OBJECTIVE:To write clinical guidelines for the use of psychotropic drugs during pregnancy and breast-feeding for daily practice in psychiatry, obstetrics and paediatrics.METHOD:As we wanted a guideline with a high degree of consensus among health professionals treating pregnant women with a psychiatric disease, we asked the Danish Psychiatric Society, the Danish Society of Obstetrics and Gynecology, the Danish Paediatric Society and the Danish Society of Clinical Pharmacology to appoint members for the working group. A comprehensive review of the literature was hereafter conducted.RESULTS:Sertraline and citalopram are first-line treatment among selective serotonin reuptake inhibitor for depression. It is recommended to use lithium for bipolar disorders if an overall assessment finds an indication for mood-stabilizing treatment during pregnancy. Lamotrigine can be used. Valproate and carbamazepin are contraindicated. Olanzapine, risperidone, quetiapine and clozapine can be used for bipolar disorders and schizophrenia.CONCLUSION:It is important that health professionals treating fertile women with a psychiatric disease discuss whether psychotropic drugs are needed during pregnancy and how it has to be administered.
Because bipolar disorder was thought to occur in discrete episodes, it was generally considered reasonable to discharge patients into the care of their general practitioner (GP) ‘between’ episodes. However, it has become apparent that a considerable degree (up to 90% in a given year) of ongoing disability and residual symptoms are present between episodes 1. Patients with bipolar disorder may change symptom status an average of six times a year and polarity more than three times annually 2. Therefore, brief contact with services only during the symptomatic phase is not optimal, and relapse prevention through psychoeducation, family work or cognitive behavioural therapy (CBT) may best be done in a dedicated service 3. The development of bipolar clinics in the UK has been slow, in part because government statements of priority for mental-health services, such as the National Service Framework (NSF) 4, did not address treatment provisions for bipolar disorder. The most recent update of the NSF 5 only addressed the National Institute for Health and Clinical Excellence (NICE) review of medications for bipolar disorder, underscoring the impetus given to rethinking bipolar service provision after the recent development and approval of several new medications. Psychiatric care for patients with bipolar disorder has typically involved out-patient appointments with a psychiatrist and long-term medication, with increased support or admission to hospital at times of relapse. In recent years, there have been changes in both the role of the psychiatrist 6 and organisation of psychiatric services aiming to reduce out-patient load and workload of consultants by favouring the transfer of patients back to primary care. Unfortunately, primary- and secondary-care services are often not equipped to treat patients with mood disorders, who require long-term care and complex medication regimens. The ideal setting to treat patients at all stages of their illness is in specialised units that operate within an existing trust and are composed of trained clinicians who understand the natural course of the disease. Typically, up to 70% of patients referred to bipolar clinics with a diagnosis of treatment-resistant unipolar major depression have been misdiagnosed and are in fact bipolar 7. The advantage of dedicated bipolar clinics compared with traditional models of care is the provision of correct diagnoses within a clinical setting along with the prescription of appropriate medication through improved knowledge of available and emerging treatment options; promotion of a longer duration of stability, through awareness of early warning signs and rapid response to early signs of relapse, as well as improved patient knowledge; adherence to a care plan; improved patient skills for managing illness; maintenance of cognitive functions; and implementation of a proven 21-week expert bipolar psychoeducation group 8. Altogether, these benefits contribute to improved treatment outcomes and inadvertently minimise the numerous risk factors that could potentially lead to suicide 1. In maximising treatment outcomes for the patient, it is vital to ensure continuous support from the clinical staff, including training to identify recurring symptoms, strategies to self-monitor illness progression (i.e. with the help of a diary, mood or life chart) 9 and the availability of emergency contact numbers to ensure a partnership that works towards a mutually agreed treatment regimen. A well-established and trusting doctor–patient alliance in bipolar disorder may be an important predictive factor in determining treatment adherence. Patient perception of a clinician's support of their autonomy has also been shown to positively influence adherence, and patient satisfaction with their service provider has been shown to predict a better attitude towards their illness. Together with joint decision-making on treatment, the consistency of meeting with a dedicated clinician should help patients to engage with their therapy and view it as a long-term and collaborative commitment 10. The role of bipolar clinics may help reduce the risk of ongoing functional impairment in all domains of life including work, relationships, physical health and substance misuse, lack of which are associated with a prolonged lack of continuous specialist care. Only half of patients with bipolar disorder are able to report early warning signs or prodromes 11; therefore, therapeutic interventions and psychoeducation for patients with bipolar disorder can only be approached outside of acute episodes when the patient is able to gain insight into their illness and learn about therapeutic opportunities and treatment options. Bipolar clinics provide a controlled and experienced environment wherein patients and caregivers can be educated about bipolar disorder to gain insight into the illness. In addition, bipolar clinics can improve society's understanding of bipolar disorder and contribute to finding opportunities for patient reintegration into society, to strive for an independent lifestyle. Moreover, a continued clinic–patient relationship can help patients with bipolar disorder overcome barriers they might encounter when returning to work 12. Therapeutic strategies that optimise community-based management and prevent recurrence and hospitalisation have been shown to reduce the economic burden of illness and improve patient quality of life 13. Psychoeducation is a cost-effective intervention for patients with bipolar disorder compared with standard care that results in a reduction in secondary-care costs, such as hospitalisation, and that has been incorporated successfully into the regular operations of many bipolar clinics throughout Europe. Psychoeducation in combination with pharmacotherapy aids patients in maintaining a controlled lifestyle, allowing them to contribute to society by maintaining their employment status between episodes, which has been shown to improve treatment outcomes and patient morale 14. The set-up of a bipolar clinic requires a number of considerations, outlined in Fig. 1, before going into operation. The first consideration is whether the clinic will be established as a separate entity from existing National Health Service (NHS) services with independent sponsorship, a dedicated group of healthcare professionals including psychiatrists, nurses, psychologists and pharmacists; or as an integrated service within existing