Rates of preterm birth were 21% for women who took selective serotonin reuptake inhibitor (SSRI) antidepressants throughout pregnancy and 23% for those who had untreated major depression throughout their pregnancies, compared to only 6% for women with neither untreated depression nor antidepressant treatment. In a prospective, observational study of 238 pregnant women by Wisner et al. (p. 557), rates were not elevated for women exposed to depression or SSRIs for no more than two trimesters. SSRI use and depression were not related to maternal weight gain, infant birth weight, number of minor physical anomalies, or any measure of neonatal adaptation except Apgar score at 5 minutes. In an editorial on p. 512, Dr. Barbara Parry assesses the risks and benefits of treating depression in pregnant women.

Long-term assessments of a community sample demonstrated that delusional-like experiences in young adults are more common among those with mental health problems at age 5 or 14. Scott et al. (p. 567) administered a rating scale for delusions to 3,617 sample members at approximately age 21. The scale includes items such as, “Do you ever feel as if other people can read your mind?” and “Do you ever feel as if all things in magazines or on TV were written especially for you?” The total score was significantly related to ratings of psychopathology at both age 5 and age 14. Participants whose psychopathology self-ratings were in the top one-fourth at age 14 were nearly four times as likely to score in the top quartile for delusions at age 21. These relationships were independent of both substance abuse and diagnoses of psychotic illness.

Advances in the understanding and treatment of borderline personality disorder are highlighted in several features. The Treatment in Psychiatry article by Gabbard and Horowitz (CME, p. 517) presents a hypothetical patient with borderline personality disorder in whom a transference interpretation by the therapist evokes anger similar to the kind it aimed to address. A strong therapeutic alliance is a key ingredient in therapy, and the timing of transference interpretations can be important. Many effective dynamic interventions proceed from mentalizing and clarifying cognitions to changing attitudes and altering maladaptive interpersonal relations. Along the way, transference interpretations may provide a crucible of mutual observation in which to negotiate attitudinal change and strengthen the alliance. The Clinical Case Conference by Goodman et al. (p. 522) examines the psychotherapy of a specific patient with many of the central features of borderline personality disorder. She was a participant in a study of the neurobiology of response to treatment. Details of the 1 year of dialectical behavior therapy highlight important facets of psychotherapy and illustrate the gains made. The patient’s hyperemotional responses are juxtaposed with her physiologic hyperreactivity and the neurobiologic underpinnings of borderline personality disorder. Gunderson (p. 530) gives a chronological account of the transformation of the syndrome, initially conceptualized as borderline schizophrenia. Borderline personality disorder eventually gained its own diagnostic criteria, but over time questions have been raised about overlap with other conditions, such as bipolar disorder. In the 1970s, treatment consisted of psychoanalytic psychotherapy, and inconsistent responses to medications slowed the search for biological origins. Pragmatic, multimodal treatment approaches, such as dialectical behavior therapy and mentalization-based treatment, emerged in the 1990s. The current decade has revealed significant genetic influences and an improved prognosis. In an editorial on p. 509, Dr. John Oldham summarizes the advances in understanding and treating borderline personality disorder. In their editorial on p. 505, Drs. Otto Kernberg and Robert Michels identify aspects of diagnosis, etiology, and treatment that need further study.