The materials in the following section are speaker comments from an educational symposium entitled Suicide: Clinical/Risk Management Issues for Psychiatrists sponsored by the American Psychiatric Association, May 16, 1999. The program chairpersons were Drs. Douglas Jacobs and Ross J. Baldessarini. The symposium was supported by an unrestricted educational grant from Solvay Pharmaceuticals.

The symposium focused on critical clinical and risk management issues about suicide as they impact clinical practice. Dr. Douglas G. Jacobs presented a suicide assessment protocol with suggestions on how to include current understanding about suicide in treatment planning. Dr. Kay Redfield Jamison reviewed bipolar disorder with an emphasis on early diagnosis, aggressive treatment, and the phenomenology of suicidal behavior. Dr. Ross J. Baldessarini discussed the lethality of bipolar depression and the effectiveness of lithium maintenance therapy to limit bipolar depression and reduce suicide risk. Dr. Jan A. Fawcett presented four clinical profiles of completed suicide and reviewed suggested treatment approaches appropriate for each that may help psychiatrists reduce the risk of suicide among their patients. Dr. Herbert Hendin explored the role psychiatrists play in performing comprehensive assessments of patients who request assisted suicide. Finally, Dr. Thomas G. Gutheil reviewed the basis for malpractice litigation and provided guidelines for preventing liability following a patient's suicide.

In September 2005, the National Institute of Mental Health published phase 1 results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, a large-scale, double-blind trial comparing the relative effectiveness of five antipsychotics used to treat patients with schizophrenia: perphenazine, a conventional antipsychotic that has been commercially available since the 1950s, and four atypical agents—olanzapine, quetiapine, risperidone, and ziprasidone—that were introduced in the 1990s. The broad intention of the CATIE study is to determine if the atypical agents used offer any demonstrable clinical and public health advantages over the conventional agents. Concerns over costs and side effects (eg, pronounced weight gain and lipid disturbances) associated with the newer, atypical antipsychotics, as well as doubts about superior efficacy relative to older, conventional agents, served as an impetus to the trial.

The study design chosen for the CATIE study—that of a “large, simple” trial—sought to bypass the limitations of clinical studies that are conducted when pharmaceutical companies seek regulatory approval of a new medication. Studies done in pursuance of drug approval attempt to establish safety and efficacy in controlled clinical settings so as to determine if a drug works at all, and if its use entails specific side effects. Hence, they are typically placebo-controlled and short-term, enroll a small homogeneous population (eg, initially hospitalized patients with no psychiatric or medical comorbidities), forbid or restrict the use of concomitant medications, and take as their endpoints well-defined side effects and measures of core psychopathology. These restrictions heighten the risk that the study findings may not be widely applicable to patients outside the confines of the protocol.

Diffusion tensor magnetic resonance imaging is an imaging modality that measures the diffusion properties of water molecules in tissues noninvasively. Water diffusion is affected by tissue constituents, such as macromolecules, membranes, organelles, as well as by tissue microstructure, architecture, and organization. From the quantities measured with diffusion tensor-magnetic resonance imaging, one can infer information about brain tissue that cannot be obtained using conventional, compositional-based (eg, proton density and chemical spectroscopy), or relaxometry-based (eg, magnetization transfer, T1, T2, and T2*) magnetic resonance imaging methods. Understanding the relationship between a measured water diffusion pattern and the underlying histological features of the tissue, however, is not simple. In the absence of a robust and comprehensive model of water diffusivity in biological tissues, the biological interpretation of diffusion measurements relies on empirical evidence. Herein, the properties of several diffusion tensor-derived quantities are reviewed, together with the experimental evidence that helps clarify their relationship with the underlying properties of brain tissue.

