Industry Supported Satellite Symposia

SS01 OPTIMIZING TREATMENT OUTCOMES IN SCHIZOPHRENIA: DEFINING THE RELATIONSHIP BETWEEN EFFICACY, SAFETY AND ADHERENCE

(CME LLC & Bristol-Myers Squibb)

Samuel J. Keith, Timothy J. Lambert, Anthony Harris

Along with the recent increase in the use atypical antipsychotics, came the recognition that while these agents reduce the potential for specific side effects such as extrapyramidal symptoms, they also have the potential to increase the likelihood of other side effects, including those that can lead to metabolic syndrome. The pharmacodynamics and pharmacokinetics vary such that each agent has an individual and distinct side effect profile. The pharmacodynamics of each individual atypical antipsychotic appears to impact the efficacy and the safety of the agent.

Because of the increased incidence of intolerable side effects, many patients fail to remain compliant with their antipsychotic medication. Poor compliance with medication regimens leads to increased relapse rates, increased hospitalization rates and costs, and a poorer long-term prognosis. The high rates of non-adherence and the increased potential for metabolic side effects of antipsychotic medications have forced physicians to consider switching from one agent to another for patients who are experiencing intolerable adverse effects. Due to the lack of guidelines, physicians need to be aware of current switching strategies in order to ensure the smoothest possible transition from one antipsychotic agent to another.

Throughout this educational symposium, the faculty will describe the current factors that affect compliance, including the efficacy and safety profiles of atypical antipsychotics, how their individual pharmacodynamic profiles potentially impact the safety profiles of each agent, and how and when to consider switching from one antipsychotic medication to another in order to ensure the best possible outcomes for their patients.

SS02 REINTEGRATION OF PSYCHIATRY AND MEDICINE IN PATIENTS WITH MENTAL ILLNESS

(Pfizer Australia)

Norman Sartorius, Charles H. Hennekens, Leon H. Chapman, John W. Newcomer

An increasing body of evidence suggests that in comparison to the general population, patients with severe mental illness such as schizophrenia or bipolar disorder have worse physical health and shorter life expectancy. Currently the evidence is particularly strong for schizophrenia and affective disorders. Poverty, urbanization, smoking, and reduced access to medical care contribute to cardiometabolic risk. Treatment-induced weight gain and dyslipidemia, which increase risk for diabetes mellitus and CVD, have been observed in patients treated with some second-generation antipsychotic agents.

Although persons with mental illness are at greater risk of developing medical conditions, many mental healthcare providers do not screen for, assess, or address possible medical conditions; these patients generally receive a lower level of medical care. There is growing interest in the lack of coordination of services between mental health and other specialists and primary care practitioners.

At the conclusion of this symposium, the participant should be able to (1) discuss the global increase in CVD and diabetes mellitus, as well as the elevated rates of morbidity and mortality from these conditions among patients with mental illness; (2) describe the interaction between mental and physical health and examine the impact of each on the other, as related to treatment choice; (3) analyze differences in medical care due to issues of access and compliance; and (4) present the role of psychiatry in forming strategies that optimize medical and mental outcomes in patients with mental illness and promote parity of care.

SS03 LONG-TERM OUTCOME OF SCHIZOPHRENIA IN DIFFERENT CULTURES

(Janssen-Cilag)

Bruce Singh, Norman Sartorius, Wolfgang Fleischhacker

Professor Sartorius is described as one of the most influential modern day psychiatrists. In particular, Professor Sartorius has championed a campaign to reduce the stigma associated with schizophrenia. Professor Sartorius joined the World Health Organization (WHO) in 1967 and soon assumed charge of the programme of epidemiology in social psychiatry. He was also principal investigator of several major international studies on schizophrenia, on depression and on health service delivery. In June 1993 Professor Sartorius was elected President of the World Psychiatric Association (WPA) and served as President-elect and then President until August 1999. In January 1999, Professor Sartorius was elected President of the Association of European Psychiatrists (AEP). Professor Sartorius holds professorial appointments at the Universities of London, Prague and Zagreb and at several other universities in the USA and China. Professor Sartorius has published more than 300 articles in scientific journals, authored or co-authored several books and edited a number of others. In this symposium, he will discuss cultural differences for the long term outcomes for patients with schizophrenia.

Professor Fleishhacker is the Vice Chair and Professor in the Department of Psychiatry at Innsbruck University Clinics in Austria, where he also serves as head of the Department of Biological Psychiatry. He is a certified psychotherapist with a specialty in behavioural therapy. Professor Fleischhacker is a member of the editorial boards of several peer reviewed journals, co-editor of the Schizophrenia Section for Current Opinion in Psychiatry and managing editor of the Journal Psychiatrie und Psychotherapie.

