This article focused our attention on the metabolic syndrome, framed in the familiar face of a young man with schizophrenia whose weight ballooned from 145 to 203 lb over a decade of antipsychotic treatment. The face of this patient represents more than just a medication side effect. The metabolic syndrome is now a national epidemic, yet we have a unique challenge in treating our patients who face multiple risk factors.
Drs. Fenton and Chavez provided a valuable service by delineating the physiological pathways that underlie the syndrome, but they also addressed the problem in the context of the patient’s life. In summarizing the case, it was the patient’s social support and personal desire to improve his health that led to his adherence to a weight-loss program.
This leaves the field with the daunting task of effecting change in a population that may be only partially receptive to behavioral interventions. Yet a public health crisis is impending, and it is insidiously afflicting our youngest patients. Consider the article in this issue by Klein et al.: “A Randomized, Double-Blind, Placebo-Controlled Trial of Metformin Treatment of Weight Gain Associated With Initiation of Atypical Antipsychotic Therapy in Children and Adolescents.” It is alarming that we are now using medications designed for age-related chronic diseases in our children, but we must be both preventive and proactive if we want to forestall the devastating consequences of the metabolic syndrome.
This year saw the publication of several large multicenter, federally funded clinical treatment studies carried out in “real clinical practice settings.” The studies were designed by clinicians, asked clinically relevant questions, and were funded by NIMH. Phase 1 of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study was published in January (Trivedi et al.), and one of its follow-up articles later in the year (McGrath et al.). This multiphase depression treatment project set out to demonstrate remission rates of depression (not just “response”) to antidepressant drugs with an established medication algorithm and measurement-based care. Moreover, STAR*D progressed through several treatment phases to test sequential medication algorithms for nonremitters. These data provide substantial generalizability of clinical treatment research findings to routine clinical practice, i.e., translating clinical research to clinical practice. These are data that clinicians need in their everyday practice, science that is important to clinical care. The Clinical Antipsychotic Trials for Interventions Effectiveness (CATIE) phase 2 studies of second-generation antipsychotic medications in schizophrenia (McEvoy et al. and Stroup et al.) were also performed in clinical practice settings; these studies provide new information about antipsychotic medications, particularly about side effects and, generally, about limited efficacy. Unfortunately, schizophrenia lacks a significant “remission” measure and as yet a tested treatment algorithm. Psychiatry is now generating scientific treatment data on medication use with comparative drug outcomes for application in clinical practice, like other areas of medicine.
Address correspondence and reprint requests to Dr. Freedman, American Journal of Psychiatry, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209; firstname.lastname@example.org (e-mail).Disclosures of the American Journal of Psychiatry editors are published in each January issue. Dr. Pine is serving in a personal capacity. The views expressed are Dr. Pine’s own and do not necessarily represent the views of the NIH or the U.S. government.