Welcome to this issue of IJPCP. We trust the following papers will be of interest to academic and clinical psychiatrists alike. Perspicacious readers will already have observed that three broad themes are addressed by groups of papers within the issue. For those with other preoccupations, these are the identification of risk factors for adverse outcomes in psychiatry; the role of naturalistic and pragmatic evaluations in extending the findings of randomised controlled trials; and the improvement of clinical practice in outpatient settings.
Improving the prediction of adverse outcomes
This clinically important theme is represented by four papers. In the first, Aysel Eksi and colleagues (Istanbul, Turkey) evaluate potential risk factors for the development of post-traumatic stress disorder (PTSD) and depression in a large sample (n=160) of children and adolescents interviewed 6–20 weeks after a local earthquake: witnessing death and extreme parental reactions were risk factors for PTSD, whereas male gender, higher trait anxiety, physical injury and loss of a family member increased the risk for developing depression. In the second paper, Angel Chu Kee Lee and colleagues (Hong Kong, China), examine predictors for the development of depression in an older group of 260 patients admitted to hospital following a cerebro-vascular accident: 24% of patients fulfilled diagnostic criteria for major depression 1 month later, risk factors being ‘psychoemotional factors’ and the level of dependency on others.
The third paper, from Jiří Masopust and colleagues (Prague, Czech Republic) examines the possible role of antipsychotic drug treatment in the development of venous thromboembolism. By comparing the prevalence of previous exposure to antipsychotics in 266 patients admitted following venous thromboembolism with that in 274 hypertensive patients, they suggest that antipsychotic treatment at least doubles the risk of thrombosis, and discuss potential pathophysiological mechanisms for this association. The theme of adverse outcomes in psychiatric practice is ended with the paper from Ladislav Hosák and colleagues (Prague, Czech Republic), which reports that a particular catechol-O-methyltransferase gene polymorphism (the heterozygous Val/Met genotype) is associated with self-reported non-abstinence at 1-year in metamphetamine abusers: could this marker have a role in identifying drug-dependent patients who are likely to do less well following withdrawal programmes?
Intriguing findings from naturalistic studies
Many clinicians believe that the findings of randomised controlled trials in highly selected patients have limited applicability in routine clinical practice, and it is pleasing to present the findings of three large naturalistic studies within this issue. Through a local retrospective case-note review, Paul Deslandes and colleagues (Cardiff, Wales) evaluate clinical outcomes in 59 patients exposed to risperidone long-acting injection. The high rate of treatment discontinuation, mainly due to a lack of effectiveness in previously treatment-resistant patients, reflects similar findings in other recent pragmatic evaluations of antipsychotic drug treatment. Only 12% of patients stopped risperidone treatment due to adverse effects, but the study observations emphasise the continuing need for well-tolerated treatments with superior efficacy. The second paper in this group, from Juan Gibert and colleagues (Cadiz, Spain), describes a naturalistic evaluation of the effectiveness and acceptability of the second-generation antipsychotic quetiapine over 6 months in a larger sample (n=2029) of patients with schizophrenia. Treatment was associated with a significant reduction in the severity of positive and negative symptoms and a low incidence of movement disorders, but somnolence was reported in over one-quarter of patients. Finally, Peter Osváth and colleagues (Pecs, Hungary) describe a prospective observational study of the treatment of 102 depressed outpatients with the antidepressant mirtazapine, and note that treatment was associated with a reduction in depressive symptom severity and an improvement in sexual function.
How to improve the management of hospital outpatients
Mental health problems are common in the general hospital, but often go unrecognised and untreated. Azizeh Ebrahami and colleagues (Tehran, Iran) describe an evaluation of the prevalence and severity of obsessive-compulsive symptoms in 144 outpatients attending a dermatology clinic, and demonstrate that 14% of patients fulfilled diagnostic criteria for obsessive-compulsive disorder (OCD), this prevalence being 4–5 times greater than in the general population. Selective serotonin reuptake inhibitors (SSRIs) currently represent the mainstay of pharmacological treatment for most patients with OCD, although at present little is known about how best to enhance the efficacy of SSRIs with supporting information. The paper from Duru Gundogar and colleagues (Isparta, Turkey) may offer some guidance: through a randomised controlled trial of the effects of providing verbal or written information or their combination in 104 patients with mild or moderate depression treated with SSRIs, the authors found that retention of information was significantly lower in patients who hade been provided with only written information: the next stage, presumably, is to see whether this greater retention leads to greater efficacy and improved treatment compliance.
We remain prepared to include topical, scientifically interesting and clinically relevant reviews and are pleased to publish the thoughtful consideration of the nature and treatment of co-existing anxiety and depressive symptoms, by Luchezar Hranov (Sofia, Bulgaria), and the review of efficacy of the SSRI fluvoxamine in the treatment of depression, from Stefano Pallanti (Florence, Italy) and Claudio Sandner (Lisbon, Portugal): how interesting that its potential superior efficacy in depressed patients with psychotic symptoms may arise from its actions on the σ1-receptor. The sigma enigma continues …