Professor Fleischhacker's main research interests relate to schizophrenia and psychopharmacology. They have led to participation in World Health Organization and World Psychiatric Association programs focusing on schizophrenia. In this symposium, he will discuss long term outcomes for patients with schizophrenia with improved medication adherence and use of long acting atypical injections.

SS04 IMPORTANCE OF RHYTHM

(Servier)

Graham Burrows, Dave Kennaway, Ian Hickie, David Cunnington

Background: Circadian rhythms are believed to have formed in the earliest primitive life forms on earth. Circadian rhythms increase the innate survival ability of organisms and can be found in bacteria, fungi, insects, fish, amphibians, reptiles and mammals. In mammals and humans circadian rhythms enable optimal and effective preparation for activity and sleep. Humans typically have endogenous circadian rhythms of just over 24hrs and zeitgebers from the external environment are able to entrain circadian rhythms to better fit the surroundings. The master biological clock is the suprachiasmatic nucleus of the hypothalamus and one important chemical involved in regulating circadian rhythm is melatonin. Disruption of circadian rhythms, such as body temperature, endocrine secreations and brain activity has been found in depressed patients and there is evidence for a possible causal relationship.

Aim: This symposium aims to investigate the relationship between disturbed circadian rhythms and depression.

Method: The presentations will examine the important role of circadian rhythms in maintaining health and the impact disrupted circadian rhythms can have on mental health and depression. Possible implications for the treatment of depression and the influence of correcting various circadian rhythms in facilitating recovery will also be discussed.

Conclusion: Professor Burrows will summarise how increased understanding of circadian rhythms can increase the understanding of mental health conditions.

SS05 UNIQUE CHALLENGES OF MANAGING DEPRESSION IN MID-LIFE WOMEN

(CME Outfitters & Wyeth)

Mario Maj, Claudio Soares, Lorraine Dennerstein

Depression among women in mid-life is a significant cause of disability.[1] It is hard to recognize and treat owing to lack of awareness of its unique manifestations and its multi-factorial etiology.[2] There are several presentations of depression in mid-life and several treatment options; nevertheless there is significant inconsistency in how patients are managed. Given the health burden of depression among perimenopausal women in terms of quality of life and medical costs, it is incumbent upon physicians to learn how to properly diagnose and treat these patients. There is an urgent need for psychiatrists to be able to recognize depression in this population and to understand how to weigh potential treatment options in light of other ongoing medical and psychosocial issues. In this interactive symposium, the experts will examine the unique clinical features of depression among perimenopausal women with an emphasis on proper diagnosis and treatment.

At the end of the CE activity, participants should be able to:

Recognize the unique features of depression in mid-life women

Develop tailored treatment plans for women with mid-life depression

Evaluate the clinical implications of comorbid medical and/or psychosocial conditions on patient management

SS06 CAN THE OBSESSIVE-COMPULSIVE SPECTRUM CONCEPT BE SUPPORTED? SIMILARITIES AND DIFFERENCES AMONGST PUTATIVE OBSESSIVE-COMPULSIVE SPECTRUM DISORDERS

(Lundbeck)

Michael Kyrios, Carl Zabel, Paul McQueen, David Castle, Susan L. Rossell, Damiaan Denys

Background: Obsessive-Compulsive Disorder (OCD), classified as an Anxiety Disorder, is chararcterised by obsessions and precoccupations, compulsions, urges, loss of control over thoughts and behaviour, and impulsivity. As many other disorders from a range of psychiatric groupings (e.g., Impulse Control Disorders, Somatoform Disorders, Substance Use Disorders) share such characteristics, the concept of the Obsessive-Compulsive Spectrum (OCS) has been proposed and is currently being discussed as part of possible changes in DSM-V. In addition to shared aspects of phenomenology and symptomatology, similarities in patterns of comorbidity and treatment are cited as supportive of the OCS concept. However, closer inspection of these factors, in addition to the cognitive profiles of disorders amongst many of the putative OCS disorders reveal few similarities and many differences.

Aim: This symposium aims to present data on specific disorders within the proposed OCS in order to examine the support base for this controversial concept.

Method: The symposium will:

describe a range of putative OCS disorders (compulsive buying, problem gambling, body dysmorphic disorder [BDD]) and compare these with OCD, the “gold standard” OCS disorder.

examine cognitive, personality and other psychological aspects of a range of putative OCS disorders.

