Last month I had the opportunity to round with second-year residents on a general psychiatry inpatient unit at a Department of Veterans Affairs (VA) medical center. The first patient we saw had been admitted following a suicide attempt. He had a history of polysubstance abuse, had been discharged from the military in the 1960s for what was called a "neurotic reaction," had been admitted to VA facilities more than 15 times over the 20 years since discharge, and was currently being treated for a panic disorder unresponsive to benzodiazapines and selective serotonin reuptake inhibitors. The next patient was also a veteran with service-connected illness who carried a diagnosis of schizoaffective disorder. Despite aggressive outpatient treatment with benzodiazepines, anti~psychotics, mood stabilizers, and two different antidepressant medications, his dysphoria, suicidal ideation, and command hallucinations had recently worsened, leading to the current admission. The third patient was admitted because of a severe depression. He had been noncompliant with medications and acutely suicidal after losing his job and being thrown out of his house by his wife. He carried a diagnosis of narcissistic personality disorder with borderline features (diagnosed by the nurses), bipolar disorder (diagnosed by the admitting resident and on several previous admissions), and posttraumatic stress disorder (diagnosed by his outpatient treatment team). The other cases were similar; they were marked by multiple diagnoses over time, noncompliance with prescribed medications, overuse of nonprescribed drugs, staggering amounts of polypharmacy, and nonresponse to both traditional and nontraditional treatment approaches. Increasingly, such difficult cases define psychiatric practice today. Consequently, Challenges in Clinical Practice, a guide to the diagnosis, epidemiology, risks, and management of treatment-refractory psychiatric disorders, is a timely addition to the psychiatric literature.