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At 47 she was happily married with an 11-year-old daughter and expressed much satisfaction with her work as a masters-level psychotherapist. Her adolescence and young adulthood, however, were different stories, filled with chaos. She described impulsive, promiscuous behaviors beginning at age 13. Heavy drug use began in her late teens, and her parents kicked her out of the house. She fended for herself as a waitress and had a series of relationships with abusive men. As age 30 approached, she began to get herself under control, stopped using drugs, and married a musician she described as “very straight.” With his encouragement, she attended a community college, majored in psychology, and ultimately obtained a masters degree in counseling. Currently she is employed at a public agency for abused women.

Practical approaches to integrating 3 aspects of a suicide assessment have been well delineated for adults and adolescents.

November/December 2009 Special Report: Forensic Psychiatry

Award ceremonies abound, from the Oscars for film to the Clio awards for advertising, but none are as important to mental health and psychiatry as the NARSAD annual awards. NARSAD is a unique organization that is dedicated to mental health research, and the NARSAD awards are considered to be the most prestigious prizes in psychiatric research. On October 30, NARSAD presented its 22nd annual awards for outstanding achievement in mental health research. This year the prizes went to 8 distinguished scientists whose work is making a huge impact on the way psychiatric disorders will be diagnosed and treated.

A number of scholars have criticized contemporary bioethics for its focus on what have been called the “neon issues”-end-of-life care, genetic technology, and resource allocation-rather than on the far less dramatic but much more common dilemmas of everyday practice, such as obtaining adequate informed consent for treatment, respecting confidentiality and privacy, and maintaining sound but reasonable boundaries in the therapeutic relationship.1-3 From the “searching and fearless” fourth step of Alcoholics Anonymous to the rigorous spiritual exercises of the Jesuits, many spiritual traditions have proposed a regular and deliberate period of introspection as an effective means of increasing the understanding of and responsiveness to ethical conscience and conduct.

Low levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) in patients with major depressive disorder (MDD) or bipolar depression were shown to be associated with increased risk of suicide attempts. Hanga Galfalvy, PhD, assistant professor of clinical neurobiology at Columbia University and the New York State Psychiatric Institute, New York, and her colleagues found that patients with the lowest levels of MHPG at baseline were more likely to commit highly lethal suicidal acts.

All pregnant women should be screened for bipolar disorder, according to a recent article by Verinder Sharma, MB, BS, professor of psychiatry and obstetrics and gynecology at the University of Western Ontario, London, Ontario, and colleagues. This is because bipolar depression may be misdiagnosed as major depressive disorder in the postpartum period, resulting in delays in appropriate treatment.

Recent reports have noted an alarming decrease in the practice of psychotherapy among psychiatrists.

As a general proposition, most scientists and physicians prefer sharpness to fuzziness, at least when it comes to defining terms. I generally share this view, as regards psychiatric diagnosis, but only up to a point. That point is defined by the well-being of my patient - and sometimes, this may call for a “fuzzy” diagnosis.

More than a thousand articles on mental disorders are published in medical journals each month! Also, clinicians have limited training, time, and inclination to keep up with reading research articles critically on a regular basis. Thus, a disturbing disconnect (for which there are no easy solutions) exists between clinical research and usual clinical practice.

The details may, by now, be familiar but they are no less shocking: Army psychiatrist, MAJ Nidal Malik Hasan, MD, accused of killing 13 people and wounding 33 others-including fellow behavioral health providers- is recovering from gunshot wounds and meeting with his attorneys.

Pediatric bipolar disorder (PBD) is a serious psychiatric illness that impairs children’s emotional, cognitive, and social development. PBD causes severe mood instability that manifests in chronic irritability, episodes of rage, tearfulness, distractibility, grandiosity or inflated self-esteem, hypersexual behavior, a decreased need for sleep, and behavioral activation coupled with poor judgment. While research in this area has accelerated during the past 15 years, there are still significant gaps in knowledge concerning the prevalence, etiology, phenomenology, assessment, and treatment for PBD.

Whether treated or untreated, if the outcome of mental illness is suicide, it is a devastating end to a life and it wreaks havoc on family members left behind. Child psychiatrist Nancy Rappaport of Cambridge, Mass, has written a moving memoir of her mother’s suicide that took place during an acrimonious custody battle. Rappaport, at age 4 years, was the youngest of 6 children left behind. She shows great courage as she risks discovering painful information and creating potential ruptures with her father and siblings, some of whom disagree with her decision to write the book.

There has been much recent attention to the deleterious effects of natural disasters and war on children and adolescents.

Psychosurgery. For some, the word connotes all the promising therapeutic applications of modern neuroscience; for others, it connotes all the baneful excesses of unregulated pseudoscience.

The press reported it in various ways-either as a “brutal gang rape” or, more forensically, as a “21/2-hour assault” on the Richmond High School campus. Any way you look at it, the horrendous attack on a 15-year-old girl raises troubling questions for theologians, criminologists and, of course, psychiatrists. How do we understand an act as brutal as rape? What factors and forces in the rapist’s development can possibly account for such behavior? And how on earth do we explain the apparent indifference of the large crowd that watched the attack in Richmond, Calif, and allegedly did nothing to stop it-or even, to report it?