Pharmacogenomic testing can be integrated into modern mental health practices to help select psychotropic drugs for individuals who have failed first-line evidence-based treatments. This can be done by the process of “equipoise”—namely, balancing the weight of all available evidence. That evidence now includes not only diagnosis-specific treatment guidelines and “personalized” patient information, such as an individual’s specific symptom profile, past response to medications, side effects, family history, and patient preference, but also “precision medicine,” which incorporates the ever-expanding base of pharmacogenomic evidence for how an individual’s own biomarkers alter the odds for that individual’s treatment response or treatment intolerance.

Herein, the background information reflecting roles of medical burden, cerebrovascular disease and risk factors, and cognitive impairment in geriatric depression are reviewed. The authors then propose a nonparametric statistical approach to the data analysis of multiple putative causal variables for late-life depression, the Classification and Regression Tree Analysis. This analysis presents a useful approach to modeling nonlinear relationships and interactions among variables measuring physical and mental health, as well as magnetic resonance imaging and cognitive measures in depressed elderly. This method uncovers the existing interactions among multiple predictor variables, and provide thresholds for each variable, at which its predictive power becomes statistically significant. It presents a “hierarchy” of the predictors in a form of a decision tree by finding the best combination of predictors of an outcome.

The authors present two models based on demographic variables, measures of vascular and nonvascular medical burden, neuroimaging indices, the Mini-Mental State Examination score, and neuropsychological test scores of 81 elderly depressed subjects.

Cognitive tests of verbal fluency and executive function are identified as the best predictors of depression, followed by the frontal lobe volume and Mini-Mental State Examination. The authors observed that an interaction between frontal lobe volume, total lesion volume, and medical burden was predictive of depression.

In recent years, a number of antidepressants with varying degrees of selectivity for the noradrenergic neurotransmitter system have become available. However, these agents represent a pharmacologically heterogeneous group and differ in terms of their precise side-effect profile and, possibly, their clinical efficacy. Bupropion, which is thought to act on both the dopamine and norepinephrine (NE) systems, has not been widely used as an antidepressant and has more recently been licensed as adjunctive therapy for smoking cessation. The serotonin-NE reuptake inhibitors venlafaxine and nefazodone, the noradrenergic and specific serotonergic antide-pressant mirtazapine, and the selective NE reuptake inhibitor reboxetine (the only truly NE-selective agent available) have all demonstrated efficacy in the treatment of depressive disorders. Evidence is now emerging for their use in the treatment of anxiety and panic disorders. There is some suggestion of a role for noradrenergic agents in other disorders, including attention-deficit/hyper-activity disorder and social phobia. The full range of disorders for which noradrenergic agents can be used remains to be seen and further research in this area is necessary.

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study for schizophrenia was designed to independently evaluate the effectiveness of antipsychotic treatment in “real-world” patients. To assess the effectiveness of the conventional antipsychotics compared to the atypicals as well as the differences among the atypicals, patients were randomized to one of four atypical antipsychotics (olanzapine, quetiapine, risperidone, ziprasidone) or a representative conventional antipsychotic (perphenazine). Effectiveness was defined by time to discontinuation and duration of successful treatment. Time to “all-cause” discontinuation reflects both efficacy (ability of a drug to reduce symptoms) and safety/tolerability. Phase I revealed discontinuation rates ranging from 64% for olanzapine to 82% for quetiapine.

Differences among the medications may be important in the selection of a drug for a particular patient. Physicians should involve the patient in choosing their medication by inquiring about the patient's past experience with medications and side effects, educating the patient on the risk-benefit ratio, and considering the patient's preference. To demonstrate how results of the CATIE study can contribute to the knowledge of practicing clinicians, this monograph presents a representative clinical case patient and illustrates how the CATIE safety and efficacy data has important implications for the patient.

