Mood disorders, particularly treatment-resistant depression, remain a significant clinical and public health challenge with high levels of disability, social and economic costs. Despite advances in pharmacological and psychological management, depression remains difficult to treat effectively and vies with cardiac illness as being the most disabling in terms of economic costs to society and level of disability. In terms of outcome unipolar depression is associated non-recovery and chronicity of symptoms (10-15%), recurrence (>50%), on-going residual symptomatology, unnatural death (6-8%) and social disability. Recent studies have also shown similar outcomes in first-episode and primary care cohorts even with intensive treatment.
MOOD DISORDER UNITS (MDU)
Incomplete recovery after an episode of depression predicts poor short- and long-term outcomes in terms of symptom chronicity, relapse risk and social functioning. Despite high prevalence of mood disorders and robust data showing that inadequate treatment leads to chronicity and poor long-term outcome, few Mood Disorders Units (MDU) with access to specialised inpatient, daypatient and outpatient treatment have been described worldwide in stark contrast to early intervention units treating psychosis. Parker and colleagues have described a predominantly outpatient tertiary referral centre in Sydney, the Black Dog Institute, and Cleare and Paykel have described the operation, treatment and outcome from inpatient units in South London, and Cambridge, UK, respectively. The Black Dog Institute provides an initial detailed assessment to both the clinician and patient with ongoing access to online and group psychoeducation followed by a 3-month outcome assessment whereas the Maudsley and Cambridge units were based on lengthy inpatient and daypatient care of treatment resistant patients. Average length of inpatient stay in the Maudsley unit was about 6 months and in Cambridge about 3 months followed by 3 months daypatient care. These lengths of treatment reflect the need for significant duration of intensive treatment to adequately treat resistant depression.
St Patrick’s Mental Health Services (SPMHS) has been developing a specialist mood disorder unit in St. Edmundsbury Hospital, Lucan Co. Dublin, over the past 5 years. This unit incorporates a 52-bedded modern inpatient unit, predominantly single ensuite rooms, in a rural setting with a spacious historical building which is used for programmatic care and relaxation, with additional units used for programmatic treatment, daypatient and outpatient services. The unit has a national catchment area and accounts for almost 20% of inpatient beds provided by St. Patrick’s Mental Health Services (SPMHS; http://www.stpatricks.ie), Ireland’s largest independent mental health service that admits almost 20% of all first admission depressions nationally. Patients with difficult to treat depression are referred from GPs or other psychiatric services, seeking further management. Three fully staffed sub-specialist multidisciplinary teams contribute to individual treatment as well as inpatient and daypatient programmes.
When developing this MDU, we assessed what components of other MDUs appeared to impact on outcome. They all emphasised the need to link clinical care to clinical and research outcomes by using standardised, easy-to-conduct rating scales which are routinely used in St Edmundsbury. In terms of clinical inputs, a detailed initial assessment subtyping disorder and co-morbidity was described as well as psychoeducation programmes, access to psychotherapy and multidisciplinary care, high-dose pharmacotherapy and long continuity of care. The facility in St Edmundsbury aims to provide a treatment care plan of approximately one year’s duration typically composed of a comprