American Psychiatric Association Annual Meeting - 18-22nd May 2019, San Francisco
The American Psychiatric Association Annual Meeting for 2019 was held in San Francisco from May 18th to 22nd. NCMD member Dr Alan Currie was there to present some of his work. Alan has been working for the last 18 months with the International Olympic Committee looking at mental health in elite athletes. He presented the outcome of his review of mood disorders in this population. The findings have also been recently published in the June issue of the British Journal of Sports Medicine.
On the first day of conference, Dr Alfredo Cuellar-Barboza presented his work on binge eating in bipolar disorder. There do seem to be several subphenotypes of bipolar disorder including those with early onset, those with psychotic symptoms, those with mixed episodes, and also those where binge eating is a feature. When the two co-occur it is noted there is often a younger onset, a preponderance of females, and that the overall psychiatric symptom burden is higher too with other features including anxiety, suicidality, and comorbid alcohol use. This was followed by a very practical session led by Dr Susan McElroy on the treatment of comorbid binge eating in bipolar disorder. She noted that binge eating is often more distressing to the patient than mood disturbance and that the emergence of eating problems can impact significantly on treatment adherence overall. She began by looking at the association between some medications used to treat bipolar disorder and weight gain. Many medications do this but there are also many that are ‘weight neutral’ including aripiprazole, lamotrigine and bupropion. She then reviewed the drugs that are available to support long term weight loss. Many, are centrally acting and therefore problematic in bipolar disorder. For example, drugs that might risk elevating mood such as bupropion, naltrexone and lorcaserin (a 5HT-2C agonist). GLP1 agonists show promise but there have been case reports of a link with suicidality. Finally, she discussed treatments for Psychotropic Induced Weight Gain (PIWG). Evidence here is somewhat scanty although metformin may be helpful. She particularly stressed that SSRI drugs do not work in this context.
Later the same day lithium and mood stabilising anticonvulsants in the treatment of bipolar disorder were reviewed. Once again it was noted that lithium is the gold standard treatment here. A ‘response phenotype’ for good response includes non-rapid cycling, euphoria rather than mixed mania and a strong family history. Genetic studies are interesting and chromosome analysis shows that telomeres (which are shortened as cells age) tend to be longer in those who are lithium responders. The place of valproate treatment was reviewed. The evidence is best in acute mania although in practice this drug is often used for prophylaxis. It was stressed that therapeutic levels tend to be higher than when valproate is used as an anticonvulsant (suggestive levels of more than 80). Valproate can also be loaded over two to three days for the treatment of acute mania although in practice many clinicians take longer. Suggestive biomarkers for valproate response include mixed episodes, rapid cycling and mania post head injury or with EEG abnormalities. Lamotrigine was also reviewed. Studies show that the time to the next depressive episode is delayed at doses of 100 to 400mg/day, and it may be as good as lithium at achieving this. Lithium is however superior in delaying the time to a further manic episode. Dose loading is a risk factor for the severe rash of Stevens-Johnson syndrome and treatment has to be introduced slowly.
The second day of congress saw some interesting reflections on the role of inflammation in depression. Some depressed patients show signs of a chronic inflammatory response with alterations in inflammatory markers such as IL6, TNF alpha and CRP. Furthermore, administration of inflammatory cytokines can induce depressed mood states and inhibition of inflammation may reduce depression in autoimmune disorders. In addition, clinical predictors of treatment resistant depression such as obesity, early trauma and concurrent medical illness are all associated with inflammation. It was suggested that pro-dopaminergic antidepressant medications may be preferable when there is known to be an associated inflammatory process (perhaps via measurement of CRP). Drugs such as bupropion or dopamine agonists such as pramipexole may produce a better response in these circumstances, and this requires further investigation. Exercise may also have a stronger antidepressant effect in those who have elevated inflammatory markers such as TNF alpha.