NHS services. Second, the role of the clinic must be established beforehand (i.e. early diagnosis, relapse prevention programmes, medical education, medical therapy or disorder management), as it will dictate the degree of specialist care required to provide adequate care for patients with bipolar disorder. The clinic could also provide additional specialist services, such as crisis teams, alcohol and substance abuse treatment, and physical health monitoring, which are common issues in patients with bipolar disorder. A further aspect to consider is the appropriate patient referral scheme (i.e. intake from primary vs. secondary care), which will determine who is responsible for initial patient assessments and how patient discharge planning and follow-up are going to be conducted. Once the role of a bipolar clinic is established, a number of key organisational issues, such as required staff levels, operation of the bipolar clinic in parallel to existing services and patient availability, must be considered. Critical decisions include whether the clinic assumes an advisory role only, with generic services remaining responsible for the case management, or whether the clinic takes over case management 24 h a day, 7 days a week vs. a 9–5-week day setting, supported by out-of-hours services. In addition, some fundamental parameters need to be guaranteed to ensure patient benefit and mental-healthcare professional satisfaction. Regular training is essential to all staff involved in a bipolar clinic. In particular, consultants unfamiliar with the concepts of psychoeducation may require preparation to ensure optimal delivery of psychoeducation in addition to standard care. A clear understanding of roles and responsibilities within a bipolar clinical team, and between a clinic and existing services, is essential to offset preconceptions that bipolar clinics increase staff workload instead of decreasing it. Potential problems regarding clinic staff workload, stress levels and patient treatment continuity can be managed through nurse-led teams, onsite medical cover and community team members as front-line staff that includes social workers and bipolar disorder specialists as part of the initial diagnosis and assessment team. One important challenge for bipolar clinics is the reintegration of patients into non-bipolar clinic services after psychoeducation. Consultants not involved in the running of a bipolar clinic may see them as a competitor service and could be less likely to take on patients released from a bipolar clinic. A goal of psychoeducation is to inform the patient on a variety of topics regarding bipolar disorder ranging from symptom awareness to medication, thus providing a basis for the patient to be actively involved in the decision-making process regarding treatment and available care programmes. However, with patients with bipolar disorder, it can be difficult to judge whether they are ready to take on those responsibilities, and it might be difficult for a consultant to accept that the patient wants to influence their treatment plan and has the knowledge and insight to do so. The typical NHS bipolar clinic should be modelled after the Barcelona Bipolar Clinic 15. Services should be provided during a day-long session, once per week with additional sessions and evening group psychoeducation on alternative days. The main objectives of bipolar clinics, as stipulated in the Barcelona model, are outlined in Table 1. In addition to risk factors and early warning signs, bipolar clinics should emphasise the need for regular physical health screening 16 associated with both bipolar disorder and its pharmacological management 17. Bipolar clinics should aim for an open and honest relationship between clinic users and staff, giving realistic but accessible expectations of access and encourage patients to provide feedback on their experience with the clinic's services, including location, timing, and accessibility for public transport and parking. The clinic's objectives should involve users in treatment planning: in the case of group psychoeducation, the mode of session delivery and the choice of whether to involve family members 9, 15 and the wider community. In addition to standard measures of outcome, the central goals of the service from first episode onwards should include functionality related improvements such as quality of life, social activities, work life and opportunities for reintegration into society. The bipolar clinic should encourage carers and families to participate in psychoeducation sessions separate to those attended by patients. Through workshops and practical sessions, bipolar clinics should educate their staff, local health organisations and commissioning bodies that good expert care reduces the burden of bipolar disorder on health services through the reduction of relapse rates. An essential part is a close working relationship with early intervention services to identify and treat comorbidities common to bipolar disorder, such as substance misuse, alcohol misuse, personality disorders and attention deficit hyperactivity disorder (ADHD) 18, and to avoid missed diagnoses. Specific themes to be emphasised in the treatment rationale of a bipolar clinic are as follows: i) the efficacy and limitations of monotherapy with mood stabilisers, such as valproate or lithium, and their safety and tolerability profiles in patients with bipolar disorder, especially in women of childbearing age; ii) the efficacy and safety of combination therapy with atypical antipsychotics and traditional mood stabilisers; and iii) the nature, duration and efficacy benefits of psychoeducation for patients with bipolar disorder. Clinical staff are encouraged to improve their expertise in the previously mentioned areas by keeping abreast of current expert literature, both original research and meta-analyses, and training in the chosen model of psychoeducation. Upon patient referral to the bipolar clinic, a thorough and structured interview should be conducted to outline a detailed psychiatric and treatment history, followed by physical health screening and appropriate medical tests. Subsequently, the patient's psychiatric status should be evaluated using standard rating instruments, such as the Mood Disorder Questionnaire (MDQ), the Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Beck's Depression Rating Scale. At first visit, patients may be seen by a nurse consultant and a junior doctor, followed by a multidisciplinary review and an additional clinical interview with medical and nursing consultants, who may initially follow up on the patient 2–4 times per week. NHS bipolar clinics may provide CBT, family sessions and psychoeducational and general support sessions depending on patients’ needs, and regularly liaise with community mental-health teams (CMHTs), psychological therapy and non-psychiatric services. The major point of continued patient contact should be a nurse consultant, who is supported by a crisis team, duty doctors, wards and non-psychiatric services to provide assistance during practice hours and out-of-hours. The average time of a patient stay in a bipolar clinic is 6–24 months; however, this time frame may increase owing to the complexity of psychological or physical comorbidities, or the complexity of drug regimes. Following treatment in a bipolar clinic, patients should be referred to the recovery service for ongoing care within CMHTs, with indefinite continued support and advice from the bipolar clinic. The patient is a woman in her mid-20s working as a chef. She is talented and enjoys her work, but frequently comes into conflict with other staff members and