It has been demonstrated that there are differences in efficacy and acceptability of commonly prescribed anti-depressants (Cipriani et al. 2009). Escitalopram, sertraline, venlafaxine and mirtazapine were the most effective.

We wished to see whether our own data showed similar outcomes to the data from the metanalysis using decrease in suicidality as an outcome measure.

To compare the efficacy of anti-depressant monotherapies in patients with unipolar depression at Bedford Hospital, using suicidality (suicidal ideation and behaviour) as the outcome measure.

We included all patients with unipolar depression on an antidepressant monotherapy in Bedford hospital in our analysis (145 in total). We examined the clinical notes for each patient to assess whether they demonstrated suicidality after being prescribed the antidepressant. This allowed us to calculate rates of suicidality for each antidepressant monotherapy.

The prescription of sertraline was associated with the greatest reduction in suicidality, closely followed by citalopram.

Our results support the findings of the meta-analysis. None of the patients on Escitalopram expressed suicidality, so a reduction in suicidality rates could not be demonstrated for this monotherapy.

This audit in a small group of patients suggests that sertraline is associated with the greatest reduction in suicidality compared to the other monotherapies prescribed.

There are differences in efficacy of commonly prescribed anti-depressants. Escitalopram, sertraline, venlafaxine and mirtazapine (‘the four’) were the most effective.

To compare the efficacy of ‘the four’ with other anti-depressant monotherapies prescribed either for the treatment of unipolar depression or other indications, using discharge rates as the outcome measure.

We studied all patients on an antidepressant monotherapy in Bedford hospital (206 in total). We examined the clinical notes for each patient prescribed antidepressants to assess whether they were discharged from the out-patient clinic. Hence we calculated rates of discharge for ‘the four’ and other antidepressant monotherapies for patients with unipolar depression or another psychiatric condition.

For patients with unipolar depression, discharge rates were higher for ‘The four’. For patients with other indications, discharge rates were higher for other antidepressant monotherapies. A greater percentage of patients with unipolar depression were discharged from clinic compared with people treated for other indications

This suggests that indication for which the antidepressant monotherapy is prescribed will affect the efficacy of treatment, as measured by discharge rates. The fact that a greater percentage of patients with unipolar depression were discharged from clinic compared with people treated for other indications may suggest that people with ‘treatment resistant depression’ may really have another disorder, for example borderline personality disorder, bipolar disorder or PTSD.

This audit suggests that ‘the four’ are more effective for the treatment of unipolar depression compared with other indications, using discharge rates as the outcome measure.

Patients who can be treated in Primary care should receive their treatment in Primary Care.

We aim to identify depression treatments used by Bedford East Community Psychiatric Team (BECMHT) and hence identify those patients who could be appropriately managed in Primary care.

We identified 299 patients from the BECMHT database with depression (F32,F33, F41.2 and uncoded). Potential patient groups to discharge were identified by analysing these patients’ data; their medications were compared to NICE guidelines and other evidence-based-treatments.

Many patients were on different combinations of medications but there were 153 (51.2%) on one antidepressant only. Half of the patients’ medication was in accordance with NICE guidelines (157/52.5%), 11 patients were on medication with a different evidence-base and 101 patients were on medication without either of these. However, 36.5% of patients had an inter-current psychiatric diagnosis.

Prescribing patterns within BECMHT demonstrate groups of patients who are more likely to need Secondary care, including those with inter-current psychiatric diagnosis and patients on medications that are not backed by NICE or a known evidence-base. Provided adequate symptom control, the patients who could be discharged include those on one antidepressant and patients on medications in conformity with NICE guidelines who do not need monitoring in secondary care. The patient's notes should be reviewed before discharge to ensure adequate future treatment. There should be good communication with Primary care, with joint protocols and the possibility for patients to easily access services appropriate to their needs.

Depression treatment outcomes within British Community Mental Health Teams have not been adequately described.

To describe factors which influence outcome of depression within Bedford East CMHT.

Patients with Depression F32, Recurrent Depression F33, and Depression and Anxiety F42.1 were identified from a database. Factors affecting outcomes, including Suicidal ideation, Alcohol problems, Drug problems, and use of Augmentation therapy, were identified. Outcome as measured by patient discharge was compared in the three groups.

