September 2010

Personalized Medicine
Even before genomic advances are ready for clinical use, "low-tech" aspects of personalized medicine can enhance psychiatric treatment.

Treating Patients with Schizophrenia: The Importance of Adherence
Antipsychotics can't work if patients don't take them. Nonadherance is a major cause of relapse among patients with schizophrenia.

Valproic Acid and Congenital Malformation
Exposure to valproic acid in the first trimester of pregnancy increases the risk of many congenital malformations in newborns.

In Brief
Bone Mineral Density Is Lower in Depressed than Nondepressed People; Few Adolescents Who Die by Suicide Have Had Recent Exposure to SSRIs

IV Ketamine Infusion Decreases Suicidal Ideation
In a study of treatment-resistant inpatients with major depressive disorder, a single IV infusion of ketamine rapidly decreased suicidal ideation.

SSRIs May Increase the Risk of Cataracts
In a pharmacoepidemiologic study, the use of selective serotonin reuptake inhibitor (SSRI) antidepressants was associated with a greater risk of cataracts among elderly patients.

In Brief

September 2010

Last year, we described a meta-analysis by Wu and colleagues which found that mean bone mineral density (BMD) was lower in depressed patients than in those who were not depressed (Osteoporos Int 2009;20:1309–1320). In a new meta-analysis including more studies and data from more patients, Cizza and others have confirmed this association between depression and deficits in BMD (Horm Metab Res 2010;42:467–482). Of 33 articles they identified on this topic, most of which described cross-sectional or prospective natural history studies, 25 (76%) showed an inverse relationship between depressive symptoms and BMD or bone turnover. A meta-analysis of data from 20 of the studies (those that included control groups) revealed that mean bone mass at three skeletal sites was lower in subjects with depression compared with controls: 4.73% lower at AP spine, 3.53% lower at total femur, and 7.32% lower at femoral neck. The authors conclude that these deficits in BMD are clinically significant and could increase the risk of fracture in depressed patients. Like the Wu report, this analysis did not investigate the effect of antidepressant treatment on bone mass. Studies we have previously described (BTP 2009;32:23–24) have found that some antidepressants increase the risk of osteoporotic fractures in people aged 50 years and older in a dose-dependent fashion. Further research in this area is needed.

In 2003, data showing a weak but statistically significant increased risk of self-harm and suicidal thoughts in adolescents treated with the selective serotonin reuptake inhibitor (SSRI) paroxetine (Paxil and others) were reported to the US Food and Drug Administration (FDA). Following a meta-analysis of randomized controlled trials of all SSRI antidepressants, the FDA required in 2005 that SSRI labeling include a "black box" warning of this risk in adolescents. This was extended in 2007 to include young adults aged 18 to 24 years. Dudley and colleagues recently examined the association between adolescents who committed suicide and their use of SSRI antidepressants by looking at data from observational studies (Australasian Psychiatry 2010;18:242–245). Of 656 studies identified, only 6 contained individual-level data about adolescent suicides and their SSRI consumption at the time of death and were representative of the wider population of youth who commit suicide. Mortality data from these studies revealed recent exposure to SSRIs in only 9 of 574 young people (1.6%) who died by suicide. These findings are limited by the studies having different methodologies and not all having control groups, but they suggest that most young people who commit suicide have not had the potential benefit of SSRI antidepressant treatment at the time of their deaths.

Heather S. Hopkins