Jan Scott

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Evidence-based guidelines for the pharmacological treatment of anxiety disorders: Recommendations from the British Association for Psychopharmacology.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

Treatment non‐adherence in affective disorders

Objective: The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders.

A systematic review of manic and depressive prodromes.

BACKGROUND This paper explores whether individuals with a mood disorder can identify the nature and duration of depressive and manic prodromes. METHODS Seventy-three publications of prodromal symptoms in bipolar and unipolar disorders were identified by computer searches of seven databases (including MEDLINE and PsycLIT) supplemented by hand searches of journals. Seventeen studies (total sample=1191 subjects) met criteria for inclusion in a systematic review. RESULTS At least 80% of individuals with a mood disorder can identify one or more prodromal symptoms. There are limited data about unipolar disorders. In bipolar disorders, early symptoms of mania are identified more frequently than early symptoms of depression. The most robust early symptom of mania is sleep disturbance (median prevalence 77%). Early symptoms of depression are inconsistent. The mean length of manic prodromes (>20 days) was consistently reported to be longer than depressive prodromes (<19 days). However, depressive prodromes showed greater inter-individual variation (ranging from 2 to 365 days) in duration than manic prodromes (1-120 days). LIMITATIONS Few prospective studies of bipolar, and particularly unipolar disorders have been reported. CONCLUSIONS Early symptoms of relapse in affective disorders can be identified. Explanations of the apparent differences in the recognition and length of prodromes between mania and bipolar depression are explored. Further research on duration, sequence of symptom appearance and characteristics of prodromes is warranted to clarify the clinical usefulness of early symptom monitoring.

Cognitive vulnerability in patients with bipolar disorder.

BACKGROUND No study has simultaneously explored key components of Becks model of cognitive vulnerability to depression in people with bipolar disorders. METHODS We compared 41 euthymic bipolar patients with 20 healthy control subjects. All subjects were assessed on the Hamilton Rating Scale for Depression, the Autobiographical Memory Test and the Mean Ends Problem-Solving procedure and also completed the Beck Depression Inventory, the Dysfunctional Attitude Scale, the Sociotropy Autonomy Scale and the Rosenberg Self-Esteem Questionnaire. RESULTS In comparison to control subjects, patients with bipolar disorder demonstrated significantly higher levels of dysfunctional attitudes (particularly perfectionism and need for approval) and sociotropy, significantly greater over-general recall on an autobiographical memory test and significantly less ability to generate solutions to social problem-solving tasks. These between group differences remained significant when age, intelligence, latency to respond to autobiographical memory test cue words, and subjective mood ratings were included as co-variates in the statistical analysis. Within the patient group, cognitive dysfunction was significantly correlated with level of morbidity (as measured by number of previous illness episodes). CONCLUSIONS This study suggests that cognitive vulnerability in patients with bipolar disorder is similar to that described in unipolar disorders. It is not clear whether this dysfunction is a cause or an effect of repeated episodes of bipolar disorder. However, the findings may have implications for clinical treatment as well as suggesting a number of important new avenues of research into psychological models of affective disorder.

Neural responses to sad facial expressions in major depression following cognitive behavioral therapy

BACKGROUND Affective facial processing is an important component of interpersonal relationships. The neural substrate has been examined following treatment with antidepressant medication but not with psychological therapies. The present study investigated the neural correlates of implicit processing of sad facial expressions in depression pretreatment and posttreatment with cognitive behavioral therapy (CBT). METHODS The patient group consisted of 16 medication-free subjects (mean age 40 years) with a DSM-IV diagnosis of acute unipolar major depression, and the comparison group were 16 matched healthy volunteers. Subjects participated in a prospective study with functional magnetic resonance imaging (fMRI) at weeks 0 and 16. During the fMRI scans, subjects performed an affect recognition task with facial stimuli morphed to display varying intensities of sadness. Patients received 16 sessions of CBT. Functional magnetic resonance imaging data were analyzed for the mean activation and differential response to variable intensity (load-response) of facial affect processing. RESULTS During an acute depressive episode, patients showed elevated amygdala-hippocampal activity relative to healthy individuals. Baseline dorsal anterior cingulate activity in patients showed a significant relationship with subsequent clinical response. CONCLUSIONS These data provide further support for elevated amygdala activity in depression and suggest that anterior cingulate activity may be a predictor of treatment response to both pharmacotherapy and CBT.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders

This paper reviews published randomized controlled treatment trials of psychological therapies added to standard psychiatric treatment vs. standard psychiatric treatment alone to explore whether adjunctive psychotherapy reduces relapse rates in individuals with bipolar disorders. Core components and characteristics of effective psychological therapies were identified from descriptions in the literature. Relapse rates were calculated for selected treatment trials and then pooled odds ratios were calculated using meta-analytical techniques that explored differences in outcome according to therapy model, type of relapse experienced and whether the subject was euthymic at entry to the study. The different therapy models have a number of similar components. A meta-analysis of eight recent studies demonstrates a significant reduction in relapse rates (of about 40%) compared to standard treatment alone. Therapies were most effective in preventing relapses in subjects who were euthymic when recruited into the treatment trial, and may be less effective in those with a high number of previous episodes (previous relapses >12). Efficacy studies demonstrate that adjunctive psychological treatments for individuals with bipolar disorders reduce relapse risk, but there is a need to undertake pragmatic effectiveness studies to determine which individuals with bipolar disorders are most likely to benefit from such interventions.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

BACKGROUND We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm. METHOD Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months. RESULTS Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20). CONCLUSION Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial

BACKGROUND About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.