Improving care for Treatment Resistant Depression

1. Improving care for Treatment Resistant Depression Prednisolone Suppression Test predicts response to intensive treatment7 • Poor naturalistic prognosis1 • Tertiary treatment works2 • -acutely • -long term • -reduced local service use • -reduced self harm • Clinical predictors of response • -Maudsley Staging Model3 • Predictors of relapse • -Social support-Residual symptoms4 • -Carer stress5 • Biological disturbance • -HPA axis overdrive6 1. Fekadu et al, J Aff Disord 2009; 2. Wooderson et al, J Aff Disord 2011; 3. Fekadu et al, J Clin Psychiatry 2009; 4. Fekadu et al, Can J Psychiatry 2011; 5. Rane et al, Psychol Med, 2011; 6. Markopoulou et al, Psychoneuroendocrinol, 2009; 7. Juruena et al, Br J Psychiatry 2009

2. Improving care for Chronic Fatigue Syndrome CBT can reverse these changes overall3 • Consistent findings of: • low basal cortisol • reduced cortisol reactivity • enhanced negative feedback control1 • Many factors interact to cause HPA change1 • Low cortisol contributes to symptoms1,2 -But patients with lowest cortisol levels respond less well to CBT treatment4 -This may be a biological marker of a need for different or longer treatments 1. Papadopoulos & Cleare, Nature Reviews: Endocrinol. 2011; 2. Cleare et al, Lancet, 1999; 3. Roberts et al, J Aff Disord, 2009; 4. Roberts et al, 2010, Psychol Med.

3. Improving care for Bipolar Depression • Clinically can’t distinguish unipolar from bipolar depression • However, treatment approaches very different • Expansion of bipolarity spectrum – when to treat as unipolar? Cortisol reactivity distinguishes bipolar and unipolar depression1 • Antidepressants may work via glucocorticoid receptors • May be a rationale for lack of good efficacy of antidepressants in bipolar depression • Suggests alternative approaches 1. Markopoulou et al, presented at ISAD 2012