

Youngsters with mood disorders often grow up to beadults with mood disorders and other serious psychi-atric comorbidity (Lewinsohn et al., 2000; Weissmanet al., 1999a). This continuity of mood disorders intoadulthood underscores the need for early recognitionand intervention. Unfortunately, efforts at early detec-tion and intervention are generally neglected by thelegislative, scientific, and medical communities(Mrazek and Haggerty, 1994). Although treatments ofearly-onset mood disorders remain inadequately stud-ied, recent efforts to examine efficacy in major depres-sion have begun to address the need for more researchin this area (Brent et al., 1998; Curry, 2001; Emslieand Mayes, 2001). More significant deficiencies existin studies of bipolar disorder and in aspects of servicedelivery for all pediatric mood disorders. More than70% of children and adolescents with serious mooddisorders are either undiagnosed or inadequatelytreated (Burns et al., 1995; Lewinsohn et al., 2000;NIMH Blueprint Report, 2001). These statistics un-derscore the crisis in mental health care for childrenand adolescents with mood disorders in a healthcaresystem that is currently inadequate to meet their needs.

CONSENSUS STATEMENT

Recognizing the need to address these concerns, theDepression and Bipolar Support Alliance (DBSA, for-merly known as the National Depressive and ManicDepressive Association [National DMDA]), the na-tion’s largest patient-directed, illness-specific organiza-tion, convened a consensus conference in October2000. The Consensus Group, which consisted of ex-perts in child and adolescent psychiatry and psychol-ogy, pediatrics, epidemiology, and mental healthadvocacy, was charged with drafting a statement defin-ing the knowledge base for early-onset mood disordersand providing recommendations for remediation. ThisConsensus Statement was developed in response to thediscussion prompted by expert presentations on diag-

nosis, risk factors, treatment, prevention, and servicesfor children and adolescents with mood disorders.

Risk Factors

Risk factors refer to agents, intrinsic characteristics,or environments that precede the onset of illness (Krae-mer et al., 1997, 2001). Ideally, risk assessment shouldconsider the entire context of the child’s life rather thanfocusing on individual factors (Beardslee and Glad-stone, 2001; Kessler et al., 1997). One salient risk fac-tor for mood disorders is family history of mooddisorder, although parental illness alone is not suffi-cient to predict, with high confidence, a childhoodoutcome. Thus, twin (Eaves et al., 1997; Eley andPlomin, 1997; Silberg et al., 2001, 1999; Thapar andMcGuffin, 1994), family (Beardslee et al., 1996; Har-rington et al., 1997, 1993; Kovacs et al., 1997; Warneret al., 1999; Williamson et al., 1995), and adoptionstudies (van den Oord et al., 1994) indicate that theetiology of mood disorders includes both genetic andenvironmental components. In one study, impover-ished children with multiple socioeconomic risk factorsand healthy mothers fared less well than children withmentally ill mothers but few other risk factors (Samer-off et al., 1987).

Gender-related changes during development repre-sent a second important set of risk factors in early-onsetmood disorders. The prevalence of depression, beingequal between boys and girls before puberty, doubles infemales during adolescence, and this doubling has beenlinked specifically to hormonal changes occurring dur-ing puberty (Angold et al., 1999b; Birmaher et al.,1996a; Garrison et al., 1990; Lewinsohn et al., 1998,1994; Reinherz et al., 1989). These changes may di-rectly influence brain function, or they may have animpact on social factors that in turn predispose to de-pression. Similarly, these changes may also influencethe manner in which genetic factors affect the risk ofdepression. Specifically, whereas environmental factorsappear to be a primary etiologic influence on depres-sion before adolescence (Silberg et al., 2001, 1999;Thapar and McGuffin, 1994), twin studies demon-strate an increasing genetic influence as girls enter ado-lescence (Silberg et al., 1999).

