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On behalf of the editors of NEJM Journal Watch Psychiatry, I am pleased to present the Psychiatry Top Stories of 2017.
The selection of the 10 best stories is always difficult for our editorial board, but it reminds us vividly of our goal: to improve the clinician's practice by enhancing assessment and improving treatment options.
Our specialty struggles with an incomplete understanding of the various problems we encounter in practice, and our treatments are limited (although continually improving). In our zeal to help our patients, we may sometimes turn to uncertain diagnostic procedures or therapies. Or, facing complex data, we might overlook a simple solution. With the democratization of information, it is increasingly hard to determine whether the various tests and treatments discussed or touted on the Web are supported by the best scientific evidence. We hope to fill these gaps, helping our readers guide their patients toward evidence-based tests and treatments.
This year, five of our Top Stories could be categorized under the rubric “above all, do not harm” or perhaps “less is more.” In a feature article prompted by the growing commercialization of genetic tests purporting to help clinicians select the best medications, three board members comprehensively review the literature and find no evidence that the tests are helpful. Two stories address the changing cultural attitudes toward marijuana. A comprehensive survey showed that users of marijuana for medical purposes resemble recreational users across many characteristics, consistent with the limited evidence supporting medical, and especially psychiatric, marijuana use. Another study on the seemingly counterintuitive use of marijuana by patients in treatment for alcohol dependence warns that this use impairs their abilities to achieve alcohol abstinence. Another of the board's picks addressed concerns about memory loss and “brain damage” that often lead patients with severe or treatment-resistant depression to avoid electroconvulsive therapy (ECT). Subjective memory loss in patients receiving ECT is infrequent, may be related to residual depression, and is probably not correlated with objective cognitive testing. Another study, of elderly patients in a memory clinic, documents the anticholinergic burden of multiple medications and their worsening effects on memory and cognition.
Five choices in our Top Stories list focus on helpful treatments and delivery approaches. Clinicians' and patients' concerns about antipsychotics' adverse effects have sometimes limited use of these highly effective agents. This year, we learned about a new treatment for tardive dyskinesia, which previously had few therapeutic options. Another longstanding concern is the heightened risk for weight gain and metabolic syndrome in schizophrenia patients taking atypical antipsychotics; liraglutide, a diabetes drug and GLP-1 agonist, seems to reduce these risks. Our board also noted an uncontrolled study with very preliminary data on minocycline, an antibiotic with anti-inflammatory effects, for treating bipolar depression.
The two final stories highlight nonmedication treatments. For bipolar depression, bright light was thought to be ineffective or even to worsen mood when administered at the usual early morning time; this new study finds that administration at an atypical time (noon), with gradual increase in light-intensity exposure, effectively reduces symptoms. The final study addresses the problem of insomnia, perhaps patients' most common complaint, and the difficulty they have in accessing cognitive-behavioral therapy; the study shows that an inexpensive Web-based program is effective, at least for motivated and Internet-savvy patients.
In 2017, the editorial board and I join you as we strive to use the best evidence in the service of providing the best care for our patients. Our best wishes for the New Year.
The Psychiatry Top Stories for 2017 are, in chronological order: