Objective.-To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications.Data Sources.-Literature review using a National Library of Medicine database search for 1975 through March 1997 on the terms attention deficit disorder with hyperactivity, methylphenidate, stimulants, and stimulant abuse and dependence. Relevant documents from the Drug Enforcement Administration were also reviewed.Study Selection.-All English-language studies dealing with children of elementary school through high school age were included.Data Extraction.-All searched articles were selected and were made available to coauthors for review. Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the articles most pertinent to the issues requested in the resolution calling for this report. Relevant information from these articles was included in the report.Data Synthesis.-Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants.Conclusions.-Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians.

OBJECTIVES:To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers. DESIGN:M EDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized. T his report reviews recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; describes barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and summarizes efforts under way to reduce these barriers. The American Medical Association's Council on Scientific Affairs produced a series of reports on depression in 1991. 1 CONCLUSIONS: METHODSM EDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.Major depression is the depressive disorder on which most research has been conducted. Other depressive disorders, such as dysthmyic disorder ("chronic" depression) and mixed depressive-anxiety states, are also common in general medical settings but have been studied far less. Similarly, most research has been done in adult populations; this report notes a few instances of information about children. Except for comoribidity, most of the research in this area has been in primary care settings rather than in more specialized medical environments; most research on treatment has been conducted in specialty mental health settings. EPIDEMIOLOGY IN GENERAL MEDICAL SETTINGSDepressive disorders are common in the general population, with a point prevalence of about 2% to 4% for major depressions 2 and about a 20% lifetime risk for the development of major depression or dysthymic disorder. 3,4 The rate of depression among women is 2 to 3 times that of men. 5 These findings are based on large community surveys using structured interviews. Of those seeking help for depression in the United States, nearly three fourths go to a primary care physician rather than to a mental health professional. The most common presentation in primary care is not dysphoria but rather complaints of sleep disturbance, fatigue, or pain. 6 Overall, 5% to 10% of ambulatory primary care patients and 10% to 14% of medical inpatients suffer from major depression. 7

Patients with psychiatric illnesses may be at higher risk for the development of certain medical problems. Those with more severe psychiatric illnesses may encounter barriers to promoting good health and to obtaining good health care when comorbid illnesses do occur. This paper reviews some of the recent literature on health care practices and health system access for the mentally ill; HIV care and its relationship to mental disorders; drug interactions between general medical drugs and psychotropics; and certain medical conditions that appear to co-occur more frequently with psychiatric disorders.

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Discrimination learning and concept formation abilities were investigated in four mature Arabian horses. A series of two-choice discrimination problems were presented on stimulus panels that could open to allow access to food bowls. Selection of the correct stimulus resulted in food reinforcement, and an incorrect choice was not rewarded. The positions of the correct and incorrect stimuli were varied randomly during each test session, and the criterion for learning each problem was 85% correct for two consecutive sessions of 30 or 40 trials. Testing progressed through six discrimination problems. The first four were simple pattern discriminations, but the last two incorporated several different triangles as correct stimuli and thus involved the concept of triangularity. Two of the subjects successfully completed only simple pattern discriminations, one showed evidence of learning in the first concept problem, and one completed all six tests, including the two concept formation problems. The results demonstrate complex pattern discrimination ability in horses, and suggest that they may also have the ability to form and use concepts in problem solving.