Various forms of psychopathology that arise beforefull-blown affective syndromes represent a third set ofmajor risk factors for major depressive disorder(MDD), as well as possibly bipolar disorder (BPD).Perhaps the most extensive and unequivocal evidenceemerges for symptoms of anxiety disorders, which ro-

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bustly predict risk for MDD and BPD (Johnson et al.,2000; Pine et al., 2001, 1998). In prospective studies,subclinical depressive symptoms also have been foundto predict full-blown episodes of MDD (Pine et al.,1999). Finally, the relationship between behavior dis-orders and mood disorders is more complicated. At-tention-deficit/hyperactivity disorder (ADHD) shows aweak association with MDD (Angold et al., 1999a),although it may show a stronger association with BPD,depending on application of particular definitions ofBPD. Conduct disorder shows a more consistent lon-gitudinal association with MDD (Angold et al., 1999a;Pine et al., 1998), although these findings are alsosomewhat controversial (Weissman et al., 1999b). Forexample, some evidence suggests variation across devel-opment in the nature of these associations: namely,mood disorders arising before puberty may show thestrongest association with behavior disorders (Weiss-man et al., 1999b), although some studies have alsofound associations in older adolescents followed pro-spectively (Kasen et al., 2001).

Findings from the studies reviewed above clarifysome aspects of risk for mood disorders, but other as-pects of risk remain less clearly understood. For ex-ample, research on familial associations has stimulatedstudies of molecular genetics. Although linkage andassociation studies have identified several sites on thehuman genome of associated heritable risk for mooddisorders, specific genes have yet to be unequivocallyidentified. Therefore, molecular genetics currentlyplays no role in early identification. This likely reflectsthe complicated role played by multiple risk factors,including genetic and environmental factors, in patho-physiology. Knowledge is accumulating linking geneticfactors to indices of brain function, and indices of brainfunction to indices of risk for depression. For example,a specific variant of the 5-HT transporter may relateboth to a measure of amygdala function and to mea-sures of personality associated with depression (Haririet al., 2002). These data are consistent with other evi-dence implicating dysfunction in the amygdala andprefrontal cortex in depression (Drevets, 2001).

Nevertheless, considerably more research is neededon the pathophysiology of mood disorders in childrenand adolescents. Such research should focus on themanner in which brain function relates to both socialand environmental risk factors for depression as well asgenes and clinical predictors of outcome. As our un-derstanding of relationships among genes, brain func-tion, and mood disorders increases, this may assist us in

redefining the classification of mood disorders andidentifying neural systems for neurobiological studiesor specific targets for pharmacological interventions,thereby guiding optimal treatment approaches.

Considerable questions also remain with respect tothe risk factors for BPD. In preliminary work, a num-ber of factors have been proposed to increase risk spe-cifically for an early-onset variety of the condition, witha family history of mania or BPD being particularlyimportant (Geller and Luby, 1997; Geller et al., 2001;Todd et al., 1996). A history of early-onset depressionor rapid-onset depression with psychosis or mixed-mood states also may be a predictor of an incipientBPD. Finally, children with a heritable predispositionfor BPD may be vulnerable to drug-induced hypoma-nia, mania, or rapid cycling with antidepressants(Geller and Luby, 1997; Geller et al., 2000). Althoughanecdotal evidence suggests that stimulants may be as-sociated with treatment-emergent mania in children atrisk for BPD, findings from controlled studies do notsupport a causal relationship (Carlson and Kelly,2001, 1998; Carlson et al., 2000, 1992). Nevertheless,each of these findings remains relatively less well rep-licated than findings on risk factors for major depres-sion. As a result, considerable further study is needed inthis area.

Diagnosis

The diagnostic criteria for major depression inschool-aged children and adolescents are the same asthose for adults and are explicit in the DSM-IV (Ameri-can Psychiatric Association, 1994). However, themethods used to elicit information concerning thesecriteria vary among adults, adolescents, and children,with children being less able to precisely describe tem-poral details of fluctuations in internal mood states(Angold et al., 1996). For a diagnosis to be properlymade, children must be able to understand questionsand provide information both on their current moodstate as well as their mood state during the previous fewweeks. Because not all children are capable of providingsuch information accurately, interviews with both thechild and the parent are necessary at least until the ageof 14. The presence of comorbid conditions (e.g.,ADHD, conduct disorders, anxiety disorders) in chil-dren with depression complicates diagnosis becausesymptoms of mood disorders are common in childrenwith these conditions, even among children who donot meet the criteria for major depression or BPD(Angold et al., 1999a).

