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Over the past decade, there has been increasing attention to the identification and management of mood and anxiety disorders related to childbearing. Emergen- cy physicians, including psychiatrists, primary care providers, obstetricians, gynecologists, and pediatricians, encounter women who are struggling with mental health issues in the context of reproductive events, such as pregnancy, pregnancy loss, and the postpartum adjustment period. In some cases, the reproductive event may precipitate a mental health crisis. In others, it may exacerbate an underlying mental health condition that, in turn, may need to be managed differently because of issues related to pregnancy or breast-feeding.

New mothers may present to the emergency department (ED) with symptoms ranging from mild anxiety to severe psychosis. Postpartum psychosis has abrupt onset and severe symptoms and usually occurs in the immediate postpartum period. Patients who have had a previous episode of postpartum psychosis or have first-degree relatives with postpartum psychosis or bipolar disorder are at higher risk.

Pregnancy and new motherhood are considered happy and hopeful times. Bad outcomes, such as miscarriages and stillbirths, occur, however, and even with good outcomes, psychiatric disorders can present or worsen at this time. The incidence of depression in women during pregnancy is about the same as that for matched controls, and because depression is common in all women, this is a significant public health issue. More than 10% of women with panic disorder describe first symptoms as occurring around pregnancy, and there is evidence that pregnancy exacerbates psychotic disorders. Within a few days of giving birth, 25% to 75% of new mothers experience emotional lability, or the "baby blues," and 10% to 20% of new mothers experience postpartum depression. The peripartum is thus a time of great joy potentially complicated by the entire range of psychiatric illness.

Women with postpartum depression frequently experience intrusive, obsessive ruminations that are part of a depressive episode. Many women with postpartum depression have significant anxiety, and many reach the level of meeting criteria for full-blown anxiety disorders. An anxiety disorder may also precede and contribute to the development of a depressive episode.

There is growing epidemiologic and clinical data that confirm progressive hypothalamic-pituitary-gonadal hypofunctioning in aging men. What role does the HPG axis play in the complex psychobiology of male sexual and affective disorders? The treatment rationale, clinical indications and risks in using exogenous testosterone for late-life depression are explored.

In recent years, depression and stress have emerged in the discussion of the impact of psychosocial aspects on coronary heart disease. Several studies indicate that these factors result in risk elevation comparable to hypercholesterolemia and hypertension.

An expert in the topic explores the historical background that led to problems with boundary violations in psychotherapeutic practice and describes community standards for professional boundaries when practicing psychotherapy. The difference between boundary crossings and boundary violations is clarified and discussed, as are the psychological types most likely to violate those boundaries. Possibilities for rehabilitation and the format for rehabilitation are also provided.

Is there such a thing as a placebo effect? If so, at what point does the drug effect really occur? How do we distinguish between the two?

Health-related quality of life can provide a simultaneous and net assessment of the therapeutic and adverse affects of psychiatric treatments for depression. While the cognitive side effects of ECT might be thought of as a limiting factor in HRQOL gains, they have not been systematically studied until recently. Find out what quantitative assessment of HRQOL following ECT for major depressive disorder shows.

Seasonal affective disorder affects 1% to 3% of the North American population. Evidence exists for the efficacy of high-intensity bright, fluorescent light. Pharmacological management with SSRIs has shown equivalent efficacy to light therapy. How can these two therapies be combined? What other therapies are available?

Patients often try to protect themselves from the world by putting up defenses. This article presents five types of defenses and shares ways a therapist may go about getting past them to help the patient.

Recent evidence suggests that reorganization of neuronal connectivity might play an important role in the pathophysiology of mood disorders and in both pharmacological and psychological treatments of depression. This evidence suggests a new framework for the etiology of mood disorders that focuses more on the problems in neuronal connectivity, plasticity and information processing in the brain than on abnormalities in chemical neurotransmission. Although this framework is still controversial and far from being complete, improved familiarity with the concepts of neuronal development and activity-dependent plasticity among mental health professionals would be useful.

A pioneer in alcohol addiction studies reviews his past accomplishments and looks toward the future.

Selective serotonin reuptake inhibitors have been shown effective in the treatment of depression with psychosis. This efficacy appears to correlate with the SSRIs’ level of affinity at the sigma-1 receptors in the brain. What role does the sigma-1 receptor play in psychotic depression? Based on this role, are there implications for other treatments?

By 2020, depression will be the second leading cause of death and disability worldwide. As the importance of depression as a public health problem has been reinforced, research efforts have followed different paths. Read about some of the latest developments.

When a family member is diagnosed with depression the whole family is affected. Additional family and marital stresses imposed on the patient with depression can add to the severity of depression and affect long-term remission rates. In order to ensure the best possible success in treatment, the therapist should integrate the family into the patient’s treatment.

Poetry of the Times: The Grave on Perry's Peak

The Centers for Medicare & Medicaid Services has been quietly working on new ways to gather health care data. What are some of these pilot programs and how might they affect payment and health care services?

Internet, Web sites, Practice management

Although public officials expressed surprise and outrage at the behavior of the some of the victims of Hurricane Katrina, research and history has shown that both altruism and violence are common after a disaster of this magnitude. Why is human behavior not a part of disaster preparedness planning?

New Clinical Drug Evaluation Unit presented new clinical data at their 45th annual meeting in Boca Raton, Fla. In the first of two articles, suicide studies, the effectiveness of antidepressants and the efficacy of drug combination therapy are explored.

Advances in technology allow more options for treating patients, tracking medications and preventing errors. What are some of these emerging technologies, and what are their benefits and their drawbacks?

The incidence of polypharmacy is on the rise, and with the increase comes a greater risk of drug-drug reactions. One survey estimated that patients seeing a psychiatrist may be six times more likely to receive multiple psychotropic medicines compared to patients seen by a primary care physician. This article provides an overview of the extent of polypharmacy, the factors driving the phenomenon and issues clinicians should consider when treating patients who are already taking medicines for other illnesses.

Migraine, Headache, Epilepsy, Vagus nerve stimulation, VNS, Stroke, Insomnia

multiple sclerosis, neutralizing antibodies, interferon beta, Avonex, Betaseron, Betaferon, Copaxone, Novantrone

Malformed, reactive astrocytes (blue) interacting with neurons (orange/red) in a human subject whose temporal lobe ultimately was removed because the epilepsy did not respond to pharmacotherapy. Reactive astrocytes are responsible for inappropriate glutamate release, which in turn triggers epileptiform seizures. Image courtesy of Maiken Nedergaard, MD.

translational research, brain tumor

complementary medicine, alternative medicine, acupuncture, and integrative medicine

The more severe the stroke, the greater the liklihood of poststroke epilepse.

This review will familiarize physicians with the embryology, types, and incidence of various interatrial communications; summarize and highlight the potential association of interatrial communications with stroke, platypnea-orthodeoxia syndrome, neurologic decompression sickness in divers, and migraine headaches; discuss various therapeutic modalities available for closure of interatrial communications; and outline future directions in this rapidly evolving field.