Marshall is a 6-year-old child who displayed significant symptoms of hyperactivity, impulsivity, defiance, and temper tantrums since 2 years of age. Marshall lives with his mother, a single parent, and two siblings, ages 4 and 1. His problematic behavior, defiance, and argumentativeness were significant problems at home for his mother, which often made her late to work in the morning. These behaviors were also problematic in the evenings at dinnertime and at bedtime not only for his mother but also for the whole family. Marshall was also having social problems at school including being increasingly shunned by other children because of his aggressiveness and impulsivity as well as being defiant and argumentative with his teachers.

His mother initially sought out her pediatrician, who indicated that Marshall was too young for medication and that better discipline techniques were necessary. Medical workup at that point was unrevealing of any significant condition responsible for Marshall's behavior. Marshall's mother continued to pursue a psychiatric evaluation for Marshall, and a formal psychiatric evaluation revealed diagnoses of attention-deficit/hyperactivity disorder (ADHD), combined type, and oppositional defiant disorder (ODD). Paper and pencil instruments were used including the Swanson, Nolan, and Pelham (SNAP) form for assessing ADHD and ODD symptoms. On the form, both Marshall's mother and teacher indicated that he was significantly elevated in both ADHD and ODD symptom domains, and target symptoms were identified: hyperactivity, impulsivity, short attention span, difficulty with follow through, defiance, argumentativeness, tantrums, and the beginnings of aggressiveness.

Chronic musculoskeletal pain is highly prevalent in the United States and includes inflammatory and non-inflammatory syndromes, such as low back pain (reported by 59 million Americans in the past 3 months), neck pain (reported by 30.1 million Americans in the past 3 months), clinical osteoarthritis (reported by 27 million Americans in the past 3 months), and fibromyalgia (FM). FM affects between 2% to 4% of the US population or 12 million people. Inflammatory pain conditions commonly reported by patients include rheumatoid arthritis (2.5 million) and gout (3 million), among others. This article will focus primarily on FM, which is a chronic pain condition that predominately affects women.

The current diagnostic criteria for FM include chronic widespread pain for at least 3 months and the presence of widespread mechanical tenderness. A patient with suspected FM must report pain in all four body quadrants and have at least 11 of 18 tender points for a positive diagnosis to be made. Tender points are areas of the body where pressure is applied until pain threshold is achieved. In addition to pain and tenderness, FM patients very frequently describe widespread stiffness and fatigue, disrupted or poor sleep, dyscognition, and mild soft tissue swelling. Patients often also report symptoms of anxiety and depression.

There are a variety of barriers to major depressive disorder (MDD) treatment which may impede access to professional help and prevent best patient outcome. These barriers include the heterogeneity of MDD, societal factors, and clinician-patient relationship as well as issues of concordance, compliance, and adherence.

Four years ago, my colleagues and I published an article titled “Why isn't bupropion the most frequently prescribed antidepressant?” The goal of that article was not to advocate bupropion as the preferred agent for treating depression, but rather to stimulate discussion about how psychiatrists choose an antidepressant as well as to highlight the gap between results of efficacy studies and clinical decision making in real-world practice.

The argument in support of bupropion being the preferred antidepressant was based on three premises: all antidepressants are equally effective; adverse effects (AEs) of greatest concern to patients who take antidepressants are weight gain and sexual dysfunction; and bupropion does not cause either of these AEs. Acceptance of these three premises suggested the title of that article.

Although many reviews of the antidepressant literature, including the revised American Psychiatric Association Practice Guideline for the Treatment of Major Depressive Disorder, conclude that antidepressants are equally effective in general, several experts in the treatment of depression have suggested that medications with >1 mechanism of action may be more effective than agents that have more selective neurotransmitter effects. In a meta-analysis of eight studies comparing the remission rates in patients treated with the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine or selective serotonin reuptake inhibitors (SSRIs), Thase and colleagues demonstrated that venlafaxine was more effective than SSRIs in achieving remission in depressed patients. However, these conclusions were tentative as most of the included studies were comparisons of venlafaxine and fluoxetine; only one study included sertraline, and there were no studies of citalopram included in the review. In addition, patients who had previously failed treatment with an SSRI were not excluded, and, although patients who fail with one SSRI may respond to subsequent treatment with another SSRI, the inclusion of SSRI failures may favor venlafaxine in comparisons with SSRIs. Lastly, all of the studies included in the meta-analysis were funded by the manufacturer of venlafaxine.

There are currently >5 million people in the United States who have been diagnosed with Alzheimer's disease. That prevalence rate is expected to triple as the population ages. The health and economic burden due to Alzheimer's disease is a worldwide problem, with some of the greatest burden coming from the developing world as people live longer in those societies. Throughout the world, the projected growth of Alzheimer's disease is dramatic. This is a worldwide public health problem of the highest order, and there is a compelling need to develop new treatments and methods of earlier diagnosis need to slow the progression of the disease and lessen its impact.