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Although the DSM-IV provides explicit diagnosticcriteria for BPD in adults, these criteria may not bebroadly applicable to children and adolescents. A pat-tern of discrete episodes of mania is the hallmark fea-ture of BPD in adults. In contrast, juvenile-onset BPDmay manifest as chronic, nonepisodic, rapid-cycling,mixed episodes, although considerable controversy onthis point remains (Geller and Luby, 1997; Wozniak etal., 1995). The presentation of early-onset BPD varieswidely, and these symptoms can overlap with otherdisorders (e.g., distractibility observed in ADHD)(Spencer et al., 2001), thus confounding the diagnosis.Moreover, studies using various external validators,such as longitudinal course or familial aggregation,generate somewhat inconsistent findings, leaving openquestions on the most appropriate criteria to apply inchildren. There was consensus that standard diagnosticcriteria for early-onset BPD that are developmentallyappropriate and that exhibit high interrater reliabilityand validity should be developed (Geller and Luby,1997; Giedd, 2000; Papolos and Papolos, 2000).

A number of structured diagnostic instruments formood disorders have been developed, and their usehas increased the reliability of diagnoses in researchsettings (McClellan and Werry, 2000). In general,there is an ongoing need for better training indiagnostic procedures, as well as a specific need forrefinements in the diagnosis of BPD. For advance-ments in the field to continue, research efforts mustmove diagnostic processes beyond semantic descrip-tions of disorders and base them on epidemiologicalcharacteristics and biological processes (McClellan andWerry, 2000).

Treatment

The early part of the 1990s witnessed a pronouncedincrease in the prescription of antidepressants to chil-dren and adolescents, before (Emslie et al., 1999;Hughes et al., 1999; Rushton and Whitmire, 2001;Zito and Safer, 2001; Zito et al., 2000) well-controlledstudies of the efficacy and effectiveness of treatmentsfor childhood and adolescent mood disorders had beenimplemented. This highlights the fact that treatmentpractice in pediatric mood disorders has been insuffi-ciently guided by available data from randomized con-trolled trials.

Advances in therapeutics research create an oppor-tunity for practice to be more comprehensively in-formed by available data. Recent studies (Brent et al.,1997; Clarke et al., 1999; Jayson et al., 1998; Kazdin,

2000), both of cognitive-behavioral therapy and inter-personal psychotherapy (Curry, 2001), as well as ofselective serotonin reuptake inhibitors (SSRIs) (Emslieand Mayes, 2001; Emslie et al., 1997; Keller et al.,2001; Nixon et al., 2001; Wagner et al., 2001), docu-ment the utility of these treatments for major depres-sion in youngsters. In particular, at least five largerandomized controlled trials document superiority ofan SSRI over placebo (Donnelly and Wohlberg, 2001;Emslie and Mayes, 2001; Wagner et al., 2001), withone of these studies also demonstrating superiority overa tricyclic antidepressant (Keller et al., 2001). More-over, more than 10 studies document the efficacy ofcognitive-behavioral therapy for MDD, with a fewstudies suggesting a possible role for cognitive-behavioral therapy in prevention (Beardslee and Glad-stone, 2001; Clarke et al., 2001; Curry, 2001). Finally,two studies document the efficacy of interpersonal psy-chotherapy, with one being conducted in a minoritysample (Rossello and Bernal, 1999). A large-scaleNIMH-funded head-to-head trial, the Treatment ofAdolescent Depression study, is also under way andwill weigh the advantages and disadvantages of SSRIsand cognitive-behavioral therapy.