Depressive symptoms and episodes dominate the long-term course of bipolar disorder and are associated with high levels of disability and an increased risk of suicide. However, the treatment of bipolar depression has been poorly investigated in comparison with that of manic episodes and unipolar major depressive disorder. The goal of treatment in bipolar depression is not only to achieve full remission of acute symptoms, but also to avoid long-term mood destabilization and to prevent relapses. A depressive presentation of bipolar disorder may often delay the appropriate management and, thus, worsen the long-term outcome. In these cases, an accurate screening for diagnostic indicators of a possible bipolar course of the illness should guide the therapeutic choices, and lead to prognostic improvement. Antidepressant use is still the most controversial issue in the treatment of bipolar depression. Despite inconclusive evidence of efficacy and tolerability, this class of agents is commonly prescribed in acute and long-term treatment, often in combination with mood stabilizers. In this article, we review available treatment options for bipolar depression, and we shall provide some suggestions for the management of the different presentations of depression in the course of bipolar disorder.

Existing literature on aggression within psychiatric hospitals suggests that treating an aggressive patient’s symptoms could be complemented by (a) milieu environments that mitigate violence and (b) hospital-wide policies and procedures that focus on creating a safe environment. Described as an ecological approach, examples of how this broader, situational approach can reduce inpatient violence in psychiatric settings are provided throughout. The authors identify potential barriers to focusing on wards and institutional rules as well as patient treatment. Last, details of how this ecological approach has been implemented at one state hospital in California are provided.

The neuropsychiatric examination includes standard neurological and cognitive examination techniques with several additional observations and tasks designed to capture abnormalities common among patients with neuropsychiatric disorders or neurocognitive complaints. Although useful as a screening tool, a single standardized rating scale such as the Mini Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) is insufficient to establish a neuropsychiatric diagnosis. Extra attention is paid to findings commonly seen in the setting of psychiatric disorders, dementias, movement disorders, or dysfunction of cortical or subcortical structures. Dysmorphic features, dermatologic findings, neurodevelopmental signs, signs of embellishment, and expanded neurocognitive testing are included. The neuropsychiatric clinician utilizes the techniques described in this article to adapt the examination to each patient’s situation, choosing the most appropriate techniques to supplement the basic neurological and psychiatric examinations in support of diagnostic hypotheses being considered. The added examination techniques facilitate diagnosis of neurocognitive disorders and enable neuropsychiatric formulation.

A definition of the objects of a science in terms of precise measuring operations M gives the objects a set-theoretical character whereby complexity, seen as a multiplicity of possible final outcomes, emerges. An adaptive strategy introduces a frequent readjustment of the M settings, which reduces that multiplicity. This way, an adaptive cognitive task can be seen as the extraction of a simple map out of a complex landscape.

Since before the time of Charcot, nonepileptic seizures (NES) have intrigued and perplexed physicians. With the advent of the electroencephalogram, particularly with the addition of continuous video monitoring, the diagnosis of NES has received increasing evaluation. Characteristic historical features and clinical signs of NES, coupled with new diagnostic techniques, have progressively refined our understanding of the disorder. The treatment of patients who have NES has received much less attention and the prognosis of these patients illustrates the need for a more comprehensive, systematic, and validated intervention. These issues are discussed with an emphasis on the need for future research.

In the same way that a war mobilizes the creative energies of a nation and often leads to major advances in science, technology, and medicine, the terrorist attacks on the World Trade Center and the Pentagon provided a powerful impetus to advance the traumatic stress field. Stung by our inability to provide policymakers with recommendations on evidence-based, early interventions for survivors of the September 11, 2001, attacks, we have been forced to confront the major gaps in our current knowledge.

These gaps are myriad and include our limited understanding of the natural longitudinal course of psychological consequences from the immediate post-impact phase to months and years later. They also include our inadequate scientific understanding of the psychological and psychobiological mechanisms underlying acute and long-term reactions to traumatic events and sparse empirical literature on which to base decisions concerning best practices for interventions. Questions of vulnerability and resilience have taken on a new urgency as we struggle to determine when to respect natural recovery processes and when to provide a formal intervention. With the recognition that there is little empirical justification for psychological debriefing as a one-stop early intervention panacea for the population-at-large has come intensification of efforts to develop and test a variety of novel early interventions that may be suitable for adults and children during the acute aftermath of catastrophic events.