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Impaired facial expression recognition has been associated with features of major depression, which could underlie some of the difficulties in social interactions in these patients. Patients with major depressive disorder and age- and gender-matched healthy volunteers judged the emotion of 100 facial stimuli displaying different intensities of sadness and happiness and neutral expressions presented for short (100 ms) and long (2,000 ms) durations. Compared with healthy volunteers, depressed patients demonstrated subtle impairments in discrimination accuracy and a predominant bias away from the identification as happy of mildly happy expressions. The authors suggest that, in depressed patients, the inability to accurately identify subtle changes in facial expression displayed by others in social situations may underlie the impaired interpersonal functioning.

Objective-Neuroimaging studies are promising components for a new diagnostic framework for bipolar disorder, but a major issue is the potential confound of psychotropic medication upon experimental measures. Withdrawing all individuals from medication and examining only unmedicated individuals may be clinically unfeasible, and examining only unmedicated individuals may render findings less generalizable.Method-The authors review structural and functional neuroimaging studies of medicated and unmedicated patients with bipolar disorder to discern the possible confounding effect of medication.Results-Findings from studies identified on MEDLINE that included medicated individuals with bipolar disorder indicated either no significant effect or ameliorative effects of psychotropic medications on abnormal structural and functional neuroimaging measures relevant to pathophysiologic mechanisms of the disorder. Different strategies for assessing medication effects are compared.Conclusions-Neuroimaging studies of bipolar disorder ideally should recruit both unmedicated and medicated individuals. Individuals who are unable to tolerate medication withdrawal likely have more severe illness and are especially informative for research examining biomarkers of illness and treatment response.The research agenda for DSM-V emphasizes the need for translating basic and clinical neuroscience research findings into a new classification system for psychiatric disorders based upon pathophysiologic and etiological processes (1,2). It also supports the recent call for such research to help create "rational treatment advances" in disorders such as bipolar depression (3) and the National Institute of Mental Health recommendation for the need to translate basic science discoveries into biomarkers, diagnostic tests, and new treatments for individuals with psychiatric disorders. Biological evidence of pathophysiologic processes can help meet critical challenges in psychiatric research by aiding the construction of diagnostic and treatment response groupings. This is particularly relevant to bipolar disorder, which is frequently either misdiagnosed or diagnosed late, often as unipolar depression in individuals without a clear previous history of manic episodes (4).Studies employing neuroimaging techniques, and functional neuroimaging techniques in particular, provide direct measures of neural system abnormalities that may be associated with different domains of pathology in bipolar disorder (2). These domains include abnormal emotion regulation and impaired cognitive control. A major issue for studies of psychiatric populations, however, is the potential confound of psychotropic medication upon Address correspondence and reprint requests to Dr. Phillips, Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Loeffler Building, 121 Meyran Ave., Pittsburgh, PA 15213; phillipsml@upmc.edu (e-mail). Dr. Fagiolini has been on the advisory boards and the speaker's bureaus of Bristol-Myer...

Executive Summary BackgroundThis Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness. Part 1: The patient and treatmentWho will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital tech-nology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central. Part 2: Psychiatry and health-care systemsDelivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries. Part 3: Psychiatry and societyIncreased emphasis on social interventions and engagement with societal expectations might be an important a ea fo ps hiat s de elop e t. This ould e o pass ad o a fo the ights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences. Part 4: The future of mental health lawMental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation. Part 5: Digital psychiatry-enhancing the future of mental healthDigital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatm...

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