Introduction: Early Career Psychiatrists April 2015

Introduction

In this month’s Early Career Psychiatrists section, we offer 4 articles on a range of important topics.

Gerretsen et al investigated the relationship between impaired insight into delusions during psychotic depression and treatment response. Using data from the Study of Pharmacotherapy for Psychotic Depression (STOP-PD), a 4-center, 12-week, double-blind, randomized controlled trial of atypical antipsychotic monotherapy versus antipsychotic medication plus a serotonin reuptake inhibitor, the group found no effect of treatment on improvement of insight into delusions, adjusted for severity of depression. However, impaired insight into delusions at baseline was significantly associated with improvement in depression during the trial. The authors theorize about why this relationship might occur in a short time frame.

Ueno and colleagues asked a practical clinical question: Would increasing the dose of mirtazapine at 1 week in nonresponders with major depressive disorder improve the rate of remission? In a 6-week, double-blind, randomized placebo-controlled trial of mirtazapine treatment, the authors found that subjects who failed to improve with 15 mg of mirtazapine at week 1 and were increased to 30 mg had a significantly greater reduction of symptoms at week 6 than those who continued taking 15 mg. No difference was found between subjects who failed to improve at week 2 with a dose of 30 mg and stayed at a dose of 30 mg compared to those who were increased to 45 mg. This study highlights the importance of studying early changes in treatment to improve rapidity of response.

Gabrielian et al studied factors that contribute to persistent homelessness in people with serious mental illness and substance use disorders, with an eye to how these data can be used to tailor interventions for those who are homeless. The authors compared groups with 3 trajectories of housing stability: stable housing, unstable housing, and continuously engaged in services. They found that those predicted to be continuously engaged in services had impaired processing speed and that those predicted to be in stable housing had fewer interpersonal difficulties. Discussion of these data emphasizes that focus on cognition and on impaired relationships are key factors in determining ability to attain stable housing.

Ward and colleagues performed a meta-review of lifestyle interventions for cardiovascular risk factors in the general medical population, highlighting successful factors in diet, exercise, and behavioral therapy, and they theorize how successful treatments can be translated for populations with severe mental illness. Dr Lydia Chwastiak, in an accompanying commentary, describes programs that put such interventions into use for vulnerable populations and, additionally, the barriers that often prevent implementation of behavioral programs in community mental health settings.

We are pleased to highlight the work of outstanding early career researchers this month. The topics of these articles—predictors of treatment response, timing of dose increase for nonresponsiveness, predictors of homelessness, and evidence-based programs that can improve health in the seriously mentally ill—are timely and clinically relevant.

Erika F. H. Saunders, MD

[email protected]

J Clin Psychiatry 2015;76(4):426 (doi:10.4088/JCP.15f09919)

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