is either fired or resigns, regularly displaying characteristics of mild violence. She usually finds alternative employment quickly, but becomes bored easily, which on occasion is cause for dismissal. The patient has a history of drug (LSD and amphetamine) and excessive alcohol use, which caused conflict with the police for drunk and disorderly conduct and possession of drugs (cannabis and cocaine). She is homosexual and has had several monogamous relationships. She has a partner of 3 years and is planning marriage. The patient has had periods of moderately severe depression, lasting for days or weeks, but there is a reactive element, in which the depression may have resulted from an unexpected setback at work or a relationship conflict. The patient is very petite (barely seven stone [44 kg] in weight) and has had problems with eating disorders. She attempted suicide by overdosing several times, as well as having had episodes of arm slashing in the previous 10 years. She has a family history of mood disorder and had been sexually abused by a male relative during childhood. Her medical history (including worsening with antidepressants), her answers to the MDQ and a more detailed family history suggested a diagnosis of bipolar disorder. She has participated in CBT and dialectical behaviour therapy with no clear benefit and often has failed to attend sessions. The patient reported that counselling sessions addressing her childhood abuse were unhelpful. She has been given a past diagnosis of emotionally unstable personality disorder, borderline subtype, with additional codes for ADHD and gender role disturbance, and was referred to a bipolar clinic for an opinion on diagnosis and treatment. The patient has had previous frequent contact with mental-health services, mainly following overdose or arm-slashing episodes. She has had some brief admission ward stays in hospital; however, she has neither found the contact helpful nor was willing to engage with ongoing services. The patient has been prescribed numerous antidepressants, antipsychotics and benzodiazepines in the past, but does not regard them as effective. Occasionally, her symptoms would worsen when using antidepressants, increasing her argumentativeness and irritability. Antipsychotics lead to sedation without noticeable impact on symptoms such as second-person hallucinations. Discussions of possible treatments were complicated by her avoidance of any treatment that might result in weight gain. After attending and completing all the psychoeducation group sessions, treatment with lithium was initiated. This treatment regimen was supplemented with aripiprazole or occasionally with quetiapine upon exceptional sleep disturbances. Upon emergence of symptoms such as depression and a feeling of worthlessness, she participated in 1–4 CBT sessions without her partner. Treatment with lithium and psychoeducation resulted in a moderation of alcohol intake and lack of consumption of drugs and antidepressants. Post-lithium symptom stability was enhanced, and conflicts at work and with the authorities were almost absent throughout 2 years of monitoring. Where implemented, NHS bipolar clinics have been a success locally and with specialisation of function trust-wide. Bipolar clinics may treat patients with related mood disorders, but their focus should be towards patients with bipolar disorder and to raise awareness of bipolar clinics as treatment facilities that uphold the best interest of the patient, their families and the community. As such, bipolar clinics provide support in optimising treatment and minimising drug interactions and toxicity, support working to a mutually agreed care plan, help to maintain employment and relationship networks, educate patients and their carers, and efficiently coordinate and manage complex care. Evidence shows that few patients treated in bipolar clinics drop out, and service provision can be made maximally accessible within local resource constraints. Even in the current climate of the UK's NHS budgetary constraints, it is possible to set up bipolar clinics within the context of existing NHS services. Resources can often be provided with some extra training and minor rearrangement of existing services. The workshop on which this supplement is based on was supported by Bristol-Myers Squibb, Uxbridge, UK. Editorial support for the preparation of this manuscript was provided by Ogilvy Healthworld Medical Education, London, UK; funding was provided by Bristol-Myers Squibb. The case study presented in this manuscript does not represent an individual patient, but is a collation of characteristics typical for patients with bipolar disorder. This manuscript is a result of a 1-day educational standalone symposium sponsored with an unconditional educational grant by Bristol-Myers Squibb, who also sponsored this publication. Professor Allan H. Young is employed by Imperial College London. He is an Honorary Consultant Psychiatrist with WLMHT (NHS UK); has given paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders; has no share holdings in pharmaceutical companies; was a Lead Investigator for the Embolden Study (AstraZeneca); BCI Neuroplasticity study and Aripiprazole Mania Study; and for investigator-initiated studies from AstraZeneca, Eli Lilly and Wyeth. He has received grant funding (past and present) from: NIMH (USA); CIHR (Canada); NARSAD (USA); Stanley Medical Research Institute (USA); MRC (UK); Wellcome Trust (UK); Royal College of Physicians (Edin); BMA (UK); UBC-VGH Foundation (Canada); WEDC (Canada); CCS Depression Research Fund (Canada); MSFHR (Canada); and is co-holder of one European patent for the use of glucocorticoid antagonists in the treatment of depression. Professor Anthony Hale is employed by Kent & Medway Partnership NHS Trust and King's College London. He has given paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders, schizophrenia, attention deficit hypersensitivity disorder and post-traumatic stress disorder. He has no share holdings in pharmaceutical companies. He is Principal Investigator for the Oasis study (DSRU for AstraZeneca) and for two pivotal agomelatine studies for Servier, as well as studies for Lilly, Lundbeck, Janssen and BMS.
OBJECTIVE:This article reviews the characteristics of bipolar disorder and approaches to minimise physical health risks, as well as treatment options, and their influence on patient quality of life (QoL).METHOD:The content of this article is based on the proceedings of a 1-day standalone symposium in November 2011 exploring how to establish a bipolar clinic within the context of existing services in the UK's National Health Service.RESULTS:Bipolar disorder is a common mental disorder and often under-recognised in patients with major depressive episodes. Patients are largely dependent on family and carers to lead normal lifestyles and have difficulties maintaining relationships. Mental health and physical health are closely linked, with risk factors such as weight gain, metabolic syndrome, smoking and diabetes contributing to cardiovascular disease and early death. Antipsychotics may induce treatment-related comorbidities, thus further contributing to a low QoL of patients. Symptoms of comorbidity or depression are frequently relieved through self-medication and substance abuse, thus increasing patient health and suicide risk. Therefore, regular health monitoring and patient education in risk factor minimisation are required.CONCLUSION:Early pharmacotherapeutic and psychoeducational interventions are required to improve treatment outcomes, as well as improving patient understanding of ways to minimise comorbidity development.
