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CANMAT Guidelines for bipolar depression: Contrasts and similarities with major depression
S12
Abstract/Journal of Affective Disorders 122 (2010) S9–S31
Methods: A systematic literature search identified relevant studies with an emphasis on meta-analyses. Pre-defined Levels of Evidence were specified for recommendations, which were then graded according to Line of Treatment, where first-line treatment represents a balance of efficacy, tolerability and clinical support. Clinical support refers to application of expert opinion of the CANMAT committees to ensure that evidence-supported interventions are realistic and applicable for clinical practice. Results: Emerging evidence suggests that some first-line antidepressants have small but still clinically relevant differences in efficacy. For incomplete response/remission, the evidence supports various switching and add-on/adjunctive strategies. Level 1 evidence supports the adjunct use of lithium and atypical antipsychotics, while evidence is more limited for other agents (e.g., thyroid hormone, adjunct antidepressants, buspirone and stimulants). Advantages and disadvantages of these strategies, and the use of clinical algorithms, will be discussed. Discussion: There is considerable evidence for efficacy of many pharmacotherapy strategies for MDD, whether as a first-choice treatment or for incomplete response/remission. However, there is still limited evidence comparing the various agents, sequencing of strategies, and algorithms. Selection and sequencing of antidepressants still requires individualized assessment of patient and clinical factors. Keywords: Antidepressants; Algorithms; Guidelines; Major depression doi:10.1016/j.jad.2010.01.022
S2.3 CANMAT Guidelines for bipolar depression: Contrasts and similarities with major depression L. Yatham University of British Columbia, Canada Introduction: Although there is international consensus on guidelines for management of unipolar depression, acute mania and prophylaxis of bipolar disorder, there continues to be wider disagreements about guidelines for managing bipolar depression. This presentation will outline the guidelines developed by the Canadian Network for Mood and Anxiety Treatments (CANMAT) group in collaboration with experts from the International Society for Bipolar Disorders (ISBD). Method: The strenght of evidence for each treatment was ranked in categories ranging from category 1 to 4 with category 1 being the best evidence as indicated by data from replicated double blind placebo controlled trials. The evidence was then translated by the group to clinical recommendations ranging from first line to not recommended categories and this took into account the evidence for efficacy, support for efficacy from clinical practice, and safety considerations. Results: The controversy was related mainly to use of antidepressants and lamotrigine. However, based on the above criteria, the group reached consensus that there is sufficient evidence to recommend Llithium, lamotrigine and quetiapine monotherapy, olanzapine plus SSRI, and lithium or divalproex plus SSRI/bupropion as first line options. New data support the use of adjunctive modafinil as a second line ption, and current evidence suggest that aripiprazole should not be used as monotherapy for bipolar depression. Conclusions: These recommendations are in contrast to other guidelines which do not recommend antidepressants and lamotrigine as first line treatments. doi:10.1016/j.jad.2010.01.023
S2.4 Disorder specific psychotherapy: Contrasts between major depressive disorder and bipolar depression S.V. Parikh University of Toronto, Canada Introduction: Acute depression in major depressive disorder (MDD) and bipolar disorder (BD) differ somewhat in presentation and extensively in pharmacotherapy. Differences in psychotherapy are less clear. Methods: The psychotherapy literature for MDD and BD was reviewed. Contrasts in goals, approaches, and outcomes were compiled. Results: Psychotherapy for major depressive disorder is among the most extensively researched treatment in psychiatry, with hundreds of RCTs involving cognitive behaviour therapy (CBT) alone. Other major psychotherapy treatments include interpersonal therapy (IPT) and psychodynamic therapy, with newer approaches including Mindfulness Based Cognitive therapy, Acceptance and Commitment Therapy, and Motivational Interviewing techniques. In contrast, psychotherapy research in bipolar disorder is limited, with less than twenty significant RCTs involving any phase of the illness. Most psychotherapy research in BD is developed for the maintenance phase, when the individual has few or no symptoms, and is designed to prevent relapse. Only one large recent RCT of psychotherapy for BD has been conducted, which showed that more intensive interventions (lumping together study arms of CBT, IPT, Family Focused Therapy (FFT)) were superior to a 3-session Psychoeducational intervention that was not a depression-specific intervention. Additionally, even in the maintenance phase, initial results supporting CBT and IPT have been moderated by more recent studies negative studies involving CBT for BD. Conclusion: In the management of bipolar depression versus major depressive disorder, it appears different interventions are warranted. This presentation will highlight common therapies and ingredients of therapies which will help reduce depressive symptoms in either disorder. In addition, important limitations of psychotherapy in acute bipolar depression will be delineated, and compared to limitations of psychotherapy in severe unipolar depression. Underlying mechanisms for each disorder will be explored as possible explanations for the differential impact of psychotherapy in BD and MDD.
doi:10.1016/j.jad.2010.01.024
Overview Symposium 3 Cognitive and temperamental vulnerability to depression Symposium Leaders: C. Kuehner1, J. Ormel2 1
Central Institute of Mental Health, Germany University Medical Center Groningen, Netherlands
2
This symposium presents recent research on cognitive and temperamental vulnerability factors related to the development, course and treatment of unipolar depression within a broader psychobiological context. To understand aetiology of psychopathology, it is important to examine how person-environment interactions shape vulnerability and resilience during childhood and adolescence, as both have long-term implications for adult mental health. Prof John Ormel will report results of the TRAILS study on interactions between
Abstract/Journal of Affective Disorders 122 (2010) S9–S31
Methods: A systematic literature search identified relevant studies with an emphasis on meta-analyses. Pre-defined Levels of Evidence were specified for recommendations, which were then graded according to Line of Treatment, where first-line treatment represents a balance of efficacy, tolerability and clinical support. Clinical support refers to application of expert opinion of the CANMAT committees to ensure that evidence-supported interventions are realistic and applicable for clinical practice. Results: Emerging evidence suggests that some first-line antidepressants have small but still clinically relevant differences in efficacy. For incomplete response/remission, the evidence supports various switching and add-on/adjunctive strategies. Level 1 evidence supports the adjunct use of lithium and atypical antipsychotics, while evidence is more limited for other agents (e.g., thyroid hormone, adjunct antidepressants, buspirone and stimulants). Advantages and disadvantages of these strategies, and the use of clinical algorithms, will be discussed. Discussion: There is considerable evidence for efficacy of many pharmacotherapy strategies for MDD, whether as a first-choice treatment or for incomplete response/remission. However, there is still limited evidence comparing the various agents, sequencing of strategies, and algorithms. Selection and sequencing of antidepressants still requires individualized assessment of patient and clinical factors. Keywords: Antidepressants; Algorithms; Guidelines; Major depression doi:10.1016/j.jad.2010.01.022
S2.3 CANMAT Guidelines for bipolar depression: Contrasts and similarities with major depression L. Yatham University of British Columbia, Canada Introduction: Although there is international consensus on guidelines for management of unipolar depression, acute mania and prophylaxis of bipolar disorder, there continues to be wider disagreements about guidelines for managing bipolar depression. This presentation will outline the guidelines developed by the Canadian Network for Mood and Anxiety Treatments (CANMAT) group in collaboration with experts from the International Society for Bipolar Disorders (ISBD). Method: The strenght of evidence for each treatment was ranked in categories ranging from category 1 to 4 with category 1 being the best evidence as indicated by data from replicated double blind placebo controlled trials. The evidence was then translated by the group to clinical recommendations ranging from first line to not recommended categories and this took into account the evidence for efficacy, support for efficacy from clinical practice, and safety considerations. Results: The controversy was related mainly to use of antidepressants and lamotrigine. However, based on the above criteria, the group reached consensus that there is sufficient evidence to recommend Llithium, lamotrigine and quetiapine monotherapy, olanzapine plus SSRI, and lithium or divalproex plus SSRI/bupropion as first line options. New data support the use of adjunctive modafinil as a second line ption, and current evidence suggest that aripiprazole should not be used as monotherapy for bipolar depression. Conclusions: These recommendations are in contrast to other guidelines which do not recommend antidepressants and lamotrigine as first line treatments. doi:10.1016/j.jad.2010.01.023
S2.4 Disorder specific psychotherapy: Contrasts between major depressive disorder and bipolar depression S.V. Parikh University of Toronto, Canada Introduction: Acute depression in major depressive disorder (MDD) and bipolar disorder (BD) differ somewhat in presentation and extensively in pharmacotherapy. Differences in psychotherapy are less clear. Methods: The psychotherapy literature for MDD and BD was reviewed. Contrasts in goals, approaches, and outcomes were compiled. Results: Psychotherapy for major depressive disorder is among the most extensively researched treatment in psychiatry, with hundreds of RCTs involving cognitive behaviour therapy (CBT) alone. Other major psychotherapy treatments include interpersonal therapy (IPT) and psychodynamic therapy, with newer approaches including Mindfulness Based Cognitive therapy, Acceptance and Commitment Therapy, and Motivational Interviewing techniques. In contrast, psychotherapy research in bipolar disorder is limited, with less than twenty significant RCTs involving any phase of the illness. Most psychotherapy research in BD is developed for the maintenance phase, when the individual has few or no symptoms, and is designed to prevent relapse. Only one large recent RCT of psychotherapy for BD has been conducted, which showed that more intensive interventions (lumping together study arms of CBT, IPT, Family Focused Therapy (FFT)) were superior to a 3-session Psychoeducational intervention that was not a depression-specific intervention. Additionally, even in the maintenance phase, initial results supporting CBT and IPT have been moderated by more recent studies negative studies involving CBT for BD. Conclusion: In the management of bipolar depression versus major depressive disorder, it appears different interventions are warranted. This presentation will highlight common therapies and ingredients of therapies which will help reduce depressive symptoms in either disorder. In addition, important limitations of psychotherapy in acute bipolar depression will be delineated, and compared to limitations of psychotherapy in severe unipolar depression. Underlying mechanisms for each disorder will be explored as possible explanations for the differential impact of psychotherapy in BD and MDD.
doi:10.1016/j.jad.2010.01.024
Overview Symposium 3 Cognitive and temperamental vulnerability to depression Symposium Leaders: C. Kuehner1, J. Ormel2 1
Central Institute of Mental Health, Germany University Medical Center Groningen, Netherlands
2
This symposium presents recent research on cognitive and temperamental vulnerability factors related to the development, course and treatment of unipolar depression within a broader psychobiological context. To understand aetiology of psychopathology, it is important to examine how person-environment interactions shape vulnerability and resilience during childhood and adolescence, as both have long-term implications for adult mental health. Prof John Ormel will report results of the TRAILS study on interactions between