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IS THERE SUCH A THING AS A CURE FOR MENTAL ILLNESS?

IS THERE SUCH A THING AS A CURE FOR MENTAL ILLNESS?. TOM SENSKY Assurance Medical and Underwriting Society March 2011. CURE versus REMISSION. CURE The complete eradication of the illness REMISSION State of absence of disease activity (usually in someone with a chronic disease).

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IS THERE SUCH A THING AS A CURE FOR MENTAL ILLNESS?

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  1. IS THERE SUCH A THING AS A CURE FOR MENTAL ILLNESS? TOM SENSKY Assurance Medical and Underwriting Society March 2011

  2. CURE versus REMISSION CURE • The complete eradication of the illness REMISSION • State of absence of disease activity (usually in someone with a chronic disease)

  3. WHAT SORTS OF ILLNESSES CAN BE CURED? Those which have .... • Clear-cut pathology • Simple aetiology (as opposed to multifactorial) Illnesses which have multifactorial causes or maintaining factors are likely to be chronic – cure here is unlikely

  4. OVERVIEW – DIFFERENT TYPES OF CONDITIONS

  5. OVERVIEW – DIFFERENT TYPES OF MENTAL HEALTH CONDITIONS

  6. OVERVIEW • Focus on depression and anxiety, as common mental disorders • Review of selective factors contributing to depression being best regarded as a chronic condition • For anxiety, focus on some primitive psychological factors associated with the persistence of symptoms

  7. DEPRESSION Depression is often referred to as the common cold of psychiatry. But this analogy is wrong: although common, most depressive disorders are not mild and self limiting. It is time that we treated depression as the chronic disease that it is. Jan Scott: Br Med J (editorial) (2006)

  8. EPIDEMIOLOGY OF MENTAL DISORDERS (Health of the Nation) • Of adults aged 16–64 years living in private households ,1 in 6 had suffered from some type of neurotic disorder in the week before the survey interview • Half of these experienced anxiety and/or depression Jenkins R et al: Br J Psychiatry (1998)

  9. EPIDEMIOLOGY OF MENTAL DISORDERS (Health of the Nation) Rates of common mental disorders higher among • women • those who were separated, divorced and widowed individuals of both genders, and among cohabiting women • the unemployed • those with longstanding physical complaints Jenkins R et al: Br J Psychiatry (1998)

  10. PREVALENCE OF COMMON MENTAL DISORDERS (AGES 18-32 years) 1972-3 Dunedin birth cohort, followed up prospectively to age 32 years (95% follow-up) Higher prevalence than previously reported attributed to prospective follow-up (likely to be more accurate) Moffit TE et al: Psychological Medicine (2010)

  11. DEPRESSION IN WOMEN : AETIOLOGICAL MODEL DEPRESSION • BACKGROUND • Personality • Genetics • PROVOKING AGENTS • Life events • Chronic difficulties • VULNERABILITY FACTORS • Maternal derivation • Parental separation • Social supports • Social circumstances After Brown GW & Harris T (1978)

  12. COMMON MENTAL DISORDERS : AETIOLOGY • FAMILY • Parental loss • Lack of care • Child abuse • SOCIAL • Marital discord • Poor social support • PERSONALITY • Neuroticism • Low self esteem • Low emotional strength • SOCIAL ADVERSITY • Poor housing • Unemployment VULNERABILITY FACTORS RATE OF LIFE EVENTS • PHYSIOLOGICAL • Genetic • Emotional reactivity IMPACT OF LIFE EVENTS PROTECTIVE FACTORS ONSET OF DISORDER • Good parenting • Good marital relationship • Psychological factors

  13. AETIOLOGICAL FACTORS RELEVANT TO DEPRESSION Sample of 10,045 primary care patients, from 7 countries, followed up at 6 and 12 months Bottomley C et al: Br J Psychiatry (2010)

  14. AFFECTIVE DISORDERS : GENETICS • Genetic loading : bipolar (BP)>unipolar (UP) • Concordance (MZ twins) : BP=70%, UP=40% • Risk of mood disorder in 1st degree relatives : BP=30%, UP=15% • Close relative with BP disorder = increased lifetime risk of both BP and UP disorder • Close relative with UP disorder = increased risk of UP disorder only

  15. EFFECT OF 5HT TRANSPORTER POLYMORPHISM ON SUSCEPTIBILITY TO LIFE EVENTS Individuals homozygous for the short allele of the 5HT Transporter gene [s/s] were significantly more likely to develop a major depressive episode in response to stressful life events than those homozygous for the long allele [l/l] Caspi A et al: Science (2003)