These data on treatment of acute major depressionstand in contrast to those on treatment of other pedi-atric mood disorders. Although there is an emergingliterature on the treatment of juvenile-onset BPD, itconsists almost entirely of case reports, open-label stud-ies, and studies using nonstandardized criteria. Double-blind, placebo-controlled studies are lacking, and theevidence base for treatment of early-onset BPD remainsinadequate (Biederman et al., 1998; Geller and Luby,1997; Giedd, 2000). Similar limitations apply to otherareas of therapeutics. These include studies of treat-ment-resistant depression and dysthymia in childrenand adolescents.

The widespread use of SSRIs before positive resultswere reported in clinical trials, coupled with the lack ofcontrolled trials in BPD, led some to question the eth-ics of using psychopharmacological treatments in chil-dren and adolescents. Further, the ambiguity ofdiagnosis, age-related safety issues in young children,and evidence of age-related differences in efficacy of thetricyclic antidepressants underscore concern about re-lying on adult data. Clearly, more research is needed oneach of these issues. Nevertheless, such questionsshould not detract from the overall conclusions thatsignificant treatment gains have been documented inrecent randomized, controlled trials for pediatric

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MDD. These findings should stimulate research de-signed to refine such effective treatments. For example,some suggest that different doses of SSRIs may beneeded across diagnoses or age groups. Others suggestthat SSRIs may be associated with unique side effects.Given that the risks associated with mood disorders inyoungsters are serious and the evidence of efficacy inMDD is strong, there was consensus that it is ethicallyacceptable to treat this population and unacceptable towithhold treatment until definitive evidence becomesavailable.

Although the identification, reporting, and monitor-ing of adverse drug events have not been carried outsystematically in children and adolescents, some cau-tions are applicable, given potential interactions be-tween pharmacological effects and development. Forexample, the tricyclic antidepressants, which are asso-ciated with adverse cardiac events and lethality whentaken in overdose, may have unique cardiac effects inchildren (Emslie et al., 1999; Ryan and Varma, 1998).Given their lack of efficacy in placebo-controlled trialsof major depression (Birmaher et al., 1996b), tricyclicantidepressants should be avoided in this population.Similarly, there is concern that the use of valproic acidin developing girls may be associated with polycysticovaries (Geller and Luby, 1997; Ryan et al., 1999).Antipsychotic drug therapy in children and adolescentsis often associated with marked weight gain and extra-pyramidal side effects. Moreover, limited evidencedocuments efficacy in any pediatric mood disorder.Children may develop akathisia on antipsychotics andSSRIs, which can be misconstrued as ADHD (Hamil-ton and Opler, 1992; King et al., 1991). The long-termeffects of lithium on renal and thyroid function, par-ticularly in children, are also a concern (Geller andLuby, 1997; Hagino et al., 1995; Ryan et al., 1999).Systematic monitoring of drug therapy, particularlywhen multiple medications are involved, should in-clude patients, parents, and clinicians as collaboratorsto increase the likelihood of recognizing adverse drugreactions.

In the context of the need for more well-controlledresearch on the treatment of mood disorders in chil-dren and adolescents, concerns about the ethics of pla-cebo-controlled trials have been raised. Questions onthe ethics as well as on the need for further placebo-controlled trials are likely to persist in light of recentdata suggesting efficacy for SSRIs or cognitive-behavioral therapy. However, there was consensus thatwhen carried out with proper informed consent and

precise safety monitoring procedures, placebos can bean integral and ethically acceptable component of validclinical studies. Rigorously designed studies of early-onset mood disorders, which include randomization ofpatients to placebo, are urgently needed. When theclinical trial evidence base evolves to the point at whicheffective treatments are consistently identified, the useof alternate non-placebo study designs should be con-sidered (Charney et al., 2002; Fost, 2001). However,even in this situation, use of placebo may still be jus-tified.