Most adults have difficulty sleeping at some time in their lives, with problems falling asleep, staying asleep, or having nonrestorative sleep. When these symptoms continue for ≥1 month and are associated with daytime dysfunction or distress, they reach the status of an insomnia disorder. Roughly 10% of adults in the United States have an insomnia disorder (hereafter referred to as insomnia), ie, that which is present on most nights and lasts ≥4 weeks. Insomnia can be primary, in which the sleep disturbance exists in the absence of co-existing medical or psychiatric disorders, or comorbid, when it is accompanied by one of these disorders.

Although a diagnosis of insomnia requires difficulty with sleep, insomnia is a 24-hour disorder. Individuals with insomnia describe difficulties with concentration, fatigue, and mood, which both influence, and are influenced by, the sleep disturbance. In addition, insomnia is associated with a substantially elevated risk of incident major depressive disorder (MDD), panic disorder, and substance abuse disorders. There is also emerging evidence that insomnia increases the risk for incident hypertension and diabetes.

Anxiety disorders are the most common of the psychiatric disorders, with an estimated prevalence of 2% to 18% worldwide. Psychiatry is gradually progressing towards a clinical neuroscience with an improved understanding of the pathophysiology of psychiatric disorders, an individualized approach to diagnosis and treatment of patients, and the potential for early disorder detection and prevention. Recently, there has been not only a growing literature on effective interventions for anxiety disorders, but also new proof of principle treatment studies based on laboratory research.

Anxiety disorders are frequently discussed at international psychiatric conferences; however, the attention these disorders receive by researchers at large is often minimal compared with their overall contribution to the substantial clinical burden and economic costs of mental disorders. There are potential advantages for clinicians and researchers to convene for the purpose of reviewing recent advances in anxiety disorder research and to exchange ideas about future progress in this field. The Anxiety Disorders Association of America has sponsored highly productive meetings in the United States for many years as well as successful meetings in other countries. Positive outcomes from these meetings encouraged the initiation of an international conference series that centers specifically on anxiety disorders.

It is a commonly held belief among mental health care providers that patients from the Western Pacific region with major depressive disorder (MDD) and anxiety disorders disproportionately present with somatic symptoms as opposed to emotional symptoms. Cultural norms, such as the stigma associated with psychiatric disorders, may lead members of this population to ignore the emotional aspects of these disorders or deny the presence of psychological symptoms. Empirical support is provided by the lower prevalence of these disorders in some Western Pacific nations in relation to the rest of the world. For example, MDD rates in India (9%), Japan (2%), China (2% to 4%), Malaysia (8%) and Australia (3%) are generally lower than rates in the United States (16%) and worldwide (10%). These discrepancies may be the result of missed diagnoses. Misdiagnosis is related to the increased somatization of MDD symptoms in these populations. As defined by the WHO, the Western Pacific region consists of 37 countries with a total population of 1.8 billion people (1.3 billion in China alone) with diverse cultural backgrounds and demographic profiles, which makes the issue of cultural effects on MDD diagnosis more complex.

Patients with MDD or anxiety disorders worldwide often present with somatic symptoms, which frequently accompany psychological symptoms. For example, in a recent report of pooled data from Canada, scores on the Somatic Symptoms Inventory, the 17-item Hamilton Rating Scale for Depression (HAM-D17), and the Hamilton Rating Scale for Anxiety (HAM-A) were used to evaluate the association between somatic symptoms and MDD. Of the 2,191 patients randomly enrolled in the study, 78% reported moderate-to-severe fatigue and weakness. Painful physical symptoms commonly occur in patients with anxiety disorders as well. In a European study, painful physical symptoms were reported by 28% of those without anxiety disorders and 45% of those with anxiety disorders.

Nonadherence to antidepressants is the rule rather than the exception. A variety of factors contribute to the problem of nonadherence, including side effects, costs, and stigma. However, residual symptoms may represent the single major risk factor for nonadherence.

Case-based learning is often considered a new innovation in medical teaching, but it is actually as old as clinical medicine. Physicians have always consulted with their peers on difficult cases and utilized the case-based form of discussion as an educational tool, as a means of understanding new diagnoses, and as a method of determining the best treatment for a particular patient. Fibromyalgia syndrome (FM), a common clinical disorder with a world-wide distribution, has been unrecognized and/or ignored for years. FM can be likened to a volcano, with pain at the very top and insomnia and depression as key, but less common, manifestations (Slide 1). However, many physicians are insecure about the diagnosis and treatment of patients with FM, because they simply do not know enough about the disorder.

The World Health Organization estimates that depression is the fourth leading cause of disability worldwide with a lifetime prevalence of ∼15% to 20%. While the antidepressants currently on the market will be effective in most patients, a significant number of patients will experience residual symptoms, treatment-resistance, and relapse. The recent Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study has shed some light on the reality of antidepressant treatment. At first, only one-third of patients on citalopram monotherapy remitted. The other two-thirds who failed to remit saw their likelihood of remission decrease with each successive trial of another antidepressant monotherapy. Thus, after four successive monotherapies were tried over the course of one year, (ie, after four treatments each lasting 12 weeks), only two-thirds of patients achieved remission (Figure 1). Besides this poor prognosis, the patients who required more treatment cycles to get better also had a higher likelihood of relapsing. Once patients reach that point, they are considered treatment-resistant.