The countertransference hatred (feelings of malice and aversion) that suicidal patients arouse in the psychotherapist is a major obstacle in treatment; its management through full awareness and selfrestraint is essential for successful results. The therapist's repression, turning against himself, reaction formation, projection, distortion, and denial of countertransference hatred increase the danger of suicide. Such antitherapeutic stances, their recognition, and the related potential for constructive or destructive action are the subject of this paper. Components of Countertransference HateCountertransference hate, like all hate, is a mixture of aversion and malice. The aversive component is the one fundamentally most dangerous to the patient and is often not clearly distinguished from the sadistic (malicious) as¬ pects of countertransference hate. Sometimes the aver¬ sion is experienced more consciously while the malice is muted; this will give rise to a sense of inner fear and fore-

Clinicians felt they learned from participating in the project and that it was therapeutic for them. Review of such cases by a disinterested independent group with no institutional ties to the therapists seems desirable.

BackgroundTwo treatments for smoking cessation—varenicline and bupropion—carry Boxed Warnings from the U.S. Food and Drug Administration (FDA) about suicidal/self-injurious behavior and depression. However, some epidemiological studies report an increased risk in smoking or smoking cessation independent of treatment, and differences between drugs are unknown.MethodologyFrom the FDA's Adverse Event Reporting System (AERS) database from 1998 through September 2010 we selected domestic, serious case reports for varenicline (n = 9,575), bupropion for smoking cessation (n = 1,751), and nicotine replacement products (n = 1,917). A composite endpoint of suicidal/self-injurious behavior or depression was defined as a case with one or more Preferred Terms in Standardized MedDRA Query (SMQ) for those adverse effects. The main outcome measure was the ratio of reported suicide/self-injury or depression cases for each drug compared to all other serious events for that drug.ResultsOverall we identified 3,249 reported cases of suicidal/self-injurious behavior or depression, 2,925 (90%) for varenicline, 229 (7%) for bupropion, and 95 (3%) for nicotine replacement. Compared to nicotine replacement, the disproportionality results (OR (95% CI)) were varenicline 8.4 (6.8–10.4), and bupropion 2.9 (2.3–3.7). The disproportionality persisted after excluding reports indicating concomitant therapy with any of 58 drugs with suicidal behavior warnings or precautions in the prescribing information. An additional antibiotic comparison group showed that adverse event reports of suicidal/self-injurious behavior or depression were otherwise rare in a healthy population receiving short-term drug treatment.ConclusionsVarenicline shows a substantial, statistically significant increased risk of reported depression and suicidal/self-injurious behavior. Bupropion for smoking cessation had smaller increased risks. The findings for varenicline, combined with other problems with its safety profile, render it unsuitable for first-line use in smoking cessation.

Over one-third of therapists who experienced a patient's suicide were found to suffer severe distress, pointing to the need for further study of the long-term effects of patient suicide on professional practice.