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When clinical practice appears to diverge from evidence-based medicine, is the clinician departing from science, or are the data not applying to practice? The challenge of developing clinical research data to inform treatment strategies for the inconstant course of psychiatric illness was recently considered by Susan Murphy, PhD, of the University of Michigan's Institute for Social Research, with colleagues from the MCATS (Methodology for Constructing Adaptive Treatment Strategies) network, and John Rush, MD, of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) investigators group.

Despite the increased use of methylphenidate in preschoolers with attention deficit/hyperactivity disorder (ADHD), few data are available regarding the efficacy and safety of methylphenidate in this population. Methylphenidate has been approved by the FDA for the treatment of ADHD in children aged 6 years or older. A recent large-scale, controlled trial of methylphenidate for the treatment of preschoolers with ADHD provides clinically relevant and greatly needed information for clinicians who treat these children.

Cocaine dependence is a devastating disorder that is associated with a host of medical and psychosocial risks. This complex disorder is made up of distinct clinical components that are interwoven into a cycle of addiction (Figure 1). Cocaine activates ancient pleasure centers that dominate our thoughts, behaviors, and priorities, producing a pleasure-reinforced compulsion to use the drug. Repeated use dysregulates brain pleasure centers and paves the way to addiction through craving and impaired hedonic function.1 Euphoria and craving drive the cycle of addiction through positive and negative reinforcement, respectively, and they provide targets for pharmacological interventions.

The construct of bipolar spectrum disorder remains a work in progress. Its precise boundaries are still a matter of considerable debate. Some psychiatrists are convinced that it is widely overdiagnosed. It is possible that depending on the clinician and the clinical setting both views are correct.

Dr Stark's article, "Neurotransmitters, Pharmacologic Synergy, and Clinical Strategies" ( Psychiatric Times , October 2006 Special Edition, page 1) offered a refreshing and sober discussion about the difficulties in treating psychiatric illnesses with the therapies that are currently available. The point regarding the error of adopting a "too-narrow focus on imbalanced neurotransmitter levels" without considering the "contributions of other biochemical and physiologic factors to the overall picture" was especially relevant. However, despite the inherent appeal of the holistic model of treatment, the practical adoption of its principles in the treatment of psychiatric patients may remain a guessing game for some time.

Despite the clinician's goal of treating the depressed patient to the point of remission, this state is generally achieved in only 15% to 30% of patients. Another 10% to 30% of patients respond poorly to antidepressant treatment, while 30% to 40% have a remitting and relapsing course.1 Patients without a major depressive disorder are likely to be treated successfully by primary care physicians and/or other mental health professionals, which leaves psychiatrists to treat patients who have forms of depression that are less responsive to treatment.

Traumatic brain injury (TBI) is one of the most common causes of morbidity and mortality, especially in young adults. Recognition and early accurate diagnosis of neurobehavioral TBI sequelae are important in reducing the severity of postinjury symptoms. Sequelae of TBI include cognitive impairments, personality changes, aggression, impulsivity, apathy, anxiety, depression, mania, and psychosis.

Anxiety is a ubiquitous, natural affective state that is essential for evolutionary survival. Nearly as common, however, are experiences of anxiety that exceed social, psychological, or physiological needs, leading to functional impairment. Indeed, primary anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD), represent the most common category of mental illness in the United States. Secondary, or reactive, anxiety is also widespread and can arise not only from numerous medical causes but also from the psychological process of coping with illness.

In a meeting this past December, an FDA advisory committee recommended that the black-box warning of antidepressant-linked suicidality in children and adolescents should also warn of the risk in young adults. Meanwhile, the NIMH had announced in November its sponsorship of 5 new studies to elucidate this adverse drug effect, particularly focusing on the SSRI antidepressants.

This article briefly describes pharmacotherapy for the treatment of alcoholism and discusses strategies to address treatment challenges like medication nonadherence.

According to the Centers for Disease Control and Prevention (CDC), there are approximately 50,000 violent deaths each year in the United States. Until recently, there were no comprehensive data available to the public regarding these deaths. It was with this in mind that the National Violent Death Reporting System (NVDRS) was created, not only to provide statistics of reported violent deaths, but also to educate and possibly prevent more violent deaths from occurring.

Generalized anxiety disorder (GAD) is characterized by excessive or unrealistic anxiety and worries about life circumstances. In the general population, the prevalence of GAD is 2% to 5%. It is the most frequent anxiety disorder seen in primary care, where 22% of patients complain of anxiety problems.1 DSM-IV lists 6 somatic symptoms associated with GAD: restlessness, increased fatigability, difficulty in concentrating, irritability, muscle tension, and sleep disturbance. These symptoms may present with hyperarousal, hypervigilance, and heightened muscle tension; autonomic symptoms are milder than in other anxiety disorders and can be absent.

A major participant in outreach efforts to Latino populations is the New Jersey Mental Health Institute, Inc (NJMHI), which recently launched the National Resource Center for Hispanic Mental Health.

Posttraumatic stress disorder (PTSD) is a severe and often chronic anxiety disorder that can develop following exposure to an event involving actual or perceived threat to the life or physical integrity of oneself or another person. Epidemiological studies such as the National Comorbidity Survey1 estimate that more than half the population of the United States has experienced one or more traumatic events and that 8% of the population has met criteria for lifetime PTSD. Thus, trauma and PTSD are significant mental health problems.

Delirium is a disorder that lies at the interface of psychiatry and medicine. It is an acute organic syndrome caused by an underlying medical condition and is defined clinically by disturbances in cognitive function, attention, and level of consciousness.1 Delirium is considered a syndrome because of the constellation of signs and symptoms associated with the disorder, coupled with a wide variety of potential etiologies.

The following case histories illustrate some of the clinical aspects of delirium that were described in the preceding article. Each case is followed by a discussion of the diagnosis, identification of the etiology, and subsequent treatment of an episode of delirium.

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

In this issue, Drs Heinrich and Sponagle present a thorough overview of the challenges of detecting and treating delirium in the emergency care setting. They also address the high risks involved when the diagnosis is missed. The difficulties of identifying and appropriately managing delirium are not new. However, the importance of doing so is taking on a greater significance because of certain current and forecasted realities that will affect the nation's emergency departments (EDs).

Ronald Fieve and his colleagues were among the first to document milder versions of manic symptoms-hypomania-in the 1970s, observations that did not make it into DSM until 1994.This book appears mainly to be intended for families and patients; clinicians might find some parts simplistic and other parts informative.

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).1 With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,2 it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

Early findings from a national study are shedding light on differences in the type and prevalence of mental disorders in US-born and immigrant Latinos, as well as differences among Latinos from various countries of origin.

Psychiatry is the go-to specialty for determining whether a patient in need of inpatient hospitalization or has an alternative motivation?

Studies have shown that many pharmacologic agents are effective in the treatment of acute mania and bipolar relapse education.

NEW YORK -- Low birth weight and child abuse combine synergistically to increase the later risks of depression by 10-fold and social dysfunction by nearly ninefold, researchers here said.

Pharmacotherapy of Acute Schizophrenia

Risk Factors for Suicide in Patients With Schizophrenia

Reading the Ability of a Patient to Change His or Her Life

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Poetry of the Times

DVD Aims to Educate Clinicians, Patients on Borderline Personality Disorder