ABSTRACTS - World Psychiatric Association

trolled trials of treatments for the three acute mood episodes of bipolar
disorder – mania, mixed states, and depression – and the prevention
of symptomatic and syndromic relapses and recurrences of these
mood states.
TL9.
MEDICAL BURDEN IN BIPOLAR DISORDER
D.J. Kupfer
Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
From a world public health perspective, bipolar disorder is one of
the ten most disabling conditions. In the last decade, several important
issues have emerged: a) The increasing awareness that bipolar
disorder is associated with a medical burden from both concurrent
medical disease and the adverse potential effect of the treatments
used for bipolar disorder; routine medical screening needs to be
implemented. b) The ongoing lack of complete recovery and full
restorative and functioning is associated with increased medical and
psychiatric comorbidity; the regular use of psychosocial approaches
is needed. c) The presence of risk factors including obesity, nicotine,
and drug use accelerate an overall increase in morbidity and mortality.
d) New comprehensive and integrated psychiatric/medical treatment
approaches are needed. These recommendations are supported
by data demonstrating that the increased medical comorbidity leads
to slower treatment response of bipolar episode, especially depression,
as well as earlier recurrence. The presence of the metabolic syndrome
necessitates an integrated care model for bipolar disorder
which seeks to positively influence modifiable medical risk factors,
medical and psychiatric diseases, as well as to improve sleep/wake
and social rhythms, and overall functioning. These customized treatment
strategies include monitoring medical disease outcomes and
medical risk factors. The following research and clinical questions
emerge from current studies. How do we prevent acute illness from
becoming chronic Can early intervention prevent “comorbid accumulation”
And finally, how can we identify subgroups with circadian
fragility or vulnerability as well as subgroups most “prone” to
develop high metabolic risk profiles
TL10.
GETTING THE EVIDENCE FOR EVIDENCE BASED
CARE OF DEPRESSION: HOW TO NARROW
THE KNOWLEDGE GAP
A.J. Rush
Department of Psychiatry, University of Texas Southwestern
Medical Center, Dallas, TX, USA
Clinicians and their depressed patients make treatment decisions
everyday, which rest on the answers to critical clinical questions based
more on “best guesses” than on empirical evidence in many instances.
For example, how long should a patient be treated to determine that
remission will not occur Which clinical features, if any, recommend
one treatment over another Yet, answers to these critical questions
profoundly affect both how treatment is delivered and its outcomes.
This paper highlights and prioritizes these clinical questions and the
available evidence to address them. The limitations both in what we
know now and in how we gather evidence to answer better these
questions in the future are discussed. Changes in how we report
research results to better inform clinicians are also suggested. In addition,
suggestions to revise our current practice procedures in order to
get more valid answers to these questions in more rapid and effective
ways are provided. The potential value of widely implementing measurement-based
care, a uniform outcome recording system, and in
establishing simple patient registries to address several of these issues
is discussed. Finally, new clinically useful and “patient friendly” study
designs illustrate potential ways to gather the evidence that we so desperately
need to put valid evidence into evidence-based care.
UPDATE LECTURES
UL1.
HOW DO WE CHOOSE MEDICATIONS
FOR PSYCHIATRIC PATIENTS
R.J. Baldessarini
Harvard Medical School and McLean Hospital, Belmont,
MA, USA
Most psychotropic drugs are palliative and not highly selective for
particular disorders: “antipsychotics” are excellent antimanics, most
“antidepressants” could as well been labeled “anxiolytics”, and drugs
for epilepsy are used for mood disorders. Most are selected by a mix
of addressing syndromes and symptoms. Research findings have a
limited impact on practice. Current clinical research is highly industrial,
oriented more toward licensing and marketing than questions of
interest to clinicians and patients, and innovation plus marketing
strongly influence drug choice. Clinical consideration of specific
treatments typically focuses first on what is relatively simple to use
and acceptable to patients: a need for regular medical monitoring or
blood tests is a potent disincentive, given simpler or safer options. As
examples, tricyclic antidepressants were displaced by the easier-touse,
but not more effective, selective serotonin reuptake inhibitors;
lithium nearly disappeared in the US as seemingly simpler, safer anticonvulsants
and antipsychotics became available, and easily-used
valproate displaced lithium even without long-term research support
or regulatory approval for prophylaxis. Regional and national differences
in drug choices suggest effects of culture or training, including
marketing influences of “thought leadership”, and even fads. Confusion
also is generated by plastic, market-oriented terms such as
“major depression”, “antidepressant”, and mood stabilizer. Notably,
depressive features of bipolar disorder are commonly conflated with
unipolar major depressive disorder, even though the syndromes are
very different and require dissimilar treatments, although they are
very commonly treated with “antidepressants”.
UL2.
PSYCHOTHERAPIES: WHAT WORKS FOR WHOM
P. Fonagy
University College London, London, UK
Sixty years of research have established psychological therapies as an
effective part of our therapeutic armamentarium of psychiatry in
work with most mental disorders. This paper reviews the indications
for specific types of psychological therapy for all common mental disorders
including the psychoses, non-psychotic disorders and Axis II
disorders. There is also an accumulating body of evidence that suggests
psychological interventions in the context of prevention of mental
disorder. However, while there appears to be no shortage of potentially
effective interventions, we are not much closer to being able to
answer the question: “What is most likely to work for whom” in
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