OBJECTIVE:Disturbances in circadian rhythms have been associated with major depression and may be an underlying mechanism for the disorder. Resynchronisation of circadian rhythms may provide a new approach to treatment, especially by manipulating melatonin secretion. Melatonin is secreted at night and is a stable marker of circadian rhythms. The timing of its secretion can be changed by exogenous melatonin, agonism of specific melatonin receptors in the suprachiasmatic nucleus, its suppression by light and by sleep deprivation.METHOD:As part of a series of papers ['Chronobiology of mood disorders' Malhi & Kuiper. Acta Psychiatr Scand 2013;128 (Suppl. 444): 2-15; and 'Getting depression clinical practice guidelines right: time for change?' Kuiper et al. Acta Psychiatr Scand 2013;128 (Suppl. 444): 24-30.] addressing chronobiology, in this article, we conducted a selective review of studies that have examined the antidepressant effects of exogenous melatonin, light therapy, sleep deprivation and melatonin receptor agonists.RESULTS:Antidepressant effects were identified for bright light therapy, especially for seasonal affective disorder; sleep deprivation, although its antidepressant effect is time limited; and for the novel antidepressant agomelatine with agonistic properties for the MT1 and MT2 receptors and antagonism of 5HT2c receptor. The role of melatonin as an antidepressant has yet to be demonstrated.CONCLUSION:Shifting the circadian secretion of melatonin using the strategies reviewed offers a new approach to treating depression.
OBJECTIVE:As part of a series of papers ['Chronobiology of mood disorders' Malhi & Kuiper. Acta Psychiatr Scand 2013;128(Suppl. 444):2-15; and 'It's time we managed depression: The emerging role of chronobiology' Malhi et al. Acta Psychiatr Scand 2013;128(Suppl. 444):1] examining chronobiology in the context of depression, this article examines recent western clinical practice guidelines (CPGs) for the treatment of depression with respect to the recommendations they make, in particular as regards chronobiological treatments, and briefly considers the implications of their methodology and approach.METHOD:Five international treatment guidelines, which had been published in the past 5 years, were identified, representing North American and European views. Chosen guidelines were reviewed by the authors, and the relevant recommendations were distributed for discussion and subsequent synthesis.RESULTS:Most current guidelines do not address chronobiology in detail. Chronotherapeutic recommendations are tentative, although agomelatine is considered as an option for major depression and bright light therapy for seasonal affective disorder. Sleep deprivation is not routinely recommended.CONCLUSION:Recommendations are limited by the lack of reliable therapeutic markers for chronotherapeutics. Current evidence supports use of light therapy in seasonal depression, but in non-seasonal depression there is insufficient evidence to support reliance on chronotherapeutics over existing treatment modalities.
Acta Psychiatrica ScandinavicaVolume 128, Issue s444 p. 1-1 Preface It is time we managed depression: the emerging role of chronobiology G. S. Malhi, G. S. Malhi Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorK. Fritz, K. Fritz Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorS. Kuiper, S. Kuiper gin.malhi@sydney.edu.au Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Sydney, NSW, AustraliaSearch for more papers by this author G. S. Malhi, G. S. Malhi Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorK. Fritz, K. Fritz Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorS. Kuiper, S. Kuiper gin.malhi@sydney.edu.au Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Sydney, NSW, AustraliaSearch for more papers by this author First published: 02 August 2013 https://doi.org/10.1111/acps.12174Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume128, Issues444Special Issue: Chronobiology of Mood Disorders and Manipulating Melatonin in Managing MoodSeptember 2013Pages 1-1 RelatedInformation
OBJECTIVE:As part of a series of papers examining chronobiology ['Getting depression clinical guidelines right: time for change?' Kuiper et al. Acta Psychiatr Scand 2013;128(Suppl. 444):24-30; and 'Manipulating melatonin in managing mood' Boyce & Hopwood. ActaPsychiatrScand 2013;128(Suppl. 444):16-23], in this article, we review and synthesise the extant literature pertaining to the chronobiology of depression and provide a preliminary model for understanding the neural systems involved.METHOD:A selective literature search was conducted using search engines such as MEDLINE/PubMed, combining terms associated with chronobiology and mood disorders.RESULTS:We propose that understanding of sleep-wake function and mood can be enhanced by simultaneously considering the circadian system, the sleep homoeostat and the core stress system, all of which are likely to be simultaneously disrupted in major mood disorders. This integrative approach is likely to allow flexible modelling of a much broader range of mood disorder presentations and phenomenology.CONCLUSION:A preliminary multifaceted model is presented, which will require further development and testing. Future depression research should aim to examine multiple systems concurrently in order to derive a more sophisticated understanding of the underlying neurobiology.
OBJECTIVE:To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37]. To provide clinically relevant recommendations for lifestyle modifications in depression, derived from a literature review.METHOD:A search of pertinent literature was conducted up to August 2012 in the area of lifestyle factors and depression. A narrative review was then conducted.RESULTS:There is evidence that level of physical activity plays a role in the risk of depression, and there is a large and validated evidence base for exercise as a therapeutic modality. Smoking and alcohol and substance misuse appear to be independent risk factors for depression, while the new epidemiological evidence supports the contention that diet is a risk factor for depression; good quality diets appear protective and poor diets increase risk.CONCLUSION:Lifestyle modification, with a focus on exercise, diet, smoking and alcohol, may be of substantial value in reducing the burden of depression in individuals and the community.
