Genes Plus Environment in Psychiatry: View Positive Studies Skeptically
Common sense dictates that genetic predispositions probably interact with life stressors to influence our mental health. Plenty of research has been published to evaluate whether this is actually true, but findings have been mixed. The first widely reported positive study, for instance, found that patients who had short alleles (versions) of the serotonin transporter gene (5-HTTLPR) were more likely to suffer depression in response to stressful life events than patients with normal alleles (Caspi A et al, Science 2003;301:386–389).
In response to this intriguing finding, a slew of studies tried to replicate this result. One meta-analysis of 14 direct replication studies found no significant link between 5-HTTLPR variation and depressive response to stressors (Risch N et al, JAMA 2009;301:2462–2471). But a later meta-analysis cast a wider net, including several indirect replications which used somewhat different measures of stress (such as hip fractures and heart disease) and depression—and it found a strong association between 5-HTTLPR variation, stress and depression (Karg K et al, Arch Gen Psychiatry 2011;68:444–454).
The latest study throws a monkey wrench into not only how 5-HTTLPR combines with stress but into all gene/ environment findings in psychiatry. Researchers examined results from all 103 published studies of gene/environment interactions in psychiatry published from 2000 to 2009. They found that while a whopping 96% of original gene/ environment interaction studies were positive, only 27% of replication attempts were successful.
Replication studies with larger sample sizes were unlikely to find significant results, while positive replications usually had smaller sample sizes—implying that the most reliable replications are the most likely to cast the original findings into doubt (Duncan LE et al, Am J Psychiatry 2011;168:1041–1049).
TCPR’s Take: Dependable findings of gene/environment associations could eventually be helpful in both diagnosis and treatment—but we must await consistent positive replications before jumping on board.
Can Instant Messaging Enhance Treatment Outcomes?
Whether you see your patients quarterly, monthly, or even weekly, you certainly are not with them as much as their cell phones are. Theoretically (at least, for some types of therapy), we could enhance treatment outcomes by texting patients therapeutic messages on a regular basis.
In a systematic review of research involving the use of cell phones and handheld computers for psychiatric interventions, researchers were able to find eight studies conducted over the past 15 or so years that met their methodological criteria. Three of these studies targeted anxiety, while the remaining five targeted smoking cessation.
In the typical cell-phone based interventions, participants were either texted or called in support of their quitting efforts. The phone-based smoking cessation programs were generally successful; however, the most successful of these were also the most interactive. The participants that received eight sessions of CBT over the phone with a real person were five times more likely to achieve smoking abstinence than a “usual care” group (researchers didn’t explain what “usual care” was). While still showing a positive result, a study that examined text message based smoking cessation counseling saw a more modest two to three times greater abstinence rate than the control condition.
The anxiety studies all involved handheld computers that offered learning modules to augment CBT that was performed in the traditional face-to-face manner. Two studies looked at augmentation of CBT for panic disorder with a computer that allowed for self-monitoring of symptoms and additional treatment modules. This intervention was superior to placebo, but CBT alone won out as the best treatment. In the final anxiety trial, people with social anxiety were given 12 weeks of CBT, 12 weeks of CBT plus handheld computer intervention, or waitlist control. The study found no significant differences between the augmentation group and the waitlist control (Ehrenreich B et al, J Nerv Ment Dis 2011;199(11):886–891).
TCPR’s Take: Judging by this study, it looks like computers aren’t going to replace you in treating anxiety. However, suggesting a phone-based intervention to your patients who are trying to quit smoking might be worthwhile. You can learn more about one of the texting interventions studied, STOMP, at http:// bit.ly/bbdB3g. Www.smokefree.gov also offers a smoking cessation text messaging program.