Psychology & neuroscience of affective disorders PDF - King's College London

Module: Psychology and Neuroscience of Affective Disorders Week 1 Introduction to affective disorders Topic 2 The impact of affective disorders - part 2 of 2 Professor Allan Young Centre for Affective Disorders Lecture transcript Slide...

Module: Psychology and Neuroscience of Affective Disorders Week 1 Introduction to affective disorders Topic 2 The impact of affective disorders - part 2 of 2 Professor Allan Young Centre for Affective Disorders Lecture transcript Slide 2: The question arises, how much depression is bipolar? This is because the major depressive episodes by themselves, do not distinguish between whether they occur in a major depressive disorder category or a bipolar category. The criteria are the same. And in terms of how many people with depression are bipolar, depends on the definition. This was looked at by Angst and colleagues, and this was one of the studies that I was involved in. If you use a narrow definition, such as the old DSM-IV, 16% of depressive episodes are bipolar. If you expand it slightly, to allow something closer to the current DSM-V, you can see that the number of people with depression who are bipolar, is 31%. And if you use a very broad definition, over half of people with depression are bipolar. Now clearly, this is a range of different outcomes. But it’s likely that bipolarity, or the number of people with depressive episodes who are actually bipolar, is under-recognized. Slide 3: It’s also clear that bipolar disorder, unrecognised bipolar disorder, is probably overrepresented in the treatment-resistant depressive group. This is shown very nicely in this study from Taiwan. This was an up to 8-year follow-up of depressed patients in Taiwan, two cohorts, one of almost 1500, and one of almost 2500 patients. When you compared difficult to treat patients, a form of treatment resistance, with treatment responders, 26% of difficult to treat switched to bipolar, or became obviously bipolar, compared to only 6% to 9% of early treatment responders. Therefore, in the treatment resistant depressive group, we should be particularly careful to look for any signs of bipolar disorder. Slide 4: This is work by Professor Lars Kessing from Copenhagen, published in the British Journal of Psychiatry. And this compared optimised treatment versus standard psychiatric follow up for people who had been recently hospitalised for mania. And you can see the group that got the mood disorder clinic did much better in terms of relapse rates than standard care. And indeed, this translated into a 3,100 euro per-head saving, in the mood disorder clinic, despite the fact, that this was a more expensive intervention. It was however, relatively simple. It involved the application of optimised treatment regimes, guided by the British guidelines, and also psychoeducational strategies. So this is a type of optimal care that should be provided for anyone who’s been admitted for mania. Slide 5: However, better treatment of depression is the number one request for patients in recent surveys. That’s shown by this paper from McIntyre. Other things that patients would like to see is, a lessened, or reduced, risk of weight gain, prevention of relapse into depression, improved quality of Transcripts by 3Playmedia Week 1 © King’s College London 1.  life, and so on and so forth. But depression is a great unmet need. And treatment of depression is a great unmet need in bipolar disorder. Slide 6: Now we have, literally, dozens and dozens of trials of antidepressants and other treatments in major depressive disorder, but very few studies in bipolar depression. And the world literature is shown in this graph here. And you can see that most of the results are equivocal. So there’s no clear separation for aripiprazole, there’s a marginal separation for lamotrigine, suggestion of a separation for lithium, the antidepressant paroxetine, which was examined in one of my studies, didn’t clearly separate from placebo. So far, most positive data is for the atypical anti-psychotic, quetiapine or olanzapine, another atypical when combined with the SSRI, fluoxetine. But there’s a huge hole in the evidence base, in terms of trials for treatments, in bipolar depression. Slide 7: Any practical consideration for diagnosis and treatment of mood disorder should go through a number of important areas. Firstly, is this a recurrent mood disorder? This, of course, is impossible to say for the first episode, but it should be borne in mind that a significant number of major depressive disorder cases will not be recurrent. What is the severity? Does it make criteria for a full major depressive disorder? Next, is there evidence of a major depressive episode? Thirdly, is there episode of mania or hypomania? It is noteworthy that mania is very reliable as a diagnosis and a feature of history, and this is why bipolar I, was more reliable in the DSM-5 field trials, than Bipolar II, which was distinguished by hypomania. Hypomania is often normalised and often difficult to find on history. Fourthly, is there a mixed state? 30% of people with mania will have three or more depressive symptoms and the contrary, with manic or hypomanic symptoms being present in depression, is also common. Psychiatric co-morbidity, as described in previous slides, should be assessed. And this is very common, including anxiety disorders, substance misuse, alcohol’s misuse and so on. Physical ill health, people with depression and bipolar disorder die, on average, 15 years younger than the healthy population. This is partly due to the increased risk of suicide, but mostly due to the common physical ill health problems, ischemic heart disease, diabetes, and so on. And it’s very important that the physical ill health needs of people with mood disorders are attended to correctly. The next point is, what is the age of onset? This may give some clue as to the nature of the disorder. For example, bipolar disorder commonly onsets slightly younger than depressive disorders. Family history, treatment history, including the history of treatment response in the family. And lastly, what is the functional and neurocognitive status? This is a very important feature of the disorder and a driver of the psychosocial costs and disabilities. Slide 8: The key requirements for individualised or personalised treatment are shown here. Firstly, any treatment package should rest on an accurate diagnosis, which includes identification of all co- morbidities, both mental and physical. And then, there should be a balance between efficacy or benefits and adverse effects or harms. And this will differ for each individual patient. Some things can move the balance one way or another, with improved social support, psychoeducation, concordance or adherence to treatment and psychological treatments being important. The goal of any treatment approach should be meaningful remission, which means optimal functioning and quality of life. Slide 9: So to conclude, this has been an introduction to affective disorders or mood disorders. These are common, complex, and costly. The two main forms of mood disorder are MDD, or Major Depressive Disorder, also known as unipolar disorder, and bipolar disorders, which is a group of disorders. There is multiple treatment approaches, both psychological treatments, lifestyle changes, neurostimulation, and pharmacotherapy, which have been applied to both. However, treatment resistance and poor outcome is an important problem for both types of mood disorder. Transcripts by 3Playmedia Week 1 © King’s College London 2.