Acta Psychiatrica ScandinavicaVolume 127, Issue s443 p. 1-5 Preface Individualized management of unipolar depression G. S. Malhi, G. S. Malhi [email protected] Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorR. Hitching, R. Hitching Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorC. M. Coulston, C. M. Coulston Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorP. Boyce, P. Boyce Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorR. Porter, R. Porter Department of Psychological Medicine, University of Otago, Christchurch, New ZealandSearch for more papers by this authorK. Fritz, K. Fritz Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this author G. S. Malhi, G. S. Malhi [email protected] Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorR. Hitching, R. Hitching Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorC. M. Coulston, C. M. Coulston Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorP. Boyce, P. Boyce Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this authorR. Porter, R. Porter Department of Psychological Medicine, University of Otago, Christchurch, New ZealandSearch for more papers by this authorK. Fritz, K. Fritz Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, AustraliaSearch for more papers by this author First published: 16 April 2013 https://doi.org/10.1111/acps.12119Citations: 9Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References 1Malhi GS, Adams D, Porter R et al. Clinical practice recommendations for depression. Acta Psychiatr Scand 2009; 119: 8–26. 2McGorry PD, Purcell R, Hickie IB, Yung AR, Pantelis C, Jackson HJ. Clinical staging: a heuristic model for psychiatry and youth mental health. Med J Aust 2007; 197: S40–S42. 3Malhi GS, Hitching R, Berk M, Boyce P, Porter R, Fritz K. Pharmacological management of unipolar depression. Acta Psychiatr Scand 2013; 127(Suppl. 443): 6–23. 4Lampe L, Coulston CM, Berk L. Psychological management of unipolar depression. Acta Psychiatr Scand 2013; 127(Suppl. 443): 24–37. 5Berk M, Sarris J, Coulson CE, Jacka FN. Lifestyle management of unipolar depression. Acta Psychiatr Scand 2013; 127(Suppl. 443): 38–54. 6Østergaard SD, Jensen SOW, Bech P. The heterogeneity of the depressive syndrome: when numbers get serious. Acta Psychiatr Scand 2011; 124: 495–496. 7Malhi GS, Parker GB, Greenwood J. Structural and functional models of depression: from sub-types to substrates. Acta Psychiatr Scand 2005; 111: 94–105. 8Holma KM, Holma IA, Melartin TK, Rytsälä HJ, Isometsä ET. Long-term outcome of major depressive disorder in psychiatric patients is variable. J Clin Psychiatry 2008; 69: 196–205. 9Solomon DA, Leon AC, Endicott J et al. Psychosocial impairment and recurrence of major depression. Comp Psychiatry 2004; 45: 423–430. 10Eaton WW, Shao H, Nestadt G, Lee BH, Bienvenu OJ, Zandi P. Population-based study of first onset and chronicity in major depressive disorder. Arch Gen Psychiatry 2008; 65: 513–520. 11Hovens JGFM, Giltay EJ, Wiersma JE, Spinhoven P, Penninx BWJH, Zitman FG. Impact of childhood life events and trauma on the course of depressive and anxiety disorders. Acta Psychiatr Scand 2012; 126: 198–207. 12Melartin TK, Rytsälä HJ, Leskelä US, Lestelä-Mielonen PS, Sokero TP, Isometsä ET. Severity and comorbidity predict episode duration and recurrence of DSM-IV major depressive disorder. J Clin Psychiatry 2004; 65: 810–819. 13Østergaard SD, Foldager L. The association between physical illness and major depressive episode in general practice. Acta Psychiatr Scand 2011; 123: 290–296. 14Stapelberg NJ, Hamilton-Craig I, Neumann DL, Shum DH, McConnell H. Mind and heart: heart rate variability in major depressive disorder and coronary heart disease - a review and recommendations. Aust N Z J Psychiatry 2012; 46: 946–957. 15Kuchibhatla MN, Fillenbaum GG, Hybels CF, Blazer DG. Trajectory classes of depressive symptoms in a community sample of older adults. Acta Psychiatr Scand 2012; 125: 492–501. 16Caspi A, Sugden K, Moffitt TE et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003; 301: 386–389. 17Batterham PJ, Glozier N, Christensen H. Sleep disturbance, personality and the onset of depression and anxiety: prospective cohort study. Aust N Z J Psychiatry 2012; 46: 1089–1098. 18Dimeo F, Bauer M, Varahram I, Proest G, Halter U. Benefits from aerobic exercise in patients with major depression: a pilot study. Br J Sports Med 2001; 35: 114–117. 19Bartholomew JB, Morrison D, Coccolo JT. Effects of acute exercise on mood and well-being in patients with major depressive disorder. Med Sci Sports Exerc 2005; 37: 2032–2037. 20Mota-Pereira J, Silverio J, Carvalho S, Ribeiro JC, Fonte D, Ramos J. Moderate exercise improves depression parameters in treatment-resistant patients with major depressive disorder. J Psychiatr Res 2011; 45: 1005–1011. 21Perraton LG, Kumar S, Machotka Z. Exercise parameters in the treatment of clinical depression: a systematic review of randomized controlled trials. J Eval Clin Pract 2010; 16: 597–604. 22McGorry PD, Hickie IB, Yung AR, Pantelis C, Jackson HJ. Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust N Z J Psychiatry 2006; 40: 616–622. 23Thase ME, Rush AJ. When at first you don't succeed: sequential strategies for antidepressant nonresponders. J Clin Psychiatry 1997; 58: 23–29. 24Yung AR, McGorry PD. Prediction of psychosis: setting the stage. Br J Psychiatry 2007; 191: S1–S8. 25 American Psychiatric Association. Diagnostic and statistical manual for mental disorders, 4th edn, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. 26 World Health Organisation. The ICD-10 classification of mental and behavioural disorders: clinical description and diagnostic guidelines. Geneva: WHO, 1992. 27Chadwick P, Williams C, Mackenzie J. Impact of case formulation in cognitive behaviour therapy for psychosis. Behav Res Ther 2003; 41: 671–680. 28Persons J, Mooney K, Padesky C. Inter-rater reliability of cognitive-behavioural case formulations. Cognit Ther Res 1995; 19: 21–34. 29Kuyken W, Padesky CA, Dudley R. Collaborative case conceptualization: working effectively with clients in cognitive-behavioral therapy. New York: Guilford Publications, 2009. 30Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003; 160: 4–12. 31Belmaker RH. Patient history must be incorporated into any guidelines. Bipolar Disord 2009; 11: 772–773. 32Persons JB. Cognitive therapy in practice: a case formulation approach. New York: Norton and Co., 1989. 33McWilliam N. Psychoanalytic case formulation. New York: Guildford Press, 1999. 34Eells TD. Update on psychotherapy case formulation research. J Psychother Pract Res 2001; 10: 277–281. 35Morris DW, Trivedi MH, Husain MM et al. Indicators of pretreatment suicidal ideation in adults with major depressive disorder. Acta Psychiatr Scand 2010; 121: 480–484. 36Isacsson G, Holmgren A, Osby U, Ahlner J. Decrease in suicide among the individuals treated with antidepressants: a controlled study of antidepressants in suicide, Sweden 1995–2005. Acta Psychiatr Scand 2009; 120: 37–44. 37Coulston CM, Bargh D, Tanious M et al. Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients. J Affect Disord 2012; 145: 54–61. Citing Literature Volume127, Issues443Special Issue: Individualized Management of Unipolar DepressionMay 2013Pages 1-5 ReferencesRelatedInformation
OBJECTIVE:To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of psychological treatments in depression derived from a literature review.METHOD:Medical databases including MEDLINE and PubMed were searched for pertinent literature, with an emphasis on recent publications.RESULTS:Structured psychological treatments such as cognitive behaviour therapy and interpersonal therapy (IPT) have a robust evidence base for efficacy in treating depression, even in severe cases of depression. However, they may not offer benefit as quickly as antidepressants, and maximal efficacy requires well-trained and experienced therapists. These therapies are effective across the lifespan and may be preferred where it is desired to avoid pharmacotherapy. In some instances, combination with pharmacotherapy may enhance outcome. Psychological therapy may have more enduring protective effects than medication and be effective in relapse prevention. Newer structured psychological therapies such as mindfulness-based cognitive therapy and acceptance and commitment therapy lack an extensive outcome literature, but the few published studies yielding positive outcomes suggest they should be considered options for treatment.CONCLUSION:Cognitive behaviour therapy and IPT can be effective in alleviating acute depression for all levels of severity and in maintaining improvement. Psychological treatments for depression have demonstrated efficacy across the lifespan and may present a preferred treatment option in some groups, for example, children and adolescents and women who are pregnant or postnatal.
