attention on narrowly defined mental disorders. Instead, clinicians are trained to interpret the adolescent’s behavior, emotions, and cognitions within the context of his or her social, physical, and experiential environment. If a decision is made to pursue treatment, efforts are made to match the young person’s needs for care to the skills and services avail- able in the local community. As a result, the clinical severity of mental health problems identified and referred for treatment through screening programs resemble those identified through community referral. Mental disorders are useful clinical heuristics that help guide decisions about treatment selection. However, com- munity mental health treatment seeking is not tied to DSM criteria. Many highly distressed individuals who do not meet full DSM criteria seek and receive mental health care. 3 At the same time, most young people with even serious emotional disturbances do not receive care. 4 Outreach efforts, such as voluntary mental health screening, offer opportunities to ex- tend mental health care access. The nation faces great challenges in broadening access to confidential, high-quality, integrated mental health care to young people in need. Two-stage voluntary mental health screening represents one promising strategy to help breakdown early barriers on the path to effective treatment. Such an approach is consistent with recent recommendations from the Institute of Medicine 5 and the U.S. Preventive Services Task Force. 6 Laurie Flynn, B.A. Mark Olfson, M.D., M.P.H. College of Physicians and Surgeons Columbia University and New York State Psychiatric Institute New York Disclosure: Ms. Flynn is the Executive Director and Dr. Olfson is the Scientific Director of the Columbia University TeenScreen Program. Dr. Olfson has received grants from AstraZeneca and Eli Lilly. He has consulted to Pfizer and AstraZeneca, and has served on the speakers’ bureau of Janssen. 1. Horwitz AV, Wakefield JC. Should screening for depression among children and adolescents be demedicalized? J Am Acad Adolesc Psychiatry. 2009;48:683Y687. 2. Cantwell DP, Lewinsohn PM, Rohde P, Seeley JR. Correspondence between adolescent report and parent report of psychiatric diagnostic data. J Am Acad Adolesc Psychiatry. 1997;36:610Y619. 3. Druss BG, Wang PS, Sampson NA et al. Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2007;64:1196Y1203. 4. Burns BJ, Costello EJ, Angold A et al. Children’s mental health services use across service sectors. Health Aff (Millwood). 1995;14:147Y159. 5. The National Research Council and the Institute of Medicine of the National Academies. Preventing Mental, Emotional and Behavioral Dis- orders Among Young People: Progress and Possibilities. Washington, DC: National Academies Press; 2009. 6. U.S. Preventive Services Task Force. Screening for Depression: Recommen- dations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2002. http://www.ahrq.org/clinic/3rduspstf/depression/depressrr.htm. Accessed July 6, 2009. DOI: 10.1097/CHI.0b013e3181b8be9c Drs. Horwitz and Wakefield reply: We thank Ms. Flynn and Dr. Olfson for their comments and information about TeenScreen. Teens have challenging environments to negotiate, and we need to address their emotional needs. Perhaps screening has a role as one way to do thisValthough the current level of enthusiasm for such screening is not based on any adequate evidential base showing cost-effectiveness in preventing major negative outcomes. The letter by Ms. Flynn and Dr. Olfson contains no claims as to what TeenScreen actually accomplishes because we simply do not know. That said, we emphasize that we did not argue against screening per se but rather against the current misleading overmedicalizing of the instruments and their results. Most important, Ms. Flynn and Dr. Olfson seem to strongly agree with our fundamental point that its advocates misdescribe teen depression screening. Contrary to standard TeenScreen material, Ms. Flynn and Dr. Olfson assert that what is identified for possible treatment in current teen depression screening ranges over a much wider terrain of human emotion than is classifiable as true mental disorder. Why, then, misrepresent screening programs as ways of identifying specific psychiatric conditions? Why not be honest and frame screening as what it is, according to Ms. Flynn and Dr. Olfson, namely, a broad- gauge measure that encompasses problematic conditions featuring marked distress and lack of adequate social role performance, whether or not they are disorders? Although Ms. Flynn and Dr. Olfson assert: ‘‘Their position presupposes a sharp and artificial dichotomy between distress and mental disorder,’’ our argument presupposes no such ‘‘sharp and artificial’’ dichotomy. However, we do assume that despite the great fuzziness and ambiguity in the boundary between normal distress and mental disorders, there is a real distinction with many clear cases on both sidesVand we argue that screening programs potentially misclassify many normal conditions as cases of disorder. As both clinicians and the lay public understand, mental disorders are real failures of functioning that represent something going wrong with mental processes. They are not conditions of transient marked distress in response to terrible circumstances or failure to perform academic or social roles because of such stresses. If Ms. Flynn and Dr. Olfson are saying, as it seems at times, that no such distinction between marked distress and mental disorder can be drawn, then we imagine that this position LETTERS TO THE EDITOR 1126 WWW.JAACAP.COM J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 48:11, NOVEMBER 2009