BOX 4-1
Some of the Knowledge Gaps in Treatment for M/SU Conditions

Therapies for children and older adults. Knowledge about how to best care for individuals at both ends of the age continuum is limited, including how to incorporate effective treatment for the most prevalent disorders of childhood (i.e., anxiety, ADHD, depression, conduct disorders) into routine care (Hoagwood et al., 2001; Stein, 2002), the effect of multiple medications on children’s outcomes, and the comparative efficacy of different therapies for severe conditions (e.g., bipolar disorder, childhood depression) (Kane et al., 2003). Evidence is also needed on how to better care for older adults with comorbid conditions and the frail elderly in usual settings of care (Borson et al., 2001).

Treatment of multiple conditions. In spite of the high frequency of comorbid mental, substance-use, and general illnesses (see Chapters 1 and 5), there is a substantial lack of knowledge about effective treatment for individuals with complex comorbidity (Kessler, 2004).

Posttraumatic Stress Disorder/Acute Stress Disorder. Better evidence is needed about effective treatment for posttraumatic stress disorder (PTSD) and acute stress disorder (ASD), e.g., how best to combine pharmacotherapy and psychotherapy, and how to relieve some specific symptoms, such as insomnia or nightmares, and in the presence of other medications. Moreover, although cognitive and behavioral therapies have demonstrated efficacy in treating victims of sexual assault, interpersonal violence, and industrial or vehicular accidents, their effectiveness in treating PTSD or ASD in combat veterans or victims of mass violence requires further study (Work Group on ASD and PTSD, 2004).

out specialized education in their use (DHHS, 1999; Essock et al., 2003; Kazdin, 2004). For example, while numerous clinical efficacy studies have documented that psychostimulant medications reduce the core symptoms of ADHD, accumulating evidence suggests that this drug treatment is much less effective as currently delivered in routine community settings (Lefever et al., 2003). For people with severe mental illnesses and many substance-use problems and illnesses, how well the clinical aspects of treatment work is often closely related to such factors as housing, income support, and employment-related activities. This complicates considerations regarding effectiveness and has resulted in calls for improved research efforts (discussed below) that can provide information on both the effectiveness and efficacy of interventions (Carroll and Rounsaville, 2003; Tunis et al., 2003; Wolff, 2000).

Although the knowledge gaps discussed above also exist for general health care, some of the tools and strategies used to build the evidence base

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