Bipolar disorder is characterised by episodes of depression and mania or hypomania. Most patients tend to experience predominantly chronic depressive symptoms or recurrent depressive episodes with the result that bipolar depression can be misdiagnosed as major depressive disorder. This can lead to inappropriate medication choices and increased healthcare costs 1, 2. Psychoeducational interventions for bipolar disorder – particularly group interventions – that are delivered alongside medication, are known to be effective in reducing rates of relapse and can have a positive impact by helping patients to develop a range of long-term, self-management skills 3. In 2008, the Cardiff University Psychiatry Service, with the help of a grant from the UK Big Lottery Fund and research funding from the National Institute of Health Research, established the Bipolar Education Programme – Cymru (BEP-C). The main aims of this programme were to deliver internet- and group-based psychoeducation to individuals with bipolar disorder across Wales and to provide an educational programme for healthcare professionals aimed at improving the diagnosis and management of bipolar disorder. The BEP-C website (www.bep-c.org) has interactive modules for three separate audiences: partners, families and carers; women with bipolar disorder; and primary-care practitioners. These three modules aim to find practical ways in which families and friends of people with bipolar disorder can make a positive contribution to their long-term care; educate pregnant and/or breastfeeding women about potential risks associated with childbirth and the use of medication during pregnancy and breastfeeding; and to provide healthcare professionals with up-to-date information about the presentation and diagnosis of bipolar disorder. Group-based psychoeducation sessions within the Cardiff BEP-C programme have a 10-session structure, with each session forming the basis for a group discussion around topics such as the causes of bipolar disorder, lifestyle influences, monitoring mood and identifying triggers, early warning signatures, medication issues, psychological approaches and the role of family and friends. The programme is delivered over 10 weekly meetings with each session lasting for 2 h. Sessions consist of a combination of presentations, group discussions and group exercises. Our experience to date has been that these sessions are valued by both patients and professionals. Patients have indicated that they benefitted from the strong sense of group cohesion during the sessions and valued the authoritative content of the material delivered. The material was considered to be very relevant to patients’ needs. These sessions are facilitated by two community psychiatric nurses under supervision of consultant psychiatrists in the BEP-C team. This online intervention allows patients with bipolar disorder to remotely participate in psychoeducation on an individual basis, but also to join online group discussions within a secure patient forum. The Beating Bipolar programme was carefully designed to address the needs of patients with bipolar disorder, including consideration of potential depressive symptoms, cognitive impairments and brief attention span 4. Eight modules were developed, each 30 min long, on topics such as the contribution of lifestyle choices to episodes, medication issues and strategies for relapse prevention (Table 1). Each module contains an introductory overview and a module summary, as well as interactive exercises to be completed by the patient. The aim of Beating Bipolar is to deliver information in a variety of ways and to actively engage users in self-management exercises 5. For example, by assessing the characteristics of how they feel, think and behave, patients can develop a symptom profile, explore changes in their behaviour and create a life chart, which aids in the identification of relapse prevention signatures and early intervention plans. Patients also create a portfolio of completed exercises that can be revisited, updated and shared with their family and healthcare providers. Module 1 What is bipolar disorder? Module 2 What causes bipolar disorder? Module 3 Medication Module 4 Lifestyle Module 5 Relapse prevention and early intervention Module 6 Psychological approaches Module 7 Partners, families and carers Module 8 Women and bipolar disorder Although group psychoeducational interventions are promising long-term options in the management of bipolar disorder 6, the translation of group material to a web-based format such as Beating Bipolar is a relatively new development. Assessments of user engagement with Beating Bipolar have indicated that the majority of patients accessed and completed approximately 75% of the content 5. The challenge for any type of psychoeducational intervention is to address the individuality, abilities and preferences of patients with bipolar disorder and to anticipate the features of the disorder that may restrict patients to participate in interventions. Patients experienced the Beating Bipolar website in different ways; some preferred the anonymity of a computer/home-based intervention, while others stated that they favoured the support and social contact arising from group-based therapies 7. One advantage of the internet-based intervention over group-based therapies is that modules are paced at 2-week intervals and can be revisited to ensure that patients have the opportunity to consolidate their knowledge and take in the information presented at their own pace. In particular, patients found the ability to share the module content and patient exercises with family and carers very helpful. However, some patients felt that the interactive aspect of the discussion forum was underdeveloped and judged it as not having reached a critical mass for valuable group conversations. Nevertheless, overall, most patients reported a greater awareness and understanding of the disorder, which resulted in lifestyle changes, behaviour changes and changes in attitude towards their illness and medication. Clearly more research is needed on the potential advantages and disadvantages of delivering structured psychoeducational interventions for bipolar disorder (and other conditions) via the internet. It is clear that the development of internet-based