Discuss possible changes and issues relating to DSM-V.

Conclusions: Following presentation of the four studies, Professor Paul Salkovskis will lead a discussion with the presenters around the findings and the merits of the OCS concept and other conceptual fraeworks being considered for classification of this range of disorders in DSM-V.

Professor Paul Salkovskis from the Institute of Psychiatry has agreed to act as a Discussant and will lead further discussion by the Symposium participants around the issue of whether the concept of OCS disorders can be supported.

CHARACTERIZING COMPULSIVE BUYING: IMPULSE CONTROL, OBSESSIVE-COMPULSIVE, MOOD OR OBSESSIVE-COMPULSIVE DISORDER?

Michael Kyrios, Carl Zabel, Paul McQueen

Background: Compulsive buying (CB) is a disabling condition characterized by excessive, uncontrolled, time consuming and repetitive buying behaviour, urges and preoccupations, and associated with negative financial, legal, personal, and social consequences. While no diagnostic criteria have been recognised formally, CB is usually characterised as an impulse control disorder. However, closer inspection of its symptoms, patterns of comorbidity, and personality profiles reveal similarities with addictive, obsessive-compulsive spectrum and mood disorders. To date, few studies have compared CB with related disorders on such factors.

Aim: This study aimed to compare compulsive buyers with a range of controls in order to better characterise its diagnostic profile.

Method: The study compared cohorts with CB, obsessive-compulsive disorder (OCD), problem gambling and normal controls on measures assessing mood, impulsivity, obsessionality, reward dependence, other personality factors, and cognitions.

Results: Compared to healthy controls, CB and other clinical controls were associated with higher degrees of depression and stress. Compulsive buyers were not necessarily more anxious. Like impulse control disorders, CB was associated with high novelty seeking and impulsivity. Like anxiety disorders, compulsive buyers exhibited high harm avoidance, although not as high as that found amongst problem gamblers and obsessive-compulsives. Like both impulse control and addictive disorders, CB was associated with high reward dependence. Finally, like obsessive-compulsive spectrum disorders, compulsive buyers rated themselves as having a higher need for completeness and perfectionism.

Conclusions: Compulsive buyers exhibited similarities to impulse control, addictive, obsessive-compulsive and mood disorders. This paper discusses the findings from diagnostic, etiological and phenomenological perspectives.

BDD AND OCD: THE SAME, BUT DIFFERENT?

David Castle

Content: While some degree of concern with appearance is normal, for some people, the concern becomes extreme and causes subjective distress and impairment in social and other life roles. In such extreme cases, individuals are considered to have body dysmorphic disorder (BDD). BDD has similarities with a number of other psychiatric disorders, including obsessive compulsive disorder, social anxiety disorder, and anorexia nervosa. These similarities (and differences) will be reviewed in a consideration of how BDD sits within the current and proposed psychiatric nosologies, and more specifically whether it should be considered a obsessive-compulsive spectrum disorder.

Objective: To review the characteristics of BDD and to explore its place in the putative OC spectrum of disorders.

Key messages: Many disorders in psychiatry share similar phenomenology, but this does not mean that they are aetiologically related.

Conclusion: BDD has some claims to membership of the putative OC spectrum, but also has similarities and overlap with social anxiety disorder, questioning the integrity of the OC spectrum construct.

COGNITION IN BDD AND OCD: RECENT DATA ON SIMILARITIES AND DIFFERENCES

Susan L. Rossell

Background: Previous research has suggested that patients with BDD and OCD demonstrate similar impairments in cognitive function. However, previous research has tended not to use cognitive tasks that are sensitive to BDD-related phenomena. research, and. AIMS: This study aims to provide additional empirical data showing both similarities and differences in cognitive functioning in BDD and OCD.

Method: BDD and OCD patients’ performance on executive functioning and facial affect processing tasks will specifically be examined.

Results: Both BDD and OCD patients demonstrate poor performance on a number of executive function measures. They exhibit poor inhibition and planning as examined on the Stroop and the Tower of London. Such data implicates poor prefrontal functioning. In contrast, BDD and OCD patients show different patterns of performance when asked to judge the emotions of faces. BDD patients are more likely to demonstrate abnormal ‘angry’ perception, whilst OCD patients show more problems with ‘disgust’ perception.

Conclusions: Such differences can be understood in terms of (a) differences in the underlying neurocircuitry of angry and disgust face perception, and (b) possible differences in attentional biases towards or away from the alternative emotions. Similarities and differences in the cognitive profiles of these disorders has implications for the obsessive-compulsive spectrum concept.