The percentage of each group discharged was 12.24 for F32, 30.53 for F33, and 29.17 for F42.1.

For F32 patients, the percentage of patients with suicidal ideation was 55.10, with alcohol problems was 32.65, with illicit drug problems was 14.28, while the percentage of patients on augmentation strategies was 38.77.

For F33 patients, the percentage of patients with suicidal ideation was 27.37, with alcohol problems was 9.47, with illicit drug problems was 1.05, while the percentage of patients on augmentation strategies was 27.37.

For F42.1 patients, the percentage of patients with suicidal ideation was 25, with alcohol problems was 8.33, with illicit drug problems was 8.33, while the percentage of patients on augmentation strategies was 54.17.

Fewer discharges occurred from the F32 group, mirroring increased suicidality and drug and alcohol use in this group. There is no significant difference in the number of patients using augmentation strategies between the F32 and F33 groups. It does not appear that augmentation strategies for treating depression are having a clear influence on outcomes.

To discuss a case study that suggests advantages for the combination of 5HT transporter inhibition plus 5HT1A receptor agonism over transporter inhibition alone.

Naturalistic clinical case study.

The patient had a documented 10 year history of poor response to SSRI's including s-citalopram. There was no suggestion of placebo response in the past. He responded well to Lu AA21004 and sustained this remission over a period of 9 months. He relapsed after Lu AA21004 was ceased. He recovered and again achieved a sustained remission after being prescribed a combination of s-citalopram plus pindolol.

The addition of pindolol (a 5HT1A receptor partial agonist) to s-citalopram adds 5HT1A receptor agonism to the 5HT transporter inhibition of s-citalopram. This is a similar profile to Lu AA21004. It is noted that Lu AA21004 also has 5HT3 receptor antagonism which is postulated to impact more on side effect profile than antidepressant efficacy. The current case strongly suggests that (in some instances at least) the addition of 5HT1A agonism to 5HT transporter inhibition might convert non-responders to responders and thus offer clinical advantage over transporter inhibition alone.

The purpose of this study is to contribute to the knowledge of the clinical characteristics of the bipolar spectrum by examining factors associated to course of symptoms in BP patients. We evaluated differences between acutely depressed versus subthreshold mixed patients.

90 depressed patients (Group 1, HDRS: 18.2±4.6, YMRS: 1.4±2.9) and 41 patients presenting a mixed subthreshold symptomathology (Group 2, HDRS: 9.1±3.2, YMRS: 9.6±6.4) were included in the study. All patients underwent structured diagnostic interviews for axis I and axis II disorders (SCID-I, SCID-II) and have been submitted to psychometric assessment with Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Young Mania Rating Scale (YMRS), Global Assessment Scale (GAS), Social Adjustment Self-reported Scale (SASS), Quality of Life Scale (QoL), at baseline and repeated follow-up (1, 3, 6, 12 months). Personality dimensions were evaluated by Temperament and Character Inventory (TCI-R).

The most important result is the slight increase in depressive symptoms in subthreshold mixed patients after 3 months of treatment. These patients were more likely diagnosed as BP-I, were non-SUD patients and/or non-comorbid for axis II personality disorders and had a shorter duration of current episode prior intake. Measures of social and functional adjustment were not different in the two groups, though a slight trend for depressed patients to report a poorer quality of life. No difference in personality traits were observed among the two samples.

Our study confirms the importance of considering subthreshold symptoms in the evaluation and treatment of patients with Bipolar Disorder.

Asenapine is indicated in adults for acute treatment of schizophrenia and manic or mixed episodes associated with bipolar I disorder with or without psychotic features. We report the safety, tolerability, and efficacy of asenapine in patients with bipolar I disorder completing up to 52 weeks of treatment.

Patients completing either of two 3-week efficacy trials and a 9-week double-blind extension were eligible for this 40-week double-blind extension. Patients in the 3-week trials were randomized to flexible-dose asenapine (5 or 10 mg BID), placebo, or olanzapine (5-20 mg QD; included for assay sensitivity only). Patients entering the extension continued their preestablished treatment; those originally randomized to placebo received flexible-dose asenapine (placebo/asenapine, 5 or 10 mg BID). Safety and tolerability endpoints included adverse events (AEs), extrapyramidal symptoms, laboratory values, and anthropometric measures. Efficacy was measured as the change in Young Mania Rating Scale (YMRS) total score from 3-week trial baseline to week 52; the placebo/asenapine group was included in the safety analyses.

