Pittsburgh Conference News

Dear In-Touch Network Member,

Having just returned from Pittsburgh and the 9th International Conference on Bipolar Disorders which finished on the 11th of June we have made it our task to select 4 or 5 items of importance which came up during the conference which we think will be of general interest and give you just a ‘taste’ of the conference’.

To pick just a few items from a 3 day conference packed with presentations, more than 700 attendees and more than 200 poster presentations alone is not an easy thing to do so please accept that these as a personal choice, deliberately picked to represent aspects of the wide spectrum of research presented.

The good news is that the conference organisers will make all the talks and slides of the conference available online as video or audio in due course and usually do this as soon as possible. We will let you know when we are aware of this.

The four areas I have selected are:

  1. Manic episodes are correlated to prefrontal grey matter reduction
  2. Creativity and bipolar disorder- a total population study
  3. Preliminary Studies of Ketamine in Bipolar Depression
  4. Discussion of Classification of Bipolar Disorder under new draft  DSMV system

Before moving on to these I thought I would let my colleague Sarah share, as a first time attender, her impression of the conference,

Kind regards

Dr Alan Ogilvie  Medical Director

alan.ogilvie@bipolar-foundation.org

An introduction to the conference

“This three-day meeting draws people into discussion from all over the world to share the latest knowledge and experience about bipolar disorders. Speakers and attendees include leading clinicians, researchers, and patients with a broad spectrum of bipolar disorders, mental health workers and consumers, all with the common goal of improving the quality of life for those living with bipolar disorders. I spoke to people and families struggling with a recent diagnosis, heard stories from recovering patients, and many older people with positive experiences of living with and managing bipolar

The content of the meeting was well balanced with presentations on molecular medical science and new treatments in neuroscience, and the latest talking therapies and support groups. Clinical research is clearly showing encouraging progress especially with the increased use and of brain imaging which displays the architecture of the brain. I was fascinated to see how fMRI scans show brain function and how this relates to bipolar disorders. As part of a programme of diagnosis and treatment, brain imaging demonstrates changes and shows which part of the brain is affected by mood swings. The use of fMRI scans can plot the progress of treatment; we can see the problem, we now need to know more about why the problem occurs. There is no doubt that research into mental health is on a massive cusp of increased understanding due to advanced technology and research. However, it remains that funding for mental health research is still more difficult to secure than other areas of medicine.

The plenary sessions of the meeting demonstrated the interest and importance in talking therapies. I was struck by the wide range of them and of how interested the health professionals are in promoting them as part of a programme of treatment together with medication. Some of the workshops were focused on therapies for the individual and some for families and friends, they also discussed advocacy and bipolar. There was a strong prevalence throughout the conference that early diagnosis of depression and bipolar was of the utmost importance in order to reduce the incidence of episodal mood swings; increased episodes are more difficult to manage and recover from. The resounding message was that early diagnosis was largely dependant on the need to break down stigma and fear around mental health. This stigma breeds misunderstanding and isolation, it’s an enormous problem which can feel overwhelming and in itself brings inertia. But I was also heartened to know that this need of greater awareness is widely acknowledged by clinicians, researcher, professional health worker, patients and carers. It is in the process of being addressed although more slowly than needed.

I came away from the meeting having a greater knowledge of the enormous complexities and comorbidities of mood disorders, of the wealth of approaches and treatments, and of the range of people working towards increasing its understanding.”

Sarah Catliff, Development and Fundraising Director

Sarah.Catliff@bipolar-foundation.org

1. Manic episodes are correlated to prefrontal grey matter reduction

Take-home: the evidence from this study is that having repeated episodes of mania is linked to having reduction of brain grey matter volume in the part of the brain called the ‘prefrontal cortex’ and supports a strong rationale why relapse prevention and keeping the number of manic episodes to a minimum is highly desirable..

The Study: the study was carried on 55 individuals in Norway with bipolar disorder using MRI imaging (voxel based morphometry with a 1.5T MRI). Correlation was made between the amount of brain grey matter in the prefrontal cortex and the number of lifetime manic episodes experienced.

Results: There was a strong correlation the number of manic episodes experienced and the reduction of volume of the dorsolateral prefrontal cortex The study found this change was related to number of episodes of mania but NOT overall duration of illness, suggesting the manic episodes themselves were associated with the effect.

Although previous studies have shown that individuals with bipolar disorder  have grey matter findings and other studies have shown that individuals with bipolar disorder display ‘cognitive impairment’ correlated to the number of episodes of illness, this study links these findings together.