The debate within the medical profession over “conflicts of interest” (COIs) has often been shrill, and sometimes seems to be based on misunderstandings or myths about what COIs entail. In this psychiatrist’s view, it is helpful to step back from confident proclamations, acknowledge that the issues involved are complex, and aspire to some semblance of humility. Nobody has cornered the market on “the right way” to deal with COI in the realms of medical research, publication, and education.1 At the same time, as Alan Stone, MD, has noted (personal communication, August 27, 2009), ethical considerations lie at the heart of any debate on COI-in particular, the ancient dictum, “Do no harm.” Indeed, ethicist James M. DuBois has pointed out a direct connection between some types of COI and harm to the general public: “Mental health consumers are at risk when studies that involve questionable scientific and publication practices are translated into therapeutic practice.”1(p205)

The NIMH-sponsored New Clinical Drugs Evaluation Unit (NCDEU) meeting is a favored venue for reports and reviews of NIH-funded psychopharmacological studies, and this was true of the recent annual meeting in Hollywood, Fla. The meeting included a workshop on new investigations of antidepressant use in Alzheimer disease and a panel session on the safety of pharmacotherapy in older adults.

Virtual reality (VR)-facilitated exposure therapy for posttraumatic stress disorder (PTSD), recently evaluated under combat conditions in Iraq, appears to be safe and effective, according to LCDR Robert McLay, research director for mental health with the US Naval Medical Center San Diego (NMCSD). Speaking at the 17th Annual Medicine Meets Virtual Reality (MMVR-17) Conference in Long Beach, Calif, McLay said that military providers need to make PTSD treatments available in such military theaters as Iraq and Afghanistan, as well as stateside. (McLay was speaking as an individual, not as a US Navy or Department of Defense representative.)

Because an increasing number of patients pay for care out-of-pocket, marketing has become an essential part of any practice, said David Sprague, chief operating officer at Physicians’ Ally, Inc, Denver. In a presentation at the US Psychiatric and Mental Health Congress in Las Vegas, he provided tips to help physicians market their practice and avoid common pitfalls.

Four simple steps can help you reduce missed patient appointments and boost profitability. So said Mark Rosenberg, MD, PhD, president of Behavioral Health Management, PC, in St Louis, who spoke at the US Psychiatric and Mental Health Congress in Las Vegas. Not only do missed appointments result in lost revenue, said Rosenberg, but also they “interrupt the flow of patient care and impede clinic productivity.”

The following medical and behavioral health providers were killed or wounded during the November 5 Fort Hood shooting rampage that left 13 dead and 29 wounded.

Many patients with HIV/AIDS experience numerous challenges beyond those posed by the physical effects of their disease-including poverty, mental illness, drug addiction, social alienation, racism, and homophobia. Counseling patients who face these issues can be difficult, but a careful risk assessment along with patient education can improve a patient’s ability to cope and lead to better outcomes, said Marshall Forstein, MD, associate professor of psychiatry, Harvard Medical School, Cambridge, Mass, in a presentation at the US Psychiatric Congress in Las Vegas. On the basis of his extensive experience in treating patients with HIV/AIDS, he said it is also important to provide hope and to encourage treatment adherence.

It is usually traumatic when parents learn that their child has an autism spectrum disorder (ASD). Be clear about the diagnosis and let families know that treatment will begin as soon as possible, said Doris Greenberg, MD, associate clinical professor of pediatrics at Mercer University School of Medicine, Savannah, Ga. In her presentation at the US Psychiatric and Mental Health Congress in Las Vegas, Dr Greenberg discussed strategies for talking to the families of children with ASDs. “Don’t talk around the diagnosis-identify the elephant in the room and get on with it,” she said.

Of the screening tools available to help identify early symptoms of Alzheimer’s disease, which is best?

Current guidelines for the management of bipolar depression are outdated because they are based on the definition and treatment of unipolar depression, according to Eduard Vieta, MD, PhD, director of the bipolar disorders program at the University Clinic Hospital of Barcelona, Spain. Dr Vieta led a study to create new definitions and algorithms for the management of treatment-resistant bipolar I and bipolar II depression.

Researchers have found evidence that the placebo effect is not all “in your mind.” This study, recently published in Science, suggests that the spinal column-specifically, the dorsal horn-may be involved in blocking pain after placebo has been administered. Eippert and colleagues1 examined pain reactions in 13 young, healthy men (21 to 30 years old) after applying 2 types of cream on their forearms. The participants were told that one cream was a highly effective analgesic (“lidocaine”) and the other was a control cream. In reality, both creams were identical and pharmacologically inactive; the one labeled lidocaine was used to measure the placebo response.

Smoking cessation services should be integrated into substance use disorder treatment programs, according to David Kalman, MD, Department of Psychiatry, University of Massachusetts, and colleagues, in their recent review of tobacco dependency among patients who sought treatment for alcoholism.1

Some would ask whether the psychiatric system at Ft. Hood adequately assessed the mental state of Army Maj Nidal Malik Hasan, the man accused of yesterday's shooting rampage on the base.