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Objective: The authors' goal was to determine whether suicide attempters with major depression received more intensive antidepressant treatment than depressed patients who had not attempted suicide., Method: One hundred eighty inpatients who met DSM-III-R criteria for a major depressive episode according to the Structured Clinical Interview for DSM-III-R were enrolled in the study. All patients were assessed for lifetime history of suicide attempts. Depressive symptoms at the index hospitalization were assessed with the Hamilton Depression Rating Scale and the Beck Depression Inventory. Strength of antidepressant treatment over the 90 days preceding the hospitalization was scored by using the Antidepressant Treatment History Form., Results: A large majority of the depressed patients with a history of suicide attempts, who were at higher risk for future suicide and suicide attempts, received inadequate treatment. Similarly, most of the depressed patients at lower risk for suicide attempts also received inadequate treatment., Conclusions: Major depression is undertreated pharmacologically, regardless of history of suicide attempt. Some suicide attempts may be preventable if the problem of underdiagnosis and undertreatment of depression can be overcome by psychoeducation for health professionals and the public.

The literature regarding risk factors for suicidal behavior in the context of major depressive episode is reviewed. An organized framework for prevention strategies is provided. Risk factors for suicide in major depression can be organized according to whether their effect is on the threshold for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. For patients sufficiently depressed to present for evaluation and treatment, severity of depression is a poor guide to risk for suicidal acts. The best predictors relate to the threshold or predisposition to suicidal acts in response to major depression. Although available literature on suicidal behavior focuses on major depression in general, the findings may be usefully applied in refractory depression. Guidelines for assessment and management of suicidal behavior in major depression are offered.

Use of a patient's second language in psychiatric evaluation and treatment has a variety of effects. Patients frequently undergo psychiatric evaluation in their second language, yet competence in a second language varies depending on the phase of illness. Evaluation of bilingual patients should ideally be done in both their languages, preferably by a bilingual clinician or by a monolingual clinician with the help of an interpreter trained in mental health issues. Cultural nuances may be encoded in language in ways that are not readily conveyed in translation, even when the patient uses equivalent words in the second language. The monolingual clinician may clarify these nuances through consultation with a clinician who shares the patient's first language and culture or with an interpreter. In psychotherapy, patients may use a second language as a form of resistance, to avoid intense affect. Therapists may use language switching to overcome this resistance and to decrease emotional intensity, if necessary. Psychotherapy can also be affected by the attitudes toward speaking that are part of the patient's culture. Discussions with bilingual and bicultural consultants can elucidate these effects for the therapist who is unfamiliar with the patient's culture.

Characteristics of ataque de nervios, a culturally condoned expression of distress that is most frequently seen in Hispanic women, are described. It has symptoms in common with affective and anxiety disorders, with which it can co-occur, and these are delineated for purposes of differential diagnosis. Possible reasons for the preponderance of the condition in women are discussed, along with suggested intervention strategies.

In transcultural psychoanalytically oriented treatments, the therapist must consider differences between the cultures of origin of both patient and therapist. The therapist also must be aware of a third relevant culture that affects the patient-therapist dyad: the psychoanalytic culture. The effect of the psychoanalytic culture and its values on the development of transference and countertransference is illustrated in three clinical vignettes from transcultural treatments. The authors offer suggestions for dealing with problems that arise because of discrepancies between the psychoanalytic cultural values and the patient's cultural values.