interventions needs to be acceptable to patients in terms of applicability, information, delivery and relevance 4. The development of the Cardiff programme was based first on a literature search identifying information on suitable programme content and design, including scientific information, the design of e-learning programmes, learner engagement, interactivity, presentation and instructional design 3, 4. The first draft of the programme content, delivery and interactivity was generated by a multidisciplinary team of healthcare professionals, including psychiatrists, psychologists and educational web designers. Further topics of discussion were participant characteristics, mix of media and engagement. Following concept development, the programme was discussed with patients and mental-healthcare professionals to gain an understanding of patient requirements and demands, particularly for Beating Bipolar. Participants of these focus groups could voice their opinion about any aspect of the programme such as inclusion of discussion forums, potential purpose and frequency of face-to-face group meetings, advantages and disadvantages of potential methods of information delivery, acceptability of proposed learning exercises and programme module content. Further discussion points included the role of a lead psychiatrist within the online discussion forum and the balance between information about depression versus manic symptoms. After several rounds of focus groups, patients were encouraged to test the online e-module and determine its level of user-friendliness, online package appearance and impact 4. To test the effectiveness of Beating Bipolar, an exploratory randomised controlled trial was conducted 6, 5. Despite statistically non-significant differences in the primary outcome measure (overall quality of life measured by the World Health Organisation Quality of Life Assessment, WHOQOL-Bref), the Beating Bipolar intervention had a modest positive impact on psychological quality of life of individuals with bipolar disorder 5. In Cardiff, we aimed to engage a younger generation of patients and use as wide a spectrum of media as possible and to this end have developed Bipol-App (a smartphone application) to help patients monitor their daily mood. With this application, patients can record mood, sleep, energy, anxiety and important events on a daily basis and review their mood chart for the preceding 7, 30 and 90 days. The goal of Bipol-App is to aid in the recognition of early warning symptoms, enable the patient to actively monitor their disorder and recognise when to seek professional help sooner rather than later. Patients also have the option of permitting healthcare professionals, carers and family members to view their mood profiles (www.beatingbipolar.org/bipol-app). A formal evaluation of Bipol-App is currently underway. Bipolar disorder is associated with considerable long-term personal and social impairment and has a significant impact on the economy. Therapeutic strategies that optimise community-based management, prevention of recurrence and unnecessary hospitalisation could reduce the economic burden of the disorder. Psychoeducational programmes such as that described above have considerable promise in this regard. Group psychoeducation is likely to be a cost-effective option compared with standard care, but further studies are required to assess this. Similarly, internet-based delivery of psychoeducation to large numbers of patients may prove cost-effective and allows geographically diverse patient groups to access these interventions more easily 8. An ongoing concern is that many individuals with bipolar disorder (particularly bipolar II disorder) may be misdiagnosed as recurrent depressive 9. It is therefore important to develop and evaluate strategies for improving the diagnostic capabilities of primary- and secondary-care practitioners alongside delivering educational interventions within busy clinical settings. Overall, the Cardiff experience has shown that psychoeducational interventions can be successfully developed in close collaboration with patient groups and delivered to relatively large numbers of patients. Our group was fortunate in having development support from the Big Lottery Fund and from the National Institute of Health Research, but our recent experience with colleagues from across the NHS has been that it is possible to deliver similar interventions at relatively low cost and that these interventions are highly valued by patients and professionals alike. The meeting on which this supplement is based was supported by Bristol-Myers Squibb, Uxbridge, UK. Editorial support for the preparation of this manuscript was provided by Ogilvy Healthworld Medical Education, London, UK; funding was provided by Bristol-Myers Squibb. This manuscript is a result of a 1-day educational standalone symposium sponsored with an unconditional educational grant by Bristol-Myers Squibb, who also sponsored this publication. Professor Allan H. Young is employed by Imperial College London. He is an Honorary Consultant Psychiatrist with WLMHT (NHS UK), has given paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders, has no share holdings in pharmaceutical companies and was a Lead Investigator for the Embolden Study (AstraZeneca), BCI Neuroplasticity Study and Aripiprazole Mania Study and for investigator-initiated studies from AstraZeneca, Eli Lilly and Wyeth. He has received grant funding (past and present) from: NIMH (USA); CIHR (Canada); NARSAD (USA); Stanley Medical Research Institute (USA); MRC (UK); Wellcome Trust (UK); Royal College of Physicians (Edin); BMA (UK); UBC-VGH Foundation (Canada); WEDC (Canada); CCS Depression Research Fund (Canada); MSFHR (Canada) and is coholder of one European patent for the use of glucocorticoid antagonists in the treatment of depression. Dr Daniel J. Smith is currently employed by the University of Glasgow but worked at Cardiff University between 2006 and 2012. He has given paid lectures and participated in advisory boards for Lilly, AstraZeneca, Shire, Bristol-Myers Squibb and Lundbeck and has received grant funding (past and present) from the National Institute of Health Research, UK, MRC/Welsh Assembly Government, NARSAD, the American Psychiatric Association/AstraZeneca and the Big Lottery Fund.