Incidence of treatment-emergent AEs was 71.9%, 86.1%, and 79.4% with placebo/asenapine, asenapine, and olanzapine, respectively. The most frequent AEs included headache and somnolence (placebo/asenapine); insomnia, sedation, and depression (asenapine); and weight gain, somnolence, and sedation (olanzapine). Mean ± SD changes in YMRS score at week 52 among observed cases in the intent-to-treat population were -28.6±8.1 for asenapine and -28.2±6.8 for olanzapine.

In this 52-week study, asenapine was well tolerated and long-term maintenance of efficacy was supported in patients initially presenting with bipolar mania.

Previous studies have suggested structural and physiological changes in Major Depressive Disorder (MDD). Unfortunately, there isn’t a consensus when defining the neuropathophysiology of depression. Hence, there isn’t a biological measure used in the clinical practice to define the differences between patients with depression and controls.

To test differences in Lempel-Ziv complexity (LZC) values between patients with major depression and controls.

Comparison of spontaneous oscillatory neuromagnetic activity using MEG between groups.

20 patients matching DSM IV-TR criteria for MDD, and 19 sex- and age-matched controls.

We found a significant positive correlation between age and LZC values within controls. This correlation was not found in MDD patients. Depressive subjects showed a tendency of higher LZC values when compared to controls. We found significant differences between groups in anterior and right regions. After six months of treatment with Mirtazapine (30 mg V.O. O.D.), we studied the Hamilton-17 rating scale values and found that this treatment was clinically effective in most patients. The main pharmacological treatment's effect was besides reducing the LZC values in patients, to recuperate the tendency observed in controls.

We could suggest that there is a relationship between a physiological metric and depression as well as symptom relief or remission after an effective treatment. According to our results we found physiological changes in the brain dynamic in depressive patients when compared to controls which means there are neurophysiological changes in depressive patients with time.

Little is known about the influence of patients’ preferences and expectations about offered treatments for depression on treatment outcome. Therefore, we investigated whether in primary care patients with depressive disorders receiving a preferred treatment is associated with a better clinical outcome.

Within a randomized, placebo-controlled, single-centre, 10-week trial with five arms (sertraline; placebo; cognitive-behavioural group therapy (CBT-G); moderated self-help group control; treatment with sertraline or CBT-G according to patients’ choice), 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at the time of patients’ screening using a single item. To assess therapy outcome, the post-baseline sum scores of the Hamilton Depression Rating Scale (HAMD-17) were used.

Depressed patients receiving their preferred treatment (sertraline or CBT-G) (N=63) responded significantly better than those who did not receive their preferred therapy (N=54) (p = 0.001). The difference in outcome between both groups was 8.0 points on HAMD-17 for psychotherapy and 2.9 points on HAMD-17 for treatment with antidepressants. This result is not explained by differences in depression severity or drop-out rates.

Patients’ preference for pharmaco- versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.

The issue of the association between depression and neurocognitive functions is of special interest due to the strong relation between primary depressive symptoms and cognitive impairments, but this relationship in PD is far from clear at present.

To examine the influence of depression on cognitive and speech performance in various stages of PD.

Forty four patients with PD were recruited from the neurology department, University Hospital of Patras in Greece. All patients satisfied PDSBB criteria and dementia was ruled out (MMSE < 24) in all cases. Patients were then divided into six groups, based on severity of PD symptoms and presence of depression. Stage of disease severity was determined using the Hoehn - Yahr Rating Scale. Presence and severity of depression was established using the Beck Depression Inventory and DSM -IV-TR diagnostic criteria for major depressive disorder and dysthymia. Patients were further assessed with a detailed neuropsychological battery and the dysarthria examination battery. All patients were receiving standard medications for their PD symptoms.

Deficits in executive functions, prosody and speech intelligibility were most profound in the late stage depressed PD group. Phonetic impairments were most profound across all stages compared to articulatory and prosodic impairments.

