IntroductionBetween 30 -50% of patients with major depressive disorder (MDD) do not respond to their first antidepressant trial. Genetic variants contribute to the variance in antidepressant response rates. The clinical utility of pharmacogenetics-based decision-support tools (DSTs) is uncertain and has been the topic of much debate. ObjectivesTo conducted a systematic review and meta-analysis of prospective, randomized controlled trials (RCTs) that examined pharmacogenetic-guided decision support tools (DSTs) relevant to depressive symptom remission in major depressive disorder (MDD). MethodsRandom-effects meta-analysis was performed on RCTs that examined the effect of DSTs on remission rates in MDD. RCT quality was assessed using the Cochrane Collaboration Criteria. FindingsA total of 1737 eligible subjects from five RCTs were examined. Individuals receiving pharmacogenetic-guided DST therapy (n = 887) were 1.71 (95% CI = 1.17 -2.48, p = 0.005) times more likely to achieve symptom remission relative to individuals who received treatment as usual (n = 850). ConclusionsMeta-analysis results showed pharmacogenetic-guided prescribing has a positive effect on the likelihood of achieving symptom remission in MDD. Pharmacogenetic-guided prescribing of antidepressants is superior to prescribing as usual in relation to remission likelihood, specifically among those with inadequate response or intolerability to previous psychotropic medications. References1. Bousman C, Eyre HA, Dunlop B et al (2019) Pharmacogenetic tests and depressive symptom remission: A meta-analysis of randomized controlled trials. Pharmacogenomics Journal.

This article was migrated. The article was marked as recommended. Clinical placement has been the cornerstone of medical training since the early foundations of the medical profession. The COVID-19 pandemic generates unprecedented challenges for the delivery of medical education, particularly in the setting of 'flatten the curve' public health initiatives to curtail transmission. As the number of cases of COVID-19 increase, hospitals are limiting medical students' attendance at ward rounds, clinics and theatre, representing a fundamental shift in clinical education from the bedside to online formats. We discuss the considerations behind these changes, review the strategies implemented during previous global infectious disease epidemics, and suggest strategies for maximising clinical education going forward.

Patients discontinue antidepressant medications due to lack of knowledge, unrealistic expectations, and/or unacceptable side effects. Shared decision making (SDM) invites patients to play an active role in their treatment and may indirectly improve outcomes through enhanced engagement in care, adherence to treatment, and positive expectancy of medication outcomes. We believe decisional aids, such as pharmacogenetic decision support tools (PDSTs), facilitate SDM in the clinical setting. PDSTs may likewise predict drug tolerance and efficacy, and therefore adherence and effectiveness on an individual-patient level. There are several important ethical considerations to be navigated when integrating PDSTs into clinical practice. The field requires greater empirical research to demonstrate clinical utility, and the mechanisms thereof, as well as exploration of the ethical use of these technologies.

Background There is a relative paucity of information on both empirical and subjective treatment strategies for treatment-resistant depression (TRD), especially in late life. This paper reviews the findings from two 2016 surveys conducted through the American Psychiatric Association publication the Psychiatric Times and via a member survey by the American Association for Geriatric Psychiatry (AAGP). Methods We present the results of the two surveys in terms of descriptive frequencies and percentages and discuss the strengths and weaknesses of various approaches to late-life TRD. Results The Psychiatric Times survey received 468 responses, and the AAGP survey received 117 responses, giving an overall sample of 585 responses. The majority (76.3%) of respondents from both groups believed that a large randomized study comparing the risks and benefits of augmentation and switching strategies for TRD in patients aged 60 years and older would be helpful, and 80% of clinicians believed their practice would benefit from the findings of such a study. Of the treatment strategies that need evidence of efficacy, the most popular options were augmentation/combination strategies, particularly augmentation with aripiprazole (58.7%), bupropion (55.0%), and lithium (50.9%). Conclusions Late-life TRD constitutes a large proportion of clinical practices, particularly of geriatric psychiatry, with lacking evidence of efficacy of most treatment strategies. These surveys indicate a clear need for a large randomized study that compares risks and benefits of augmentation and switching strategies.

Psychiatrists and other mental health professionals have a unique opportunity to contribute to improved mental health outcomes in Asia.