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The Royal College of Psychiatrists Improving the lives of people with mental illness

North West Conference Reviews 2013

 

North West AUTUMN Conference Review - 20 NOVEMBER 2013 in MANCHESTER:

Depression – Treatments and Life Cycle

 

Lecture 1:  Drug Treatment: From first episode to refractory depression

Dr Peter Talbot, Senior Lecturer in Molecular Neuro-imaging, University of Manchester

 

The day started with Dr Talbot asking if antidepressants work. The answer was yes – antidepressants are as effective as drugs for physical health and the more severely ill a patient the greater the response. He described the work of the specialist clinic (SAD – specialist affective disorder) in Manchester where they conduct an initial assessment to check that this is the correct diagnosis, assess substance use, check for physical diseases, check for depressogenic medication and exclude bipolar disorder.

 

Dr Talbot recommended a stepped approach to moderate to severe depression:

 

Step 1 use SSRI e.g. Sertraline - 50-100mg or Mirtazepine if need sedation for 4 weeks – if no response

 

Step 2 try another SSRI or SNRI e.g. Escitalopram, waste of time going to a high dose

 

Step 3 go to augmentation – lots of research support for adding second generation antipsychotics or lithium

 

In his conclusions Dr Talbot stated that it was hard to predict outcomes, but clinicians should aim for remission, instil hope, give individual medication trials for 12 weeks maximum, have a stepped plan, use ECT and psychology, for treatment resistance work through evidence based treatment, refer to tertiary services and don’t forget neurosurgery.

 

 

Lecture 2: ECT are you still doing that?

Dr Richard Barnes, Consultant Old Age Psychiatrist, Merseycare NHS Foundation Trust

 

Dr Barnes started by describing how ECT began as an empirical treatment that has become scientifically evaluated, that is safe with only 1 in 20,000 life threatening incidents when used and has proven to be a most effective treatment.

 

The process involves an induced modified fit plus muscle relaxant, anaesthetic and monitoring. There has been a reduction in the use of ECT.

 

Does ECT work? Research shows that ECT is effective and drugs plus ECT is better than ECT or drugs alone. How does it work? The induced fit is needed for it to work and increases monoamine receptor sensitivity, increases monoamine receptor numbers, changes cerebral blood flow and changes brain connections.

 

Dr Barnes suggested discussing the options of unilateral (takes longer, more side effects and less effective) and bilateral (quicker, more side effects and more effective) with patients and recommended switching to a different medication.

 

 

Lecture 3: Mindful Based Treatments

Dr Russell Razzaque, Consultant Psychiatrist, North East London NHS Foundation Trust

 

Dr Razzaque described mindfulness as the non-judgemental awareness of the present moment; an awareness of thinking and of observing thoughts. He described a key correlation between experiential avoidance of unpleasant emotions and mental illness.

 

We did a small mindfulness exercise during the lecture. The use of mindfulness is now recommended by NICE for depression and is being incorporated into other psychological therapies. Mindfulness is a relaxed awareness, a method for developing resilience. Dr Razzaque strongly suggested that clinicians should use mindfulness themselves before advising others. The approach needs cultivation like gardening, incorporating into your day and for it to be practiced regularly.

 

 

Workshops:

 

Workshop 1

Mental Health Treatment Gap: Can we deliver psychological interventions to British South Asians? Dr Nusrat Husain

 

This session enabled participants to understand the need for cultural adaptation in interventions to facilitate engagement and improve outcomes in patients of British South Asian background as well as recognise themes and adaptations in interventions that are specific to South Asian culture and which impact on treatment when interacting with patients from this community.

 

Workshop 2

Computerised Therapy for Depression: Dr Sarah Knowles

 

Computerised CBT (cCBT) is recommended by NICE for treating depression and anxiety. However, there has been a lack of research into patient experience of technologically-delivered therapy, and no independent trials of effectiveness have been conducted in routine primary care. This workshop discussed the results of the REEACT trial, the largest independent trial of cCBT to date, including insights from interviews with patients and professionals. Barriers to engagement and implementation, and potential methods for improving patient experience in the next generation of cCBT programmes, were outlined.

 

Workshop 3

Does Trans-cranial Magnetic Stimulation have any noticeable effect? Professor Peter Lepping

 

This session presented results of a systematic review and meta-analysis answering the question whether there is any clinical utility of Trans-cranial Magnetic Stimulation, using a novel method to examine the clinical relevance of the existing results from the literature.  The review concluded that TMS showed a modest advantage over sham TMS for depression but not for treatment resistant depression.  The review also found that ECT was superior to TMS in all comparisons.