Depressed mood may exacerbate cognitive and speech impairments and affective variables should be an integral part in the treatment of PD in all stages of the disease process, but especially in the later stages.

Compare quetiapine+antidepressant (AD) with lithium+AD, and quetiapine monotherapy with lithium+AD in open, rater-blinded treatment.

Patients with treatment resistant depression (Thase et al 1997 stage 1 and 2) with severity of MADRS ≥25 received: quetiapine XR 300mg/day plus AD (SSRIs or venlafaxine) (n=229), lithium (monitored to between 0.6 to 1.0 meq/l) plus AD (n=221) or quetiapine XR alone (300mg/day) (n=225) for 6 weeks. Primary efficacy measure was change from baseline in MADRS total score. The pre-specified non-inferiority limit was 3 points on the MADRS.

Fewer patients discontinued on quetiapine+AD (15.2%) than lithium+AD (20.5%) and quetiapine monotherapy (21.5%). Quetiapine+AD and quetiapine monotherapy, were not inferior to lithium+AD in the primary (per protocol) analysis with a mean difference (97.5%CI) on the MADRS of -2.32 (-4.6 to -0.05) favouring add-on quetiapine and -0.97 (-3.24 to 1.31) favouring quetiapine monotherapy. This mandated superiority testing on the modified ITT population showing no significant difference at endpoint.

In a post hoc analysis discounting multiplicity, quetiapine+AD was significantly more effective than lithium+AD on the MADRS change from baseline, p=0.046. The advantage was observed at day 4 (p=0.007) and persisted throughout. Efficacy was supported by CGI-I (p=0.07). Quetiapine+AD showed a numerically greater advantage over lithium+AD in those with two failed treatments (Stage 2) rather than one (Stage 1).

Quetiapine+AD and quetiapine monotherapy, were non-inferior to lithium+AD in treatment resistant depression. There was an early significant and persistent efficacy advantage on MADRS for quetiapine augmentation compared with lithium augmentation of SSRI or venlafaxine treatment.

A recent metanalysis has demonstrated that there are differences in efficacy and acceptability of commonly prescribed anti-depressants (Cipriani et al. 2009). Escitalopram, sertraline, venlafaxine and mirtazapine were the most effective.

We wished to find out whether the data from our own practice corresponded with the data from the metanalysis.

To compare the efficacy of anti-depressant monotherapies in patients with unipolar depression at Bedford Hospital, using discharge rates as the outcome measure.

We included all patients with unipolar depression on an antidepressant monotherapy in Bedford hospital in our analysis (145 in total). We examined the clinical notes for each patient to assess whether they had been discharged from the out-patient clinic after being prescribed the antidepressant. This allowed us to calculate discharge rates for each antidepressant monotherapy.

A higher percentage of patients prescribed Escitalopram were discharged from clinic compared to theother anti-depressant monotherapies.

Our results support the findings of the meta-analysis. The discharge rates from Bedford hospital suggest that Escitalopram in particular is the most efficacious.

This audit in a small group of patients suggests that Escitalopram leads to the highest discharge rate compared to the other monotherapies prescribed.

Since it has been shown that depressed individuals experience deficits in executive cognitive functions, current study investigates the impairments of working memory in patients suffering from major depressive disorder (M.D.D) in comparison with normal control group in terms of DSM-IV criteria.

The two groups (25 patients and 25 normal) were matched via gender, age and education. All completed Beck Depression Inventory and participated in two working memory tasks: “Paced Auditory Serial Adding Test (PASAT)” and “Wechsler Digit Span Scale”.

Using T test for independent groups, the results indicated that the patient group were experiencing significant impairments in working memory in comparison with control group(p< 0.0001) and results of Regression Analysis showed that severity of depression has a significant effect on the amount of impairments that subjects had experienced in working memory.

Depression had impaired working memory performance in individuals and the amount of impairment will increase as the severity of depressive symptoms are increasing.

Major depression (MDD) presents among other symptoms with cognitive impairment and diurnal fatigue. Residual fatigue in non-remitted patients often shows neuropharmacological treatment resistance. The relationships between cognitive dysfunction, vigilance, fatigue and affective symptom intensity is poorly described in treatment-resistant MDD (TRD).

