Re-make, re-model
What's stopping drug repurposing in mental health? Plus: the long shadow of 9/11, autism and schizophrenia, and trouble at medical school
Re-make, re-model: what’s stopping drug repurposing in mental health?
I’ve been a fan of drug repurposing for years: the idea that you can take a currently available agent, identify a mental health use case, and then get it rolling through trials and—hopefully—to the clinic strikes me as the quickest of wins.
Unusually for me, I might have been too optimistic (and not just because of recent disappointment in this trial of adjunctive simvastatin for depression).
This JAMA Psychiatry Viewpoint discusses a major problem with repurposing: that there is little financial incentive to develop off-patent medications for mental health use:
While IV ketamine may be one of the most prominent examples of drug repurposing, many FDA-approved drugs have never been repurposed for new indications despite promising clinical evidence. It is often purely a business decision: there is no long-term intellectual property protection, no significant profit projection, no investment into repurposing. Patient needs rarely play a role.
The author proposes that the US should create a federal research programme that unites the NIH, the FDA, and pharmaceutical and research industries in ranking promising drugs for repurposing, and providing funding for evaluation and approval. Whether this will be a priority in the US’s altered funding and regulation landscape remains to be seen: perhaps other international bodies or funders could pick up the gauntlet?
The long shadow of 9/11
The take-home message from this Nature Mental Health paper is that PTSD can be a long, long road. The researchers used annual monitoring data from 12,822 responders to the terrorist attacks on New York on September 11, 2001, to look at how PTSD symptoms evolved over the decades that followed.
The main findings are, first, that PTSD symptoms can take a while to emerge; they didn’t peak until around a decade after exposure, and median time for symptomatic improvement in people with PTSD was 8–10 years. And despite the fact that free treatment was available, 10% of this group had worsening or persisting symptoms after 20 years.
The authors conclude that that PTSD could be considered “a chronic condition that can last at least 20 years after initial trauma”. I wonder to what extent the aftermath of 9/11 can be generalised to other traumatic events, but this study certainly raises questions about how long and to what extent we need to monitor for PTSD symptoms following disaster.
Autism and schizophrenia
A bold and interesting opinion piece in The Lancet Psychiatry asks whether it is time to return the term “autism” from its current usage—denoting autistic spectrum conditions—to its original meaning of a phenomenon seen in schizophrenia:
“a frail constitution of and indwelling in the lifeworld. [Philosopher Edmund] Husserl described the lifeworld as ‘the world in which we are always already living’—it is the ‘realm of original self-evidence’, the implicit grounding soil of everyday social life and practicalities.”
I really like the approach of going back to the archives and re-examining the rich descriptions of mental health conditions set down by pre-DSM generations of psychiatrists. That being said, I’m not sure that thinking about “autism” in the broad terms set out above is going to solve that many problems. I don’t think that “returning the borrowed concept of autism to the psychopathology of schizophrenia”, as the authors put it, will necessarily clear up clinical and conceptual confusion around the condition.
Even if I don’t completely agree with the authors’ conclusions, revisiting our assumptions about diagnostic categories and phenomenology, and recognising how these shape our perceptions, is always worthwhile. As a final point, it would be good to hear what people with experience of autistic conditions, psychosis, or both make of this paper.
Trouble at medical school
A short but worrying BMJ Mental Health article reports a considerable rise in depression and anxiety in US-based medical students between 2018 and 2023, based on data from the Healthy Minds study:
Between 2018 and 2023, the prevalence of anxiety increased by 12.3 percentage points from 21.6% to 33.9%, depression increased by 13.1 percentage points from 14.0% to 27.1%. and counselling service utilisation increased by 17.2 percentage points from 6.7% to 23.9%.
Why is this happening? The authors point to a combination of factors, including financial hardship and academic pressure, as well as the COVID pandemic and civil unrest. Whatever the cause, this study suggests there is a vulnerable generation of medical students who will need the care and support of older colleagues and the health system as they move into the stresses of practice.