“An Ounce of Prevention Is Worth a Pound of Cure”

767 J Clin Psychiatry 68:5, May 2007 he future of child and adolescent psychiatry lies in the identification of prodromal presentations and risk factors associated with the onset and progression of psychopathology. Only once we begin to understand the early clinical manifestations of psychiatric disorders and the risk factors, genetic and environmental, associated with illness onset and outcome will we be able to develop early intervention and ultimately, preventive treatment strategies. In this issue of “Focus on Childhood and Adolescent Mental Health,” we present 4 studies, each enhancing our understanding of potential targets for secondary prevention strategies as we move toward the ultimate goal of primary prevention of mental illnesses. Specifically, Wade and colleagues examined the impact of severity of substance use on adolescents and young adults with first-episode psychosis and found that heavy substance use is independently associated with more severe positive symptoms and poor functional outcome during follow-up even after controlling for potential confounding factors such as medication adherence. The co-occurrence of psychotic and mood disorders with substance use disorders has been well established. However, few studies have examined treatment options for individuals with this cooccurrence. In fact, patients with co-occurring mood or psychotic disorders and substance use disorders are excluded from treatment studies of mood, psychotic, or substance use disorders alone. This article clearly identifies targets for establishing tertiary prevention strategies for patients with psychotic disorders as well as the need for developing primary prevention strategies for substance use in patients with psychotic disorder. Riala and colleagues investigated the relationship between smoking and subsequent suicide in a large Finnish cohort who smoked regularly at age 14 years and reported that regular smoking may increase the risk of suicide by age 34 years more than 4-fold. Although additional studies are needed to determine mediators and moderators for the relationship between smoking and later suicide, this observational study provides preliminary support for potential targets in the prevention of suicide. The other 2 studies (Findling et al. and DelBello et al.) describe initial attempts to examine specific secondary prevention strategies for bipolar I disorder. Although specific prodromal presentations for bipolar I disorder have not yet been established, both studies examined treatments in samples of children and adolescents at high risk for developing bipolar I disorder (i.e., those with a familial risk for developing bipolar disorder and who present with mood disorders other than bipolar I disorder). Although preliminary open-label studies suggested divalproex may be effective as an early intervention strategy for this population, Findling and colleagues conducted a more rigorous double-blind, placebo-controlled study that indicated divalproex does not result in clinically significant improvements in children and adolescents who are at high risk for developing bipolar I disorder. In contrast, in an open-label study, DelBello and colleagues demonstrate that quetiapine was effective for reducing mood symptoms in adolescents with a high risk for developing bipolar I disorder. However, double-blind, placebo-controlled studies are clearly needed to confirm this preliminary finding. This issue’s special section highlights studies that are helping bring the field of child and adolescent psychiatry to a new era of preventing mental illness.