Controlled studies of the expanding number of an-tidepressants, mood stabilizers, psychotherapeutic in-terventions, and combined pharmacotherapy/psycho-therapy need to be carried out in the pediatric andadolescent age groups. There is a particular need forstudies in young children. These findings then need tobe translated into effectiveness research in real-worldclinical settings. The management of youngsters withmood disorders can be difficult at best, and attention tofamily dynamics, peer relationships, and coping skills isneeded for favorable, long-term outcomes. Long-termsafety and neurobiological consequences of the use ofthese interventions in the developing nervous systemmust be explored in subhuman primates and docu-mented in clinical trials. The determination of the op-timal duration of treatment, markers for relapse, andmethods for relapse prevention also need to be deter-mined.

As noted above, the findings of some but not allintervention studies have suggested that certain featuresof depression may be prevented. In contrast, researchon prevention is silent with regard to early-onset BPD.Two studies that assessed the outcome of brief groupsessions in at-risk adolescents demonstrated a signifi-cant reduction in depressive symptoms (Clarke et al.,1995; Jaycox et al., 1994). In other studies, a clinician-facilitated or lecture-based intervention program in-volved families in which one or both parents had amood disorder. This intervention resulted in parentsreporting significant sustained changes in focus ontheir children, communication, and understanding ofthe illness. Adolescents whose parents experienced im-provement in their mood disorders reported bettercommunication and improved overall functioning(Beardslee et al., 1996, 1997a,b). In contrast, one studyof a home-based, family intervention program in de-pressed and nondepressed children and adolescentswho had attempted suicide found that psychosocialintervention failed to reduce suicidal ideation in sub-

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jects with major depression (Harrington et al., 1998).Clearly, much more research on universal and targetedinterventions for early-onset mood disorders must beundertaken (Mrazek and Haggerty, 1994).

Services

Currently available services are inadequate to meetthe needs of at-risk youngsters and those with mooddisorders. More than 75% of children with mentalhealth needs do not receive any services, and the unmetneed is highest among minority youth (NIMH Blue-print Report, 2001). There are many barriers to theavailability and delivery of care, including a scarcity ofchild psychiatrists and insufficient funding. In addi-tion, the services infrastructure inadequately addressesthe needs that span primary care, schools, mentalhealth settings, foster care, social services, and the ju-venile justice system. There is a marked lack of insur-ance parity, especially among minority populations,who often have difficulty obtaining healthcare, andpoor private benefits for mental health care comparedwith general medical care. In addition, there are nonational data on children or adolescents with mooddisorders, which limits the research and service plan-ning capabilities (Wells et al., 2001).

Child and adolescent psychiatrists are scarce, andcare is often unavailable even for patients with insur-ance. The mean number of child psychiatrists per100,000 youngsters is 6.7 nationwide. However, thenational distribution is markedly inequitable, rangingfrom 0.8 per 100,000 in Mississippi to 18.9 per100,000 in Massachusetts (Thomas and Holzer, 1999).The National Center for Health Workforce Informa-tion and Analysis estimates that the current number ofchild psychiatrists (approximately 6,300) will increaseto approximately 8,300 by 2020, which falls far shortof the nearly 30,000 needed to meet demand (AACAPWorkforce Group, written communication, May2003). Pediatricians and other primary care physiciansare in a unique position to fill this void by recognizingand treating mood disorders in youth. However, timeconstraints, lack of reimbursement for case manage-ment, and poor training in diagnosis hinder the deliv-ery of care (U.S. Public Health Service, 2000). Primarycare physicians should work with local mental health-care providers (e.g., psychiatrists, psychologists) to con-sult about interventions for youngsters with or at riskfor mood disorders.

Given adequate training and time for assessment andfollow-up, there was consensus that primary care phy-

sicians can diagnose and treat mood disorders in un-complicated patients who are not seriously ill. Mostprimary care physicians are not adequately trained inthe diagnosis and treatment of severe and/or complexmood disorders, particularly BPD, and often do nothave sufficient time to provide adequate assessment andfollow-up. In these instances, consultation with or re-ferral to a child and adolescent psychiatrist is recom-mended, particularly for bipolar or suicidal patients. Assuch, there is a desperate need to establish an infra-structure to support closer alliances by way of primarycare and mental health practitioners working with chil-dren.

