ABSTRACTS - World Psychiatric Association

ESI SM TOP-CITED SCIENTIST LECTURES
TL1.
THE TREATMENT GAP IN PSYCHIATRY
R.C. Kessler
Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA
Data are presented on patterns, self-reported reasons for, and sociodemographic
correlates of unmet need for treatment of mental disorders
in 23 countries around the world. The data come from general
population surveys carried out as part of the World Health Organization’s
World Mental Health (WMH) Survey Initiative. Results show
that a high proportion of people with DSM-IV mental disorders in all
countries’ surveys fail to receive any form of professional treatment
for their mental disorders. The data also show that many patients
receive treatments that fail to meet even the most minimal acceptable
standards of treatment quality. Unmet need for treatment is lower for
more severely impairing than less severe cases, but is quite high even
in more severe cases. Reason analysis shows that lack of perceived
need, predisposing factors, and enabling factors all play separate roles
in accounting for this treatment gap. Important insights into the
causal processes that lead to associations between socio-demographic
sources of health care disparities and unmet need for treatment
emerge by including these factors in the reason analysis.
TL2.
PSYCHIATRIC GENETICS: A CURRENT
PERSPECTIVE
K. Kendler
Virginia Institute of Psychiatric and Behavioral Genetics,
Medical College of Virginia/Virginia Commonwealth University,
Richmond, VA, USA
This paper will first review the four major paradigms currently active
in psychiatric genetics: simple genetic epidemiology, advanced genetic
epidemiology, gene-finding methods and molecular genetics. It will
then review selectively advances in each of these areas, trying to illustrate
the methodological strengths and limitations of each approach.
In the area of advanced genetic epidemiology, we will review examples
of genetic models of development, sex-modification of genetic
effects, gene by environment interaction, and gene by environmental
correlation. In the section on gene finding methods, we will review
candidate gene association and linkage but focus on gene-wide association
methods. We will provide an up to the minute assessment of
progress in this very rapidly moving area. We will also briefly touch on
genomic approaches, especially copy number variants and the challenges
posed by allelic heterogeneity and the rare variant common
disease model for psychiatric disorders.
TL3.
BIPOLARITY: A BROAD SPECTRUM (SPECTRA)
IN SEARCH OF TREATMENT
H.S. Akiskal
University of California at San Diego, La Jolla, CA, USA
“Bipolar spectrum” first appeared in the psychiatric literature in a
1977 paper on a prospective follow-up of cyclothymic individuals:
most developed depression or bipolar II, fewer developed full blown
manic-depressive illness and, significantly, nearly half the sample
treated with antidepressants developed increased cycling. Much of
the evidence for this broadened bipolar concept has come during the
past few years. Subthreshold bipolar conditions have been identified
in the community and several epidemiological studies, in both
Europe and the United States, showing an average population prevalence
of 5%. Prospective follow-up has shown progression of subthreshold
bipolarity to full-blown bipolar disorders. There has been
great momentum in the clinical literature to study the various forms of
the bipolar spectrum, which, in addition to the well-known types I
and II in the DSM-IV and ICD-10 terminology, include depressions
with shorter hypomanias, hypomanias elicited by antidepressant
treatment, depressions arising from various bipolar temperaments
such as the cyclothymic and the hyperthymic, as well as depressions
with intra-episode hypomania (depressive mixed state). Despite criticism
from some quarters, bipolar validation has been achieved for
most of these forms in rigorously conducted studies coming from various
clinics in the world, particularly the United States, Italy, Germany,
Switzerland and Hungary, as well as two national studies from
Poland and France. Other proposed bipolar concepts refer to issues
that have to do with “unipolar” depressions with high recurrence,
atypical depression, seasonality, early age at onset, depressive and
dysthymic states with bipolar family history, and affective states
occurring in the setting of multiple anxiety disorders, as well as those
in the post-partum period. In addition, controversial proposals have
been made to hypothesize that borderline personality disorder, dissociate
states, polysubstance abuse, particularly cocaine and stimulant
abuse, might be related to the bipolar spectrum. Other “candidates”
for the bipolar spectrum include affective comorbidity with migraine,
eating disorders, gambling and a variety of impulse-control disorders.
This is a large terrain and beyond the conventional literature, but of
major significance for public health, clinical psychiatry, psychiatric
theory and research methodology, including genetics. Thus, the field
has progressed to the point of proposing some “soft” bipolar conditions
as behavioral endophenotypes for bipolar disorder, for which
genetic loci have been proposed in preliminary studies. While uncritical
acceptance of such a broad spectrum (or spectra) is not justified,
criticisms of the bipolar spectrum without adequate familiarity of the
entire literature are equally unwarranted. Much of what has driven
treatment in practice has involved applying what works for the hard
spectrum to the soft spectrum and beyond. Such therapeutic application,
currently largely the domain of clinical judgment, should move
to rigorous therapeutic trials in the service of public health, as it is
happening in such fields as diabetes and hypertension. Primary and
secondary prevention, including that of suicidal behavior, is an eloquent
driving force to address the spectrum of therapeutic challenges
in psychiatry in this broad domain – challenges which are no less in
magnitude than those in medicine at large.
TL4.
PHARMACOTHERAPY OF BINGE EATING
DISORDER
S.L. McElroy
Lindner Center of HOPE, Mason, OH; University of Cincinnati
College of Medicine, Cincinnati, OH, USA
Binge eating disorder (BED) is the most common eating disorder.
Patients with BED engage in frequent, recurrent episodes of binge
eating without the compensatory weight-loss behaviors of bulimia
nervosa or anorexia nervosa. Many of these patients suffer from mood
symptoms or disorders and/or obesity. A growing number of pharma-
1