Borderline personality, agomelatine and unpublished trials
Patients with borderline personality disorder, an illness characterised by high levels of instability in their interpersonal interactions and increased risk of self-harm and suicide, express a range of symptoms with variable severity. Bateman & Fonagy (pp. ) used data from a mentalising v. structured clinical management treatment study to demonstrate that the severity of symptoms at baseline was not able to predict outcome at the end of the treatment. They found that having additional Axis II diagnoses did have a negative impact on treatment outcome, and that these patients may have done better in the more specialised, mentalising treatment arm of the study. On the basis of their preliminary observations, they suggest that patients with more complex illness may benefit from the more specialised treatment, but given the lack of concordance between their different severity measures, outcome measures for borderline personality disorder require further development. An accompanying editorial explores the broader background issues in assessing clinical severity in psychiatric disorders, and more specifically with regard to borderline personality disorder. Moran & Crawford (pp. ) sound a note of caution with an approach predicated on placing excess emphasis on any one indicator of severity, especially if it is to be used for stratifying patients in order to allocate them to specific treatment pathways. They also raise the issues of treatments being delivered in groups in these studies, where the outcomes of an individual may also reflect the balance of illness severity among the group members – potentially giving different results if the group were to exclusively comprise patients with more severe illness. There is a prominent contemporary focus on disclosing all clinical data – both published and unpublished – predominantly relating to commercial drug studies. Koesters and colleagues (pp. ) carried out a systematic review and meta-analysis of the efficacy of agomelatine, a novel antidepressant drug approved by the European Medicines Agency in 2009, including both published and unpublished data. They found that there were conflicting results between the unpublished and published studies, with none of the negative studies having been published. They concluded that it was unlikely that there was an important difference between agomelatine and placebo in the treatment of depression. They proposed that the European Medicines Agency should aim to have a more robust procedure for evaluating novel drugs, including aggregating individual study data using meta-analytic techniques, and insisting on submission of all available drug studies, rather than relying on a selection of relevant studies provided by the manufacturer.
Post-traumatic stress disorder and social ecology
There has been an increasing awareness of the prevalence of post-traumatic stress disorder (PTSD) and its sequalae, particularly given the rise of social media and accessibility of news, perhaps best exemplified recently by almost immediate access to activity within conflict zones across the world. There has been an increase in the number of children involved with armed forces, who are at risk of developing PTSD, but it is not clear whether their outcomes differ from the outcomes of adults with PTSD. Betancourt and colleagues (pp. ) examined longitudinal data from child soldiers in Sierra Leone and found rates of PTSD of 32% at baseline, which had decreased to 16% some 4 years later. The baseline rates were correlated with war experiences and post-conflict family abuse, while positive symptom change was associated with family acceptance, and negative symptom change with death of a parent or post-conflict stigma. They conclude that social ecology, family and community factors evidenced through levels of social support, acceptance and stigma played an important role in predicting the outcome of PTSD symptoms. An accompanying editorial by Kohrt (pp. ) emphasises both the commonalities of experiences between child soldiers in lower-income countries and adult soldiers from high-income countries, and the value of social ecological approaches in examining their experiences, and outcomes, on return to their post-conflict status. He suggests that this can best be examined prospectively through multi-level assessments relating to aspects of families, communities and political regions.
Cognition in schizophrenia and effects of prior antipsychotic treatments
Cognitive deficits are present at all stages of schizophrenia, across a range of cognitive domains, and have an impact on functional outcomes. Choi and colleagues (pp. ) performed a meta-analysis of adjunctive treatments for cognitive deficits and found that cholinergic medications were the only pharmacological interventions that produced improvements in learning and memory; however, none of the interventions targeting glutamatergic, serotonergic and cholinergic neurotransmitter systems had any effect on composite measures of cognition. They suggest that future interventions could be focused on drugs that affect broader neuroprotective brain mechanisms. An editorial by Joyce (pp. ) reviews the assessment of cognitive function in schizophrenia in the context of the wider research data from studies of intelligence in the healthy population. She describes the role of crystalline and fluid aspects of intelligence and data that support specific deficits in processing speed and executive functioning in schizophrenia. In drawing these data together, she suggests that a focus on the frontoparietal neural network underlying fluid intelligence may prove a fruitful avenue for future research and therapy. Clinical medication trials in schizophrenia often include patients who have transferred from another medication, with an appropriate wash-out period; however, Barnes and colleagues (pp. ) demonstrate that a switch from a long-acting antipsychotic injection to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year than similar switches made from other oral antipsychotic medication. They suggest that this effect may be moderated by adherence, and may need to be factored into the randomisation process during the design of clinical outcome studies.
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