Schools provide an underused setting where childrenat risk for mood disorders can be identified and referredfor treatment. However, the scarcity of mental healthprograms and the lack of awareness among teachers andschool administrators about mood disorders, in con-junction with large class size, limit opportunities foridentifying children in need of care. There is a growingtrend toward the use of school-based general healthservices, which provide an opportunity for clinicians toscreen and educate students and, in some cases, toprovide treatment for depression. However, such ser-vices are unlikely to be adequately used unless methodsfor identifying cases in need are implemented in aschool-based setting. For example, parents might takeadvantage of screening instruments that could be ac-cessed privately via the Internet. Alternatively, a closeralliance with mental health practitioners and schoolprofessionals might address the need for implementingbetter case-finding methods.

Clearly, public health education is needed for teach-ers, students, and families to address stigma and toincrease their awareness of mood disorders and the op-portunities for treatment. Discussion of mood disor-ders should be included in the health curricula with thesame emphasis as is currently given to substance abuse,and teachers should be made aware of the cognitiveeffects of mood disorders, the risk of suicide, and theassociated academic and interpersonal dysfunction thatcan help identify children at high risk.

Overcoming the barriers to care requires changes inpractice and policy that include increasing personnelcapacity, training front-line providers to be capable ofrecognizing mental health problems in children, andimproving insurance coverage for uninsured and un-derinsured children. Some barriers may be removedonce the costs of not preventing and not treatingchildhood mood disorders are identified. Enhance-

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ment of clinical services will require relocating theminto schools, homes, and other community settings,ensuring that they are evidence-based, developing poli-cies to provide adequate reimbursement for clinical casemanagement, ensuring that services are age-appropriateand culturally responsive to the diverse needs ofall children and families, and developing strategiesfor long-term maintenance in community treatmentsettings.

In this era of limited resources, funding and person-nel must be directed where they will be most useful andcost-effective for the greatest number of youths in need.Clearly, children at risk represent the largest number,which argues for a significant allocation of resources forevaluating prevention strategies and providing preven-tion services. Research needs to be carried out onpromising interventions, such as prevention-orientedcognitive-behavioral therapy and integration of pre-vention research into research on other childhoodpsychiatric disorders. Mood disorders have an early ageat onset and high rates of chronicity, recurrence, andsuicide, all of which underlie concerns about the readi-ness of the current healthcare system to improve themorbidity of future adults and the next generation ofchildren and adolescents. The next group of childrendeserving of resource allocation are those with mooddysregulation. Research needs to be carried out on earlyidentification and the development of educational pro-grams on mood disorders for primary care personnel,teachers, and families. Finally, the large number ofyoungsters with clearly diagnosable mood disordershighlights the need for more training in diagnostic pro-cedures. Much more needs to be learned about thecourse of these disorders, their response to treatment,especially in real-world community settings (i.e., effec-tiveness research), and the effect of early treatment onthe course of illness. Research to identify factors leadingto relapse and other negative sequelae needs to be car-ried out.

CONCLUSIONS

The public health crisis in the delivery of mentalhealthcare for children and adolescents with depressionor BPD stems from multiple sources. Of these, stigma,lack of insurance parity, scarcity of child and adolescentpsychiatrists, inadequate psychiatric training for pedia-tricians and other primary care providers, ill-equippedschool systems, and insufficient funding to increasepublic awareness about mood disorders in youth arekey factors that severely limit the capacity of the exist-

ing healthcare system to provide for children in need.In addition, insufficient funding for research on riskfactors, diagnosis, treatment, and prevention impedesthe advancement of the field. Addressing these issuesrequires immediate and sustained action from parents,schools, clinicians, the media, the research community,consumer advocates, and the government.

DBSA CONSENSUS DEVELOPMENT PANEL

DBSA Consensus Development Panel Co-ChairsDennis S. Charney, M.D.; Joseph T. Coyle, M.D.