During a prospective study protocol, 17 in-patients hospitalized for TRD were compared to a healthy control group (n=17). Patients were under SNRI or SSRI and free from diurnal benzodiazepines. All subjects underwent structured psychometry (HAMD, HAD), cognitive assessment and vigilance measurements (behavioral sleep résistance task, BSRT; psychomotor vigilance test, PVT; Auditory Verbal Learning, AVLT; trail making test, TMT). Subjective fatigue and sleepiness were assessed by the Fatigue Severity and the Epworth Sleepiness Scales respectively. All measures have been performed at two time points (T1 and T2) with a 10-day interval.

T1 and T2 showed higher fatigue and sleepiness in MDD (p< 0.05). With exception for the BSRT, between group comparisons showed significant differences for all variables.Comparison for repeated measures (T1 and T2) showed improvement in depressive symptom intensity (HAMD, p< 0.0005) but cognitive and psychomotor performances only improved for the TMT (TMT-B, p=.001).

TRD presents here with psychomotor slowing, with impaired mental flexibility (executive function) and declarative memory dysfunction. Interestingly, despite subjective complaints (ESS), objective sleepiness (BSRT) had not been revealed. Furthermore affective symptom improvement was not associated to an increase in declarative memory or psychomotor performances.

Developed as an antipsychotic, quetiapine displays moderate, transient occupancy of dopamine D2 receptors. Characterization of norquetiapine indicates this major human metabolite potently inhibits the norepinephrine transporter and binds to D2 receptors with affinity similar to quetiapine. Clinical pharmacology studies indicate pharmacodynamic differences between the immediate-release (IR) and the recently developed extended-release (XR) quetiapine formulation. The objectives of this study were to further investigate the pharmacokinetics of these formulations, and to relate D2-receptor occupancy to quetiapine and norquetiapine exposures.

Eleven healthy male volunteers, aged 20-45 years, underwent PET using the radioligand [11C]raclopride. After baseline measurements, quetiapine XR was administered once-daily for 8 days, with titration to 300 mg on Days 5-8. Quetiapine IR was administered at 300 mg daily on Days 9-12. PET measurements were repeated after the last doses of XR and IR at predicted times of Cmax. D2-receptor occupancy was calculated using a reference tissue model. Concomitant pharmacokinetic measurements were performed.

For quetiapine XR, mean D2-receptor occupancy at Cmax was 32% (SD ±11%; n=11). For quetiapine IR, mean D2-receptor occupancy at Cmax was 47% (SD ±9%; n=10). Quetiapine XR produced lower peak D2 occupancy than quetiapine IR in all subjects.

Pharmacokinetic differences between quetiapine XR and IR formulations translate to different profiles of brain receptor occupancy. Quetiapine XR was associated with lower peak D2-receptor occupancy than quetiapine IR at corresponding doses. This observation may provide important mechanistic underpinnings for emerging clinical data comparing the 2 quetiapine formulations.

Supported by funding from AstraZeneca Pharmaceuticals LP.

Symptoms of mania in geriatric patients (> 65 years old) have received much recent attention, in part due to Akiskal's Bipolar Spectrum classification (Akiskal, 2000), in which subtype VI is «bipolarity in the setting of dementia». The authors present a through revision of the issue, and 3 clinical cases are presented.

Data was collected through Medline/Pubmed website research, literature revision and other sources. Three clinical cases are presented (identifying data and sociodemographic details, history of present illness, personal history, …), which were obtained through direct observation of the patient and consultation of hospital inpatient clinical file.

We found 11272 articles, of which 458 were reviews. We were involved in direct care to 3 elderly manic patients, in our clinical activity in 2 Psychiatric Hospitals in Lisbon.

Elderly mania is a relatively rare and ill-defined syndrome, with many possible causes (genetic, iatrogenic, metabolic, infectious, oncological, traumatic SNC injuries, epilepsy, and many other neurological disorders). Appropriated exclusion of organic pathology through a correct differential diagnosis is mandatory to obtain a suitable therapeutic approach and favorable prognosis. The growing life expectancy suggests that this neuropsychiatric syndrome should be a focus of attention for psychiatrists, internists, and other health care technicians, especially those directly involved in the care of elderly patients in settings such as state/private hospitals, private clinics, day care facilities and nursing homes.