therapies for children, major gaps remain in our knowledge in this area. For example, despite the increasing use of psychotropic medications, little is known about the effect of multiple medications on children’s outcomes or about the efficacy of different therapies for severe conditions (e.g., bipolar disorder, childhood depression) (Kane et al., 2003). Insufficient evidence exists to guide follow-up and long-term management of attention deficit hyperactivity disorder (ADHD), despite its being considered a chronic condition (Stein, 2002). There also is very limited knowledge about treatments for co-occurring conditions in childhood.


Therapies for other population subgroups There is little evidence on the effectiveness of treatment modalities for certain subgroups of patients, such as racial and ethnic minorities, as well as the frail elderly (Borson et al., 2001).


Relative effectiveness of different treatments (alone and in combination) More than 550 psychotherapies are currently in use for children and adolescents, but little helpful information exists for clinicians or consumers on their comparative effectiveness (Kazdin, 2004). As in other areas of health care, the Food and Drug Administration’s drug approval rules offer little incentive for head-to-head clinical trials (Pincus, 2003), and there is a lack of substantial capital investment in the development and testing of psychosocial approaches. Moreover, our knowledge about the optimal use of combination treatments (e.g., medications and psychotherapies) is limited.


Prevention studies Large gaps remain in our knowledge about how to prevent M/SU illnesses.

Gaps in Knowledge About Effective Care Delivery

In addition to the above gaps in our knowledge of effective treatments, there is a profound lack of knowledge on the effective delivery of treatments already known to be efficacious. Chapter 4 describes the efficacy–effectiveness gap that exists in M/SU health care. That discussion demonstrates that there has been more research on the efficacy of specific treatments than on how to make these treatments effective when delivered in usual settings of care (Essock et al., 2003; Kazdin, 2004). Other chapters of this report identify gaps in our knowledge about additional health care delivery issues that affect the ability to make effective use of what is already known, as well as the ability to meet the quality aims and apply the rules for care set forth in the Quality Chasm report (IOM, 2001) (see Chapter 2).


Providing patient-centered care Knowledge is lacking about what factors contribute to patient recovery; how to prevent discrimination in health



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