SpeakersWilliam R. Beardslee, M.D.; John F. Curry, Ph.D.; Graham J. Emslie,M.D.; Norman C. Fost, M.D., M.P.H.; Sherry A. Glied, Ph.D.;Stephen E. Hyman, M.D.; Ronald C. Kessler, Ph.D.; Maria Kovacs,Ph.D.; Kathleen R. Merikangas, Ph.D.; Charles B. Nemeroff, M.D.,Ph.D.; Cynthia R. Pfeffer, M.D.; Neal D. Ryan, M.D.; David Shaffer,M.D.; Judy L. Silberg, Ph.D.; Thomas J. Spencer, M.D.; Ordean L.Torstenson, M.D.; Kenneth B. Wells, M.D., M.P.H.; Julie M. Zito,Ph.D.

Workgroups

Workgroup 1. Risk Factors:Richard D. Todd, M.D., Ph.D. (Workgroup Leader); Jerome Kagan,Ph.D.; Maria Kovacs, Ph.D.; Kathleen R. Merikangas, Ph.D.; DanielS. Pine, M.D.; Judy L. Silberg, Ph.D.; Jenifer L. Wood, Ph.D.

Workgroup 2. Diagnosis:Paramjit Toor Joshi, M.D. (Workgroup Leader); Barbara Huff; Cyn-thia R. Pfeffer, M.D.; Uma Rao, M.D.; Neal D. Ryan, M.D.; ThomasJ. Spencer, M.D.; Elizabeth B. Weller, M.D.

Workgroup 3. Treatment:Gabrielle A. Carlson, M.D. (Workgroup Leader); John F. Curry,Ph.D.; Graham J. Emslie, M.D.; Martha Hellander, J.D.; MichaelStrober, Ph.D.; Ordean L. Torstenson, M.D.; Karen Dineen Wagner,M.D., Ph.D.

Workgroup 4. Services and Prevention:David Reiss, M.D. (Workgroup Leader); William R. Beardslee, M.D.;Sherry A. Glied, Ph.D.; Kimberly Hoagwood, Ph.D.; Beverly BensonLong, M.S., M.P.H.; Kenneth B. Wells, M.D., M.P.H.; Julie M. Zito,Ph.D.

Conference SponsorDepression and Bipolar Support Alliance; Lydia Lewis, Executive Di-rector

WriterSally K. Laden, M.S.

DBSA Consensus Development Panel AffiliationsHarvard University, Boston (Drs. Beardslee, Coyle, Kagan, Kessler,and Spencer); SUNY Stony Brook (Dr. Carlson); NIMH, Bethesda

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(Drs. Charney, Merikangas, Pine, and Wood); Duke University Medi-cal Center (Dr. Curry); University of Texas Southwestern MedicalCenter, Dallas (Dr. Emslie); University of Wisconsin Medical School,Madison (Dr. Fost); Columbia University, New York (Drs. Glied andShaffer); Child and Adolescent Bipolar Foundation, Wilmette, Illinois(Ms. Hellander); New York State Psychiatric Institute, New York (Dr.Hoagwood [affiliated with the NIMH at the time of the ConsensusConference]); Federation of Families for Children’s Mental Health,Alexandria, Virgina (Ms. Huff); George Washington University,Washington, DC (Drs. Joshi and Reiss); University of PittsburghSchool of Medicine (Drs. Kovacs and Ryan); Scientific TherapeuticsInformation, Inc., Springfield, New Jersey (Ms. Laden); Depressionand Bipolar Support Alliance, Chicago (Ms. Lewis); World Federationfor Mental Health, Alexandria, Virginia (Ms. Long); Emory Univer-sity, Atlanta (Dr. Nemeroff); Weill Medical College of Cornell Uni-versity, White Plains, New York (Dr. Pfeffer); UCLA School ofMedicine (Drs. Rao, Strober, and Wells); Virginia CommonwealthUniversity, Richmond (Dr. Silberg); Washington University School ofMedicine, St. Louis, Missouri (Dr. Todd); American Academy of Pe-diatrics, Madison, Wisconsin (Dr. Torstenson); University of TexasMedical Branch, Galveston (Dr. Wagner); University of Pennsylvania(Dr. Weller); University of Maryland, Baltimore (Dr. Zito).

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