  16. AUTOBIOGRAPHICAL MEMORY The ability to recall specific memories in response to cues

  17. ATTRIBUTIONS: AN EXAMPLEBeing criticised for a piece of work

  18. REFORMULATION OF THE LEARNED HELPLESSNESS MODEL: ATTRIBUTION TYPES Attributions by depressed people for NEGATIVE events EXTERNAL SPECIFIC UNSTABLE STABLE Attributions by depressed people for POSITIVE events GLOBAL INTERNAL Abramson LY, Seligman K, Teasdale J: J Abnormal Psychology (1978)

  19. ASSOCIATION OF STRESS AT WORK WITH DEPRESSION: SYSTEMATIC REVIEW Sigrist J: Eur Arch Psychiatry Clin Neurosci (2009)

  20. ASSOCIATION OF STRESS AT WORK WITH DEPRESSION: SYSTEMATIC REVIEW Sigrist J: Eur Arch Psychiatry ClinNeurosci (2009)

  21. WORK-RELATED FACTORS CONTRIBUTING TO DEPRESSION ONSET • Longitudinal study examining onset of depression in 7 countries (6 European) • Examined influence of 39 potential risk factors • Sample: 7558 people not depressed at baseline Bottomley C et al. British Journal of Psychiatry 196 (1):13-17, 2010

  22. OFFSPRING OF SEVERELY DEPRESSED PARENTS • Prospective 20-year follow-up of offspring of severely depressed patients • Matched comparison group – offspring of parents without psychiatric morbidity • Mean age of offspring at follow-up was 35 years WeissmanMMet al: Am J Psychiatry (2006)

  23. OFFSPRING OF SEVERELY DEPRESSED PARENTS • Prospective 20-year follow-up of offspring of severely depressed patients • Matched comparison group – offspring of parents without psychiatric morbidity • Mean age of offspring at follow-up was 35 years WeissmanMMet al: Am J Psychiatry (2006)

  24. ADVERSE EVENTS IN CHILDHOOD AND ADULT DEPRESSED MOOD • Survey of 9508 adults registered with a health maintenance organisation • Assessed a variety of adverse childhood events, including abuse, violence against mother, parent in prison, etc • Assessed the odds of having at least 2 weeks of depressed mood in the past 12 months Felitti VJ et al: Am J Prev Med (1998)

  25. ETHNIC DENSITY AND COMMON MENTAL DISORDERS • Random community sample (N=4281) • After adjusting for confounders, as own-group ethnic density rose, the prevalence of common mental disorders decreased in (a) the whole ethnic minority sample; (b) the Irish group; (c) the Bangladeshi group • This was despite areas of high minority ethnic density being socially deprived • These results were not explained by discrimination, social support or social networks Das-Munshi J et al : Br Med J (2010)

  26. WILL THE INCIDENCE OF DEPRESSION RISE IN MEN? • All research to date indicates higher incidence of depression in women • Women tend to derive their self-esteem from reflected appraisals, while men focus on social comparisons, particularly regarding ‘traditional’ male roles • Women are increasingly the primary household earners (4% in 1970, 22% in 2007) • Male jobs are arguable more sensitive to the effects of recession than female jobs Dunlop BW & Mietzko T: Br J Psychiatry (2011)

  27. DEPRESSION RELAPSE RATES – ANTIDEPRESSANTS vs PLACEBO 2.4* 3.1* 3.1* 4.2* 4.5* 5.0* * Number Needed to Treat S Reid & C Barbui. Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants. BMJ 340 (mar26_1):c1468, 2010.

  28. EFFICACY OF ANTIDEPRESSANT TREATMENT FOR DEPRESSION IN PRIMARY CARE Arroll B et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev (3):CD007954, 2009

  29. UK PRESCRIPTION OF ANTIDEPRESSANT MEDICATIONS From www.tuesday1st.blogspot.com/ (dated 28 January 2010)

  30. VARIATIONS IN ANTIDEPRESSANT PRESCRIBING IN ENGLAND Northern doctors prescribe more antidepressants, study reveals Patients in areas such as Blackpool are prescribed up to three times as many antidepressants as those in parts of London James Ball and Sarah Boseley guardian.co.uk, Friday 4 March 2011 21.30 GMT http://www.guardian.co.uk/news/datablog/2011/mar/05/data-store-pharmaceuticals-industry?intcmp=239#

  31. GP DIAGNOSIS OF DEPRESSION • Meta-analysis of 41 studies involving 50,371 patients • Weighed sensitivity = 50% • Weighed specificity = 81% • GPs tend to rule out non-cases more effectively than recognising cases, but the modest prevalence of depression means that there are more false positives than missed cases • For every 100 unselected cases seen, 10 true cases of depression are identified, 10 cases missed, and 15 people diagnosed as false positives Mitchell AJ et al. Lancet 374 (9690):609-619, 2009.

