Psychiatry Top Stories of 2012
Novel perspectives on the most important research in the field from the past year
The editors of Journal Watch Psychiatry are pleased to present the Psychiatry Top Stories of 2012. These stories were chosen by the editorial board, with an eye toward relevance to clinical practice. At Journal Watch Psychiatry, we cover many different areas of the field. With the coming changes in DSM-5, I suspect that diagnostic controversies and debates may generate new data and insights that could affect future clinical care.
For our editors, the task of choosing the best stories was difficult. We used a two-step voting process to determine our list. First, the editors looked at all 236 summaries published between November 16, 2011, and November 15, 2012. Each editor chose his or her favorite 20 stories and from these named their top 10 favorites. This list was consolidated into the highest-ranked 16 stories, and the editors voted again — this time, separating the 16 stories by three levels of preference.
Without our intending to do so, we have chosen stories that cluster around two themes. The first highlights new information or approaches that might improve the clinical care of our most challenging patients, especially those who might be refractory to their initial or current treatment, primarily for depressive disorders, or who are suffering from serious side effects. The second theme involves broader public health controversies and priorities.
Overall, the stories highlight a continuing problem for both treatment researchers and the patients hoping to benefit from this research: The paucity of studies examining how best to treat patients who have not benefitted from an initial (or several initial) courses of treatment. Unfortunately, most newly published studies these days follow protocol guidelines designed to obtain FDA approval (even psychotherapy studies funded by the National Institute of Mental Health do this). That is, they recruit "treatment-free" patients to show that a treatment can beat placebo medication or wait-list or a less-effective control psychotherapy. If the treatment meets these criteria, it is added to a long list of effective entry-level treatments.
But we already know that 40% of patients with depression substantially improve with any of several treatments. We don't need more of these treatments. We do need to know which treatments can help patients who have not recovered. In clinical treatment studies of epilepsy, participants continue to take whatever antiepileptic medications they are already on, and the bar is set high: A new treatment must beat what is already out there. This situation is atypical, but doing such studies without allowing ongoing treatment would make it difficult to enroll the most ill patients, who cannot stop their medication without further deterioration. We believe that similarly designed protocols should be required for patients with psychiatric disorders. The disappointing results of STAR*D notwithstanding, we need to know how the many second- and third-line treatment options compare. Eventually, researchers could even use genotyping to select clusters of patients especially likely to do well. Hopefully, such studies will be forthcoming, although regulatory and funding barriers (not to mention the infrastructural requirements for recruiting the large numbers of patients necessary) pose significant challenges.
Here is our list of Top Stories of 2012:
We hope that you will peruse the list and enjoy reading the stories, whether they are already among your personal favorites or are unknown to you. Either way, please enjoy the feature, and let us know what you think by sending us an e-mail at email@example.com or by using the Reader Remarks feature at the bottom of this letter.
Best wishes for 2013,
Published in Journal Watch Psychiatry December 28, 2012
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