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Letters to the Editor

Searching For Serendipity

See the reply

Searching For Serendipity

To the Editor: I read with interest the recent excellent article by Andrew C. Leon concerning the evolution of the field of clinical psychopharmacology.1 Quite understandably, this article recognizes the contribution of serendipity in the discovery of our present classes of psychiatric medications and laments the observation that we have not been continuing to discover truly novel "blockbuster" interventions and/or new mechanisms of action in more recent decades.

Part of this lack of finding additional agents through serendipity may have to do with the most powerful, or most broadly useful, agents’ naturally being prone to being discovered first, and we may simply be in the situation of having already harvested the "low-hanging fruit." But another factor may be modern restrictions concerning venues in which we are permitted to search. Not just psychopharmacology but, Dr Leon observes, the field of ethics has also evolved since the 1940s and 1950s. Quite appropriately, it is no longer permissible to test new drugs on the back wards of psychiatric facilities (or in prisons either, for that matter), with little or no requirement for truly informed consent or freedom from coercive circumstances. These facilities had provided exquisite venues for serendipity—where agents being tested for safety in relationship to various medical conditions had the chance to be discovered, by accident, to be of value in the treatment of identifiable psychiatric disorders. In our more modern age, of course, engaging in such investigations at such venues would be entirely improper.

Are there any places remaining where broad-ranging serendipity in psychiatric medication finding may still be available? At least one such place does present itself—and the information-sharing capabilities of computerized medical records may make this a more feasible locale than it might have been in the past. This place is our own outpatient psychiatric clinics. Much recent attention has been given (with good reason) to the extent and variety of medical illnesses occurring in psychiatric populations and their attendant need for treatment.2,3 As these medical illnesses are appropriately addressed, myriads of people with psychiatric conditions are exposed to a wide array of "medical" agents (some of them old and some of them new). In the setting of this vast "experiment of nature," serendipity invites us to maintain a sharp lookout for "outlier" patients who experience sudden, unexpected, and dramatically positive changes in their global psychiatric conditions in the context of a recently initiated "medical" treatment. Isolated highly favorable cases could trigger searches for other patients in similar circumstances, creating case series and the possibility of identifying relevant patterns.

It is just possible that such careful and targeted surveillance could, with serendipity, lead to the identification of a new generation of "low-hanging psychopharmacologic fruit," expanding our vision and enriching our clinical and investigative opportunities.

References

1. Leon AC. Evolution of psychopharmacology trial design and analysis: six decades in the making. J Clin Psychiatry. 2011;72(3):331-340. PubMed doi:10.4088/JCP.10r06669

2. Kane JM. Creating a health care team to manage chronic medical illnesses in patients with severe mental illness: the public policy perspective. J Clin Psychiatry. 2009;70(suppl 3):37-42. PubMed doi:10.4088/JCP.7075su1c.06

3. Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry. 2008;69(4):514-519. PubMed doi:10.4088/JCP.v69n0401

Samuel G. Siris, MD

ssiris@nshs.edu

Author affiliation: The Zucker Hillside Hospital, Aftercare Clinic, Glen Oaks, New York. Potential conflicts of interest: None reported. Funding/support: None reported.

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