Lydia Lewis

Mood Disorders in the Medically Ill: Scientific Review and Recommendations

OBJECTIVE The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Depression and Bipolar Support Alliance Consensus Statement on the Unmet Needs in Diagnosis and Treatment of Mood Disorders in Children and Adolescents

OBJECTIVE To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources. METHOD The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained. RESULTS The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants. CONCLUSIONS Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.

A consumer perspective concerning the diagnosis and treatment of bipolar disorder.

The National Depressive and Manic–Depressive Association (National DMDA) is concerned about the diagnosis and treatment of bipolar disorder. As the nation’s largest patient-directed, illness-specific organization, we represent the millions of people suffering from this disorder. As such, our perspectives may differ at times from those of physicians, researchers, and family members. The public wants to learn more about bipolar disorder. They are searching for easy to understand, scientifically and medically accurate, unbiased information. Nearly 5000 people call National DMDA’s information line every month. In addition, our website receives a quarter million hits monthly. The primary reasons people contact us are to receive information, to find a doctor with expertise in treating mood disorders, and for referral to a DMDA support group. While National DMDA and the other consumer advocacy organizations have achieved significant outreach, we have a long way to go. Our efforts continue to be hampered by the stigma these illnesses carry—by the widespread belief of patients and providers that mood disorders are not real illnesses but rather “personality flaws.”

Patient perspectives on provider competence: a view from the Depression and Bipolar Support Alliance.

Health care providers want the very best for the patients they treat, and spend years studying treatment and keeping their medical knowledge current. But how providers put this knowledge into practice, more often than not, has a greater impact on outcomes than the knowledge itself. The Depression and Bipolar Support Alliance (DBSA) is a national patient-directed advocacy organization. Our mission is to improve the lives of people living with depression and bipolar disorder. DBSA is committed to empowering patients and their loved ones to become partners with their health care providers. This empowerment is achieved through education, improved communication, and setting wellness goals agreed upon by both health care provider and patient. In 2003, more than four million people, including patients, their loved ones, and providers asked for help from DBSA. The challenges these people struggled with revealed some basic but significant factors that are crucial to recovery for all people receiving mental health care. For optimum recovery, three factors must be in place: communication that is clear, thorough, and collaborative; treatment plans that include patient input, preferences, and needs; and recovery-oriented treatment that instills hope.

Use of placebo in clinical trials of mood disorders

On behalf of the Depression and Bipolar Support Alliance (DBSA), I commend you on the Journal’s coverage of the use of placebo in trials of new antidepressant medications, as stated in your recent article on November 27. As the nation’s largest patient-directed, illness-specific organization for those living with depression and bipolar disorder, we strongly agree that “the inclusion of a placebo group has major scientific importance in trials of new antidepressant medications and efforts should continue to minimize the risks so studies may be conducted in an ethically acceptable manner.” We realize this is a unique position for a patient-directed organization to take. However, we were so concerned about this issue, we convened our own consensus conference, bringing together patients, researchers, and clinicians. The conference resulted in a “Consensus Statement on the Use of Placebo in Clinical Trials of Mood Disorders.” Last year, DBSA’s consensus statement was published in the Archives of General Psychiatry (Charney et al., 2002). The statement determined that the use of placebo is ethical and appropriate in clinical trials when there is no existing treatment, or when a newer class of drugs is being studied. DBSA believes that the use of placebo is necessary in developing new treatment options. Clinical trials without placebo can increase the time to develop a drug that may be helpful in alleviating the suffering of the more than 23 million people living with mood disorders. However, we also believe that placebo-controlled trials are not ethical when patients are inadequately protected from serious risk. A patient’s safety and wellbeing must come first. Our statement also calls for more documentation in future studies about the use of placebo and urges improvements in informed consent. Thank you for your coverage of this important topic.