Author contact CJ Ekman carl-johan.ekman@sll.se

Bipolar Disorders 13 (suppl 1.) 27-107 p40

2. Creativity and bipolar disorder- a total population study

Take-home: The first really large meticulous population based study to support the creativity and bipolarity relationship. It finds an increase in creative professions being represented both in people with bipolar disorder and their first degree relatives. It lends some weight to a selection bias hypothesis favouring the persistence of bipolar disorder in the community through history.

The Study: An enormous community based study of more than 26,000 people with bipolar disorder compared to controls. Done in Sweden.

Compared the frequency of occurrence of being in the “creative professions” in patients with bipolar disorder and their 1st ,2cnd and 3rd degree relatives compared to controls and their relatives.

Definitions: “creative professions” were defined artistic or scientific occupations

Results:

1. People with bipolar disorder were significantly more likely than controls to be in a ‘creative profession’ (OR 1.35, 95% CI 1.22-1.48) and this was primarily due to artistic professions. (OR 1.42, 95% CI 1.27-1.59)

2. First degree relatives of people with bipolar disorder were also more likely than controls to hold a creative profession but this was more likely to be a scientific than an artistic profession

Author contact CJ Ekman simon.kyaga@ki.se

Bipolar Disorders 13 (suppl 1.) 27-107  p64

3. Preliminary Studies of Ketamine in Bipolar Depression

Take-home: a preliminary study showed that intravenous infusion of ketamine in bipolar depressed patients with significant suicidal ideation had a rapid effect on suicidal ideation within hours and which persisted for as long as 9 days.

This data was presented in a talk by Dr Carlos Zarate, Chief of the Experimental Therapeutics and Pathophysiology Branch, Section on Neurobiology and Treatment of Mood and Anxiety Disorder from the National Institute of Health in the USA- one of the leading establishments in ‘proof of concept’ research studies.

Recent studies of the anaesthetic Ketamine which acts on ‘NMDA receptors’ have found that a single intravenous infusion dose can have a rapid antidepressant effect.

One of the problems in severe depression- (bipolar and unipolar) is severe suicidal ideation and suicide risk and it is an unfortunate fact that even when current antidepressant treatment methods are started, they do not generally have significant impact on symptomatology within the first days to a week.

One study Dr Zarate presented was impressive showing marked reduction of suicidal ideation in patients with severe suicidal ideas within hours of ketamine infusion and which persisted up to 9 days after the infusion. In clinical practice this would potentially ‘buy a window of time’ for other antidepressant agents to start to work and for other treatment to be optimised.

It is vital to emphasise that Ketamine is still only being used at an experimental stage at this time but these findings bring hope of antidepressants which really will have a rapid effect and will not require the current ‘painful delay’ of waiting for onset of action.

4. Discussion of Classification of Bipolar Disorder under new draft  DSMV system

A whole session of the conference was devoted to discussion of how bipolar disorder will be classified in the new DSMV (Diagnostic and Statistical Manual of the American Psychiatric Association, version 5), although there were psychiatrists, other researchers and also advocacy group members from across the world present.

The reason for this is that DSM has and will act as a guide for practice and research and it is vitally important to integrate all new research evidence available into the new version to make it as ‘evidence based’ as possible.

In particular Professor Jules Angst from Zurich made a presentation of data from the BRIDGE study of almost 6000 people from across 18 countries the the data from which was being used to inform decision making about certain key issues. To emphasise how international the countries included are Portugal,Morocco,Spain,Netherlands,Germany,Bosnia,Slovakia,Bulgaria,Macedonia,Egypt,Ukraine,Georgia/Armenia.Iran,Pakistan.China, Vietnam,Taiwan South Korea. The US was not even included, though obviously other US data sets were also being considered.

The take-home is that the decisions about what to change and what to leave the same in DSMV compared to DSIVTR are not arbitrary. They are very carefully thought out and based on lots of epidemiological evidence, all trying to make the diagnostic categories more reflective of the patterns of the illness.

The main areas which look like they will change are:

  1. Duration required for hypomania will probably go down to 4-6 days
  2. Mixed Episodes will cease to be specific “Episodes” and “mixed symptoms” will become a “specifier “ which can apply to manic, hypomanic or depressive episodes. This will require probably 3 symptoms of the opposite pole (ruling out ambiguous symptoms which appear in both depression and mania/hypomania).
  3. Exclusion Criteria- antidepressant induced mania will almost certainly cease to be an exclusion criteria.

Dr Ellen Frank from Pittsburgh, made the point that one of the reasons for the change around the mixed features specifier was that the current criteria which require full criteria for both a major depressive episode and manic episode to me met at the same time for weeks duration are almost never met. To ignore mixed symptoms which were often particularly painful was not an acceptable way forward.

Work continues and will do into next year and the outcome won’t just affect our American friends.

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