CONCEPT OF IMPULSIVITY AND COMPULSIVITY IN OBSESSIVE-COMPULSIVE SPECTRUM DISORDERS

Damiaan Denys

Background: In the research planning agenda leading up to DSM-V, two topics are being discussed that will influence the way that impulsive and compulsive disorders are perceived. First, there is the concept of removing obsessive-compulsive disorder from the anxiety disorders and creating an obsessive-compulsive behaviours spectrum. Second, there is the concept of expanding the impulse control disorders-not otherwise specified, which will be called impulsive-compulsive disorders.

Aim: This paper aims to examine the concepts of impulsivity and compulsivity in order to better evaluate the conceptualisation of related disorders.

Method: The presentation offers a phenomenological analysis of the concepts impulsivity and compulsivity, and reviews their neurobiological underpinnings.

Results: The group of obsessive-compulsive spectrum disorders, including impulsivity as well as compulsivity will ultimately be determined by demonstrating a shared endo-phenotype and underlying pathophysiology.

Conclusion: Changes are proposed in the conceptualization of compulsivity and impulsivity that might have important implications to the way that clinicians recognize and treat obsessive-compulsive spectrum disorders.

SS07 COMPARATIVE EFFECTIVENESS OF ANTIPSYCHOTIC DRUGS IN SCHIZOPHRENIA: WHAT HAVE WE LEARNED FROM THE CATIE STUDY

(Eli Lilly)

Jeffrey A. Lieberman, T. Scott Stroup, Joseph P. McEvoy, Marvin S. Swartz, Robert A. Rosenheck, Diana O. Perkins, Richard S. E. Keefe, Sonia M. Davis, Clarence E. Davis, Barry Lebowitz, John Hsiao, Joanne Severe

The National Institute of Mental Health (NIMH) initiated the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) program to evaluate antipsychotic drugs in clinical situations. The CATIE schizophrenia trial compares relative effectiveness among and between first generation antipsychotic drugs (FGAs), introduced in the 1950′s, and second generation antipsychotic drugs (SGAs), used extensively since their introduction in the 1990′s.

Approximately 50 US sites enrolled 1,500 persons with schizophrenia. The primary outcome was all-cause treatment discontinuation. Secondary outcomes included symptoms, side effects, neurocognitive functioning, and cost effectiveness. Phase I, double-blind and randomized, compared treatment with SGAs olanzapine, quetiapine, risperidone, and ziprasidone to perphenazine, a midpotency FGA. If the initially assigned medication was not effective, subjects could choose a Phase II trial: (1) randomization to open-label clozapine or a double-blinded SGA that was available but not assigned in Phase I; or (2) double-blinded randomization to ziprasidone or another SGA that was available but not assigned in Phase I. If the Phase II study drug was discontinued, subjects could enter Phase III, an open-label treatment based on the individual's experience in Phases I and II. The initial efficacy and safety results of Phases I and II of the trial have been reported (Lieberman et al [2005], Stroup et al. [2006], McEvoy et al [2006]).

The CATIE study indicates, not unexpectedly, that medications work; but with substantial limitations. In fact, 74% of patients elected to seek something better, rather than stay on their assigned medication. The biggest surprise was that the older medication, perphenazine, was comparably effective to at least 3 newer SGA medications, and not much worse than the best SGA, olanzapine. However, olanzapine had the most side effect incidence of weight gain and changes in glucose and lipid metabolism. Contrary to expectations, the older medication did not cause substantially more neurological side effects than the newer; we believe, because we administered a lower potency APD at moderate doses.

In Phase II for patients who discontinued their Phase I medication due to lack of symptom control and went into the clozapine pathway, clozapine was substantially better than all the other SGA medications.

In Phase II for patients who discontinued their Phase I medication and went into the ziprasidone pathway, it is important to examine the results separately, per the reason for discontinuance. If the reason was inadequate control of psychotic symptoms, those taking olanzapine or risperidone stayed on their medication significantly longer than those taking quetiapine or ziprasidone. If the reason was side effects, no significant difference among the four Phase II medications was revealed. Thus, the success of symptom control and side effects experienced by the patient on the first medication may help predict which medication may be more successful next.

The CATIE Phase II results show that for patients whose symptoms are not wholly responsive to other antipsychotic medications, clozapine is an effective choice for the next step. Olanzapine and risperidone are more effective than ziprasidone and quetiapine. But olanzapine is associated with substantial weight gain and metabolic problems, while ziprasidone is consistently associated with reduction in weight and improvement in metabolic indicators.