The current supplement of Acta Psychiatrica Scandinavica collates the outcomes of a 1-day standalone symposium (both supplement and symposium were sponsored by Bristol-Myers Squibb, including editorial support) on 3 November, 2011, in London, England, discussing how to set up a bipolar clinic within existing National Health Service (NHS) services in the UK. This supplement includes four papers – two clinical overview articles (1, 2) and two discussion articles (3, 4) – outlining and discussing the nature of bipolar disorder, disease progression and associated comorbidities, as well as potential routes to recovery through psychotherapeutic interventions delivered in bipolar clinics. The objective of the current supplement is to emphasise the need for bipolar clinics with psychoeducation programmes and provide useful hints for their implementation along with a successful real-life example. A workshop carried out during the symposium explored the first steps, challenges and possible barriers for the implementation of bipolar clinics. In addition, the supplement provides an overview of the history of bipolar disorder, physical health considerations associated with pharmacotherapy and the role of psychoeducation as add-on therapy to medication in the treatment of bipolar disorder. Psychiatric care for patients with bipolar disorder usually involves out-patient appointments with a psychiatrist or mental-health team member and long-term medication, with increased support or admission to hospital at times of relapse. However, hospitalisation during acute episodes places a great financial strain on healthcare services (5). Therefore, prevention of acute manic episodes rather than episode management could potentially reduce the financial burden on healthcare systems. Early diagnosis and pharmacotherapy coupled with psychological interventions that educate patients on how to monitor their symptoms and the importance of medication are key factors in the prevention of acute episodes. As a chronic mental illness, bipolar disorder can be managed with pharmacotherapy. However, the risk of developing chronicity through recurring episodes with incomplete remission is high. Young and Grunze (1) discuss studies showing that patients with bipolar disorder are at a high risk of developing medical comorbidities, such as metabolic syndrome, diabetes and cardiovascular disease (6), partly as a consequence of standard pharmacotherapy (7). Regular physical health monitoring is required for the prevention and management of comorbid conditions (8). In addition, many patients self-medicate or abuse substances in response to affective symptoms (9), ultimately leading to low quality of life and an increased physical health burden. Stafford and Colom (2) discuss psychoeducational programmes as a tool for the long-term management of bipolar disorder. As an intervention, psychoeducation aims to provide patients with knowledge about their illness and methods to prevent recurrence of episodes or the development of comorbidities. By increasing the patient’s ability to manage their disorder, the goal is to instil a proactive attitude and enhance their competence to decide when to seek help. The goal of psychoeducation is to empower the patient to actively contribute to their care plan by learning how to recognise and handle destabilising factors, such as substance abuse and emotionally straining situations. This chapter highlights the importance of a functional relationship between the patient and clinician in the successful treatment of bipolar disorder, as well as the challenges and ideals of the development of bipolar clinics as a setting for the delivery of psychoeducation, and as an environment for regular interaction between the patient and clinician. Although considered beneficial for the patient, the challenges of setting up a bipolar clinic within existing NHS services are considerable. These are discussed by Young and Hale (3), and highlight the results of workshop discussions among the healthcare professionals attending the 1-day symposium. The considerations necessary to set up a bipolar clinic through the real-life set-up of a bipolar clinic in the UK are shared. Concerns of
OBJECTIVE:This article reviews psychological therapies in the treatment of bipolar disorder, in particular psychoeducation, and how the inclusion of four fundamental principles - patient/therapist communication, flow of information, patient involvement and a trusting relationship - can improve patient outcomes.METHOD:The content of this article is based on the proceedings of a 1-day standalone symposium in November 2011 exploring how to establish a bipolar clinic within the context of existing services in the UK's National Health Service.RESULTS:Certain psychological interventions have emerged as beneficial add-on treatments to pharmacotherapy in bipolar disorder and are associated with greater stabilisation of symptoms, fewer relapses and longer time to relapse. Psychoeducation is a simple approach to support prevention of future episodes by delivering behavioural training to improve illness insight, early symptom identification and development of coping strategies. Empowering patients to actively participate in their treatment provides independence, counteracts the current disconnect of therapist and patient, and increases awareness and understanding of the challenges of living with and treating bipolar disorder.CONCLUSION:Psychoeducation enables patients to understand bipolar disorder, get actively involved in therapy planning, and be aware of methods for episode prevention, therefore effectively contributing to improved treatment outcomes and patient quality of life.
OBJECTIVE:Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century.METHOD:We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia.RESULTS:Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms.CONCLUSION:Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.
OBJECTIVE:To review evidence of trauma and exile-related mental health in young refugees from the Middle East.METHOD:A review of four empirical studies: i) a qualitative study of 11 children from torture surviving families, ii) a cohort study of 311 3-15-year-old asylum-seeking children, iii) a qualitative study of 14 members of torture surviving families and iv) a follow-up study of 131 11-23-year-old refugees.RESULTS:The reactions of the children were not necessarily post-traumatic stress disorder specific. Seventy-seven per cent suffered from anxiety, sleep disturbance and/or depressed mood at arrival. Sleep disturbance (prevalence 34%) was primarily predicted by a family history of violence. At follow-up, 25.9% suffered from clinically relevant psychological symptoms. Traumatic experiences before arrival and stressful events in exile predicted internalizing behaviour, witnessing violence and frequent school changes in exile predicted externalizing behaviour. School participation, Danish friends, language proficiency and mother's education predicted less long-term psychological problems.CONCLUSION:Psychological problems are frequent in refugee children, but the extents are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children while aspects of life in exile are important for the children's ability to recover from early traumatization.
OBJECTIVE:To propose ideas for the development of a core strategy for monitoring patients with schizophrenia to ensure physical health and optimal treatment provision.METHOD:A panel of European experts in the field of schizophrenia met in Bordeaux in June 2006 to discuss, 'Patient management optimisation through improved treatment monitoring.'RESULTS:Key consensus from the discussion deemed that weight gain, oral health and ECG parameters were core baseline parameters to be monitored in all patients with schizophrenia. Further, an identification of a patient's own barriers to treatment alongside local health service strategies might comprise elements of an individualised management strategy which would contribute to optimisation of treatment. Any monitoring strategy should be kept simple to encourage physician compliance.CONCLUSION:A practical solution to the difficulties of providing holistic patient care would be to suggest a limited set of physical parameters to be monitored by physicians on a regular basis.
OBJECTIVE:To review and make recommendations for the definition and presentation of the terms 'response' and 'remission' in schizophrenia.METHOD:Selective review of publications on definitions of response and remission in schizophrenia.RESULTS:When the Brief Psychiatric Rating Scale (BPRS) or the Positive and Negative Syndrome Scale (PANSS) are used for definitions of response, a cut-off of at least 50% reduction of the baseline score should be used for acutely ill, non-refractory patients and a cut-off of at least 25% reduction for refractory patients. When percentage BPRS/PANSS reduction is calculated, the 18/30 points minimum scores meaning 'no symptoms' on the should be subtracted. In addition, responder rates from 0-100% could be presented in a table in steps of 25%. For large and simple practical trials, the Clinical Global Impression scale with suggested improvements could be used 1-7 scale.CONCLUSION:To show how many patients are still symptomatic at the end of study and to show the overall amount of change in both remission and responder criteria should be presented.
