ABSTRACTS - World Psychiatric Association

cologic treatment options are now available to treat BED. These
agents include selective serotonin reuptake inhibitors, the anti-obesity
agent sibutramine, and the anticonvulsant topiramate. This paper
reviews the current clinical evidence for these and other medications
in the treatment of BED.
TL5.
ENVIRONMENTAL CAUSES OF MENTAL DISORDER
M. Rutter
Institute of Psychiatry, London, UK
Half a century ago, there was a general acceptance of the view that
environmental causes of mental disorder were strong and determinative.
That view has been seriously challenged and it has become clear
that the strong and deterministic notion of environmental causation
was extremely misleading. Nevertheless, powerful research strategies
have demonstrated the reality and importance of environmental causation.
This paper reviews the challenges and how they have been
met; summarises the ways in which the early views have had to be
modified; and indicates the current state of the art and the challenges
that remain. Six issues constitute the main focus: a) the identification
of key elements of risk, together with the appreciation that the casual
effects may be prenatal as well as postnatal, and include both physical
and psychosocial hazards; b) the recognition that with multifactorial
disorders there cannot be any single “basic” cause; rather the
need is to identify key individual causal components and the direct
and indirect pathways involved in the causal process; c) the reality of
reverse causation, as exemplified by child effects on parenting; d) the
need to consider possible genetic mediation of risks associated with
specific environments; e) the role of “natural experiments” in testing
causal inferences; f) the heterogeneity of response to environmental
risk, the reality of resilience and the importance of the effects of environments
on biology and the need to consider how “environments get
under the skin”.
TL6.
THE CAUSES OF SCHIZOPHRENIA: THE STRIATUM
AND THE STREET
R.M. Murray
Institute of Psychiatry, London, UK
Much evidence suggests that the final common pathway to at least the
positive symptoms of schizophrenia is dopamine dysregulation in the
striatum. It is clear that an individual can develop this dysregulation
consequent upon a number of different aetiological factors. Firstly, we
have known for many years that inheritance contributes, and the evidence
from the plethora of molecular studies over the last 6 years suggests
that in most cases this operates through the interaction of a number
of genes of small effect. However, in a small proportion of cases, a
copy number variation may play a major role possibly through impairing
neurodevelopment. Certainly, some pre-schizophrenic children
have cognitive and neuromotor impairments, and at first presentation,
many individuals with schizophrenia have obvious brain structural
and neuropsychological abnormalities. Furthermore, the risk-increasing
effect of obstetric complications has been demonstrated for schizophrenia,
and these are known to be associated with both structural
brain and cognitive abnormalities and with dopamine dysregulation.
Thus, a second aetiological pathway implicates deviant neurodevelopment.
The excessive use of stimulant drugs and cannabis also
increases risk of schizophrenia, and once again this appears to be via
their effect on striatal dopamine. Finally, there is increasing evidence
implicating exposure to a number of social factors, including migration,
urbanisation, and possibly childhood maltreatment. Of course,
in many patients, more than one of these risk pathways is involved,
and a combination of genetic, developmental and social factors project
the individual over the threshold into illness.
TL7.
LONG-TERM MANAGEMENT OF DEPRESSION:
THE ROLE OF PHARMACOTHERAPY
AND PSYCHOTHERAPIES
M.E. Thase
University of Pennsylvania School of Medicine and Philadelphia
Veterans Affairs Medical Center, Philadelphia, PA, USA
This paper deals with the treatment of recurrent major depressive disorder,
focusing on strategies for prevention. There is broad consensus
in practice guidelines that virtually all patients who respond to antidepressant
medications should receive a 6 to 9 month course of continuation
phase therapy to reduce the risk of relapse and that patients
who have experienced three or more lifetime depressive episodes
should receive a longer course of maintenance phase therapy to prevent
recurrent illness. For those who do not obtain a full remission
during acute phase therapy, there is increasing evidence that simply
continuing the incompletely effective strategy is not sufficient to offset
the risk of relapse. With respect to maintenance phase therapy,
there are surprisingly few studies of truly long-term courses of pharmacotherapy
(i.e., across 2 or more years). It does appear that all
medications with established short-term efficacy are also significantly
more effective than placebo for prevention of relapse or recurrence.
There is also evidence that various forms of cognitive behavior therapy
(CBT) have some degree of enduring prophylactic efficacy and
may reduce the risk of recurrent illness following withdrawal of antidepressant
medications. Although studies of interpersonal psychotherapy
(IPT) have yielded mixed results, the value for ongoing
monthly sessions of IPT – in lieu of pharmacotherapy – has been
shown in studies of adults under the age of 70, particularly when therapeutic
focus is maintained on key areas of interpersonal vulnerability.
Areas of controversy are also discussed, including questions pertaining
to tachyphylaxis and whether or not the benefit-risk profile of
longer-term antidepressant therapy has been exaggerated.
TL8.
WHAT IS A MOOD STABILIZER
P.E. Keck, Jr.
Lindner Center of HOPE and University of Cincinnati College
of Medicine, Cincinnati, OH, USA
The term “mood stabilizer” first entered the scientific lexicon in 1960,
and did not refer to lithium, but rather to an obscure first generation
antipsychotic agent then in development. This may have been prescient,
however, as pharmacologic agents from different classes and
different therapeutic designations have increasingly come to be
described as mood stabilizers. Mood stabilizers have, in turn, been
conceptualized as treatments for bipolar disorder, although the
course of major depressive disorder for many patients suggests that
this latter illness could benefit from mood stabilizing concepts as
well. This paper considers the question of what a mood stabilizer is in
the context of definitions formulated by investigators in the field of
bipolar disorder, and in the light of evidence from randomized, con-
2 World Psychiatry 8:S1 - February 2009