ABSTRACTS - World Psychiatric Association

US20.
VIOLENCE, TRAUMA AND VICTIMIZATION
US20.1.
THE CUMULATIVE LONG-TERM EFFECTS
OF EXPOSURE TO TRAUMATIC EVENTS: THE COST
AND CHALLENGE FOR TREATMENT SERVICES
A.C. McFarlane
University of Adelaide Node, Centre of Military and Veterans
Health, Adelaide, Australia
Increasingly evidence suggests that there is a lifetime cumulative risk
for psychiatric disorders following exposure to repeated traumatic
events. Previously, the focus on post-traumatic stress disorder (PTSD)
has led to an underestimation of the public health significance of
traumatic stress, because the role of these events in the onset of other
disorders such as major depression and substance abuse has been
underappreciated. Epidemiological and long-term cohort studies are
providing valuable insights into how individuals become progressively
sensitized to adverse health outcomes following trauma exposure.
These findings have major implications for understanding the underlying
neurobiological mechanisms that contribute to symptom formation.
The progressive disruption of the homeostatic mechanisms controlling
arousal appears to be a central aetiological process. Furthermore,
it appears that traumatic memories are far more common than
full-blown psychiatric syndrome is following exposure to these events
and represent an important marker of risk. These findings have practical
significance for a number of areas, particularly in the military
and emergency services, highlighting the need to monitor populations
and manage their cumulative stress exposure. To date, the treatment
literature for PTSD has focused on single incident traumas and has
demonstrated the effectiveness of both psychological and pharmacological
interventions. However, the major challenge, which needs to
be confronted in clinical practice, is how to optimally treat individuals
who have a chronic disorder arising from repeated trauma exposure.
In particular, there is a frequent comorbidity of physical disorders,
such as irritable bowel syndrome, fibromyalgia and musculoskeletal
pain, which need to be addressed simultaneously with the
related psychological disorders.
US20.2.
PREVENTION OF POST-TRAUMATIC STRESS
DISORDER BY EARLY TREATMENT
A.Y. Shalev
Department of Psychiatry, Hadassah University Hospital,
Jerusalem, Israel
The effectiveness of early interventions is limited by the accuracy of
case identification, barriers to using mental health services and treatment
efficacy. Several early interventions for post-traumatic stress
disorder (PTSD) have been evaluated. Some have failed altogether
(e.g., debriefing, minor tranquilizers). Others were efficient in small
samples (trauma-focused cognitive behavioral therapy, CBT), and
others (theory-driven pharmacological preventions) are in an experimental
stage. The effectiveness of early interventions for PTSD has
not been studied. The Jerusalem Trauma Outreach and Prevention
Study (J-TOPS) evaluated the accuracy of case identification, the
desirability of early clinical contacts and the relative efficacy of cognitive
behavioral and pharmacological interventions in a comprehensive
sample of 5470 adult survivors of traumatic events. More than
half of those at high risk for developing PTSD declined an offer of
assessment and treatment. Clinical assessment within a month after
the traumatic event optimally identified survivors at risk. CBT with or
without exposure effectively reduced the prevalence of PTSD among
survivors. The effect of a selective serotonin reuptake inhibitor, escitalopram,
did not differ from that of placebo. Early and delayed CBT
had similar long-term effects. Survivors with partial PTSD recovered
as well with or without treatment. Declining early assessment and
treatment were associated with smaller reduction in PTSD symptoms.
Barriers to accepting early interventions should be addressed in
future planning of preventive strategies.
US20.3.
ACCESS TO CARE IN POST-TRAUMATIC STRESS
DISORDER
R.C. Kessler
Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA
We present data on patterns, self-reported reasons for, and sociodemographic
correlates of unmet need for treatment of post-traumatic
stress disorder in the wake of Hurricane Katrina. The data come
from an epidemiological survey carried out in the representative general
population sample of nearly 3000 people who lived in the areas
affected by Katrina in Alabama, Louisiana, and Mississippi in the
United States and who participated in the Hurricane Katrina Community
Advisory Group. The data show that, although structural barriers
were major determinants of unmet need for treatment shortly
after the hurricane, psychological barriers became increasingly
important as objective access to care increased over time. We discuss
innovative strategies needed to document the magnitude of unmet
need for treatment, modifiable determinants of this unmet need, and
the success of intervention efforts to address unmet need in future
disaster situations.
US21.
THE CHALLENGE OF BIPOLAR DEPRESSION
US21.1.
ADVANCES IN THE SHORT-TERM MANAGEMENT
OF BIPOLAR DEPRESSION
J. Calabrese
Case Western Reserve University School of Medicine, Cleveland,
OH, USA
It is now widely recognized that patients with bipolar disorder spend
the majority of their symptomatic lives in the depressed phase of the
illness. Despite the absence of an evidence base, antidepressant
monotherapy continues to be the most commonly prescribed initial
treatment for bipolar disorder. Used this way, the traditional antidepressants
carry a marked risk of inducing mania. Lamotrigine delays
time to re-emergence of mood episodes, but only 2 of 6 studies support
its acute efficacy. Pilot data support the use of divalproex in mood
stabilizer naïve patients with bipolar depression. Like the anticonvulsants,
the atypical antipsychotics were initially studied in mania, but
what separates members of this class is efficacy in bipolar depression.
Olanzapine-fluoxetine combination and, to a lesser extent, olanzapine
have been shown to effectively reduce depressive symptoms. Two
studies of aripiprazole monotherapy failed to show acute efficacy in
bipolar I depression. The results from four acute 8-week bipolar I or II
depression studies (BOLDER I and II, EMBOLDEN I and II) support
the use of quetiapine monotherapy in type I and II presentations,
rapid cycling and non-rapid cycling, anxious and non-anxious pre-
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