ABSTRACTS - World Psychiatric Association

UL13.
COMBINED AND SEQUENTIAL TREATMENT
STRATEGIES IN DEPRESSION
AND ANXIETY DISORDERS
G.A. Fava
Affective Disorders Program, Department of Psychology,
University of Bologna, Italy
There is increasing awareness that monotherapy (whether pharmacotherapy
or psychotherapy) is unlikely to yield full remission in
mood and anxiety disorders. The joint use of psychotherapeutic and
pharmacological strategies has produced limited benefits when the
two treatments have been administered simultaneously. More promising
results have been obtained with their sequential combination,
particularly when psychotherapeutic approaches have followed the
administration of pharmacotherapy. In unipolar depression, there is
substantial evidence that decreasing residual symptoms and/or
increasing psychological well-being and coping skills in remitted
patients may decrease relapse rate during follow-up up to 6 years. The
sequential strategy does not fall within the realm of maintenance
treatments. It is an intensive, 2-stage approach, which is based on the
fact that addressing one dimension of illness after an earlier feature
has improved can increase the likelihood of more complete and lasting
remission. The planning of treatment in mood and anxiety disorders
requires determination of the first line approach (e.g., pharmacotherapy)
and tentative identification of other areas of concern to be
addressed by concomitant or subsequent treatment.
UL14.
MULTIMODAL MANAGEMENT OF ANOREXIA
AND BULIMIA NERVOSA
K.A. Halmi
Weill Medical College, Cornell University, New York, NY, USA
The allostatic model is useful to conceptualize the development of the
multimodal management of anorexia and bulimia nervosa. Allostasis
is a dysregulation of brain reward circuits in response to the failure of
homeostasis, a self-regulating process for multi system coordination
of an organism’s response to an acute challenge, starvation in anorexia
nervosa (AN) and binge/purge behavior in bulimia nervosa (BN).
The state of allostasis reflects both genetic and environmental factors
and the allostatic load represents the presence of excessive demand
on regulatory systems. Multiple brain mechanisms could contribute
to produce the allostatic state that underlies the severe psychopathology
in anorexia and bulimia nervosa. Evidence exists for biological
vulnerabilities and genetic factors leading to an allostatic state in
these disorders. Dysfunction of neurotransmitters (serotonin,
dopamine and norepinephrine) regulating eating behavior are present,
as well as aberrations of neuropeptides (NYP, opioids, leptin,
CCK, ghreline, melanocortins, adiponectin, agouti-related protein
and BDNF) which affect eating. Genetic studies show significant
linkage on chromosome 1 for restricting AN and on chromosome 10
for BN. The key multimodal elements in the treatment of AN and BN
are commensurate with the allostatic model. Medical management
requires weight restoration with nutritional rehabilitation, rehydration
and correction of serum electrolytes. The core eating disorder
psychopathology requires specific cognitive-behavioral therapy. Adolescents
with eating disorders require family therapy. Comorbidities
and severe impairment of function require pharmacotherapy. Few
randomized controlled treatment trials exist to provide guidelines for
treatment of AN. In the past 5 years, additional family therapy studies
and an olanzapine-placebo controlled trial have provided evidence
for treatment of AN. In a recent trial, adolescents with BN were effectively
treated with family therapy. Innovative treatments are especially
needed for adults with chronic AN. Attention must be focused on
resistance to treatment and extremely high dropout rates.
UPDATE SYMPOSIA
US1.
THE EVOLVING SCIENCE AND PRACTICE
OF PSYCHOSOCIAL REHABILITATION
US1.1.
DEVELOPMENTS IN PSYCHOSOCIAL
REHABILITATION: INNOVATION OR RE-INVENTION
R. Warner
Department of Psychiatry, University of Colorado Health Sciences
Center, Denver, CO, USA
Since the Second World War, we have seen tremendous changes in
psychosocial rehabilitation methods. The development of the therapeutic
community, dramatic reforms in hospital care and early discharge
to the community have led to the dissolution of large psychiatric
institutions across the developed world. The psychosocial clubhouse
has proven useful in tackling the powerlessness, boredom and
social exclusion that many people with mental illness experience when
they achieve a stable existence in the community. Supported employment
and social firms have helped address the problem of unemployment.
Cognitive behavioral therapy seeks to decrease the discomfort
created by persistent psychotic symptoms, and cognitive remediation
aims to reduce the handicap caused by the cognitive symptoms of psychosis.
Which of these developments are truly an innovation and
which are a reformulation of an earlier approach What social, political
and economic factors drive the emergence of new rehabilitation
methods What are the next barriers we must confront
US1.2.
VOCATIONAL REHABILITATION IN EUROPE:
LESSONS FROM THE EQOLISE TRIAL
T. Burns
University of Oxford, UK
The severely mentally ill invariably have low rates of employment
despite extensive rehabilitation efforts. Recently there has been a shift
in vocational rehabilitation in mental health, away from the more traditional
structured rehabilitation programmes (often referred to as
“train-and-place”) to more direct “place and train” approaches. The
most widely researched of these approaches is independent placement
and support (IPS) and several US randomized controlled trials
have demonstrated very significant advantages over high-quality traditional
rehabilitation measured as obtaining open employment.
However, we have learnt from bitter experience that complex community
interventions do not always work as well when translated to
different social contexts, and the European employment situation is
very different to that in the US. We conducted a multisite trial of IPS
in Europe. The trial involved a random allocation of 302 psychotic
subjects, 50 from within each of six European countries, to either IPS
or local standard vocational rehabilitation. Subjects were followed up
for 18 months by independent researchers. Primary outcome was
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