 

 

Afternoon Session

 

Lecture 4: Treating Adolescent Depression

Dr Bernadka Dubicka, Honorary Senior Lecturer in Child Psychiatry, University of Manchester/Consultant Child and Adolescent Psychiatrist Lancashire Care Foundation Trust

 

Dr Dubicka started by reminding us that this was a complex comorbid condition with increased suicidality and increasing levels of distress particularly in girls.

 

Treatment options recommended are multi-modal with SSRI’s and in particular Fluoxetine first line treatment. Sertraline is the recommended second line treatment and Escitalopram has increasing research data to support its use. Paroxetine is contraindicated due to agitation and hostility with tricyclics not recommended due to toxicity and lack of evidence.

 

Dr Dubicka described the role of CBT as useful for targeted cases such as patient choice, comorbid anxiety or OCD. The CBT should be manualised specialist care and treatment goals can include psychoeducation, optimism, realistic expectations, emotional first aid and family work. However there can be poor outcomes in adolescents due to difficulties with motivation and engagement with homework.

 

Dr Dubicka recommended managing insomnia by using melatonin, sleep hygiene, and addressing lifestyle. She emphasised the importance of identifying and treating depressed mothers.

 

Dr Dubicka also discussed the risk of suicidality describing a consensus that fluoxetine is the safest medication. She described more concerns about under treatment and not over treatment and research evidence suggesting that suicidality decreases once start any treatment.

 

 

Lecture 5: Depression with Psychosis in EIP Services

Dr Iain Macmillan, Consultant Psychiatrist, South of Tyne EIP Service

 

Adolescence is a time of increased mortality and morbidity because of increasing mental illness, with mood disorders presenting commonly after puberty. Patients presenting with depression with psychosis in follow-up approximately 50% over 15 years go onto develop mania. Those with recurrent depression are more likely to develop bipolar disorder.

 

Dr Macmillan suggested a staging model as used for schizophrenia and this can be used as a basis for planning treatment. At a lower stage use simpler treatment, for a better prognosis, better response, and decreased risk. US study found for those exposed to antidepressants more seemed to develop mania than those not exposed to medication.

Recent research suggests using a dietary intervention with the least healthy diet giving an increased odds ratio of depression.

 

Dr Macmillan concluded that prevention of depression was feasible and diagnosis and stage of illness informed treatment options. Depression was a highly recurrent illness with increasing disability that required early use of best treatments and that antidepressants may worsen disease course. The subjective report of hearing voices predicted the need for treatment.

 

 

Lecture 6: Self harm and recent findings from the Centre of Suicide Prevention: Links with Suicide and Depression

Dr Jayne Cooper, Senior Research Fellow, Institute of Brain, Behaviour and Mental Health, University of Manchester

 

Of completed suicides 9 out of 10 have a psychiatric disorder, 50-70% have depression. 15% of depressed people die by suicide with a 20 fold increased risk of suicide.

 

The suicide centre has been collecting data from 1997, they have found rates of suicide decreasing but since 2008 rates have been increasing again. They have found that females consistently more likely to self-harm but male rates are increasing faster and closing the gap.

 

Kapur et al 2013 used the study’s data to examine which treatment works with the main outcome measure of repeat DSH. Psychosocial assessment some aspects work e.g. opportunity to talk about problems, validation of distress, key time to inspire hope and follow up needs to occur if promised. Dr Cooper recommended holistic assessments including physical health, self-care and medication with integration of mental and physical care.

 

Following up of the DSH of 30,000 patients found approximately 300-400 killed themselves, with suicide 20x more likely than the general population.

 

 

Lecture 7: Depression in Older People

Dr Wendy Neil, Consultant in Old Age Psychiatry Leeds and York Partnership Foundation Trust

 

There is a relative lack of data in the management of depression in later life especially in over 80s. Research does show that cognitive impairment reduces antidepressant efficacy. There are only 9 trials of psychotherapeutic treatment, CBT shown to be effective. Dr Neil recommended embedding therapy within a package of care.  In older people ECT improved remission, patients responded well with no increase in side effects. There is no evidence of efficacy for TMS, VNS, DBS in older people.

 

Recent meta-analyses have shown that SSRIs, SNRIs are effective, Ciprani in 2009 recommended Sertraline and possibly Escitalopram. Dr Neil recommended having a sequenced plan with prolonged treatment (6-8 weeks) for refractory depression and considering the use of augmenting or combining drugs. She stated there was no evidence for use of larger doses and advised caution in switching antidepressants.

 

She advocated maintenance treatment as risk of recurrence was significantly greater on discontinuation, with a NNT of 4 to prevent recurrence.

 

In conclusion Dr Neil emphasised the importance of recognising depression, education, embedding a psychological approach, monitoring symptoms and side effects, and having a sequential plan with the next step planned.

 

 

North West Conference Spring 2014 – Commissioning and service development

North West Conference Autumn 2014 – Update on treating personality disorders

 

A Khawaja

Academic Secretary, North West Division

 

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