  32. ARE ANTIDEPRESSANTS EFFECTIVE IN TREATING DEPRESSION? • Meta-analysis of all clinical trials submitted to the US (FDA for licensing of the four new-generation antidepressants for which full datasets were available • 35 clinical trials involving 5,133 patients (3,292 randomised to antidepressants, 1,841 to placebo) Kirsch I et al: Plos Medicine (2008)

  33. COMPARATIVE EFFICACY OF ANTIDEPRESSANT MEDICATIONS Data from Ciprianiet al (2009) – table from Bandolier (http://www.medicine.ox.ac.uk/bandolier)

  34. META-ANALYSIS OF COMPUTER CBT FOR DEPRESSION AND ANXIETY Andrews Get al : PLoS ONE (2010)

  35. DEPRESSION TREATMENT: SHORT-TERM EFFECTS OF ANTIDEPRESSANT MEDICATION OR COGNITIVE THERAPY • Severely depressed patients (n=240) were randomized to ADM (n = 120), CT (n = 60) or a (pill) placebo control (n = 60) treatment. • ADM involved paroxetine, augmented with lithium or desipramine as needed. • Treatment phase lasted 16 weeks. • The clinicians providing either ADM or CT were experienced practitioners who received feedback and supervision throughout the period of the study. DeRubeis R et al: Nature Reviews Neuroscience (2008)

  36. CBT vs ANTIDEPRESSANTS: CHANGE IN COGNITIONS I Simons AD et al (1984) Arch Gen Psych 41:45-51

  37. CBT vs ANTIDEPRESSANTS: CHANGE IN COGNITIONS II Simons AD et al (1984) Arch Gen Psych 41:45-51

  38. PROGNOSIS OF PEOPLE DIAGNOSED WITH DEPRESSION • Prospective cohort study of people diagnosed with depression • 8-11 year follow-up (N=61) • 18% of the cohort never achieved asymptomatic status Kennedy N et al: Br J Psychiatry (2005)

  39. DEPRESSION TREATMENT: DIFFERENCES WITH/WITHOUT ANXIETY PRESENT Data from STAR*D trial – 2,876 adults with major depressive disorder, started initially on treatment with citalopram Fava M et al: Am J Psychiatry (2008)

  40. EFFECTS OF PAST HISTORY AND SUBTHRESHOLD DEPRESSIVE SYMPTOMS ON LATER DEPRESSION INCIDENCE • Prospective cohort study from the Netherlands • N=1167 • Community sample • 2-year follow-up • Those who had depression within 6 months of baseline assessment were excluded Karsten J et al: Br J Psychiatry (2011)

  41. FACTORS PREDICTING LESS FAVOURABLE PROGNOSIS IN PEOPLE DIAGNOSED WITH DEPRESSION Kennedy N et al: Br J Psychiatry (2005)

  42. DEPRESSION: RELAPSE FOLLOWING ANTIDEPRESSANT MEDICATION OR COGNITIVE THERAPY • After 16 week treatment phase, patients on ADM were randomised to continuation with ADM or placebo • Patients who had CBT were allowed no more than 3 booster sessions after acute treatment DeRubeis R et al: Nature Reviews Neuroscience (2008)

  43. ANXIETY - AETIOLOGY

  44. THE EXPERIENCE OF ANXIETY • Many people who experience anxiety recognise their fears as unwarranted • Such people know (“intellectually”) that they have no need to be anxious, yet the anxiety persists • Very simple psychological factors contribute to this persistence • Conditioning (classical and operant) • Social learning

  45. CLASSICAL CONDITIONING (PAVLOV’S DOG)

  46. CLASSICAL CONDITIONING Context eg playground Bullying Anxiety Unconditioned stimulus Unconditioned response Conditioned stimulus Conditioned response Context eg playground Anxiety

  47. CLASSICAL CONDITIONING Waterway Accident in boat in water Anxiety Unconditioned stimulus Unconditioned response Conditioned stimulus Conditioned response Waterway Anxiety

  48. PROBLEMS WITH REGARDING SPECIFIC PHOBIAS AS CLASSICALLY CONDITIONED • There isn’t always a past history of a traumatic event • If there is a past history of trauma, it does always lead to development of a phobia Mineka S & Zinbarg R: American Psychologist (2006)

  49. VICARIOUS CONDITIONING • In ‘normal’ classical conditioning, the individual is exposed directly to the fearful stimulus • Laboratory-reared rhesus monkeys (not afraid of snakes) became afraid of snake by seeing wild-reared monkeys reacting fearfully to snakes • Humans can develop fears by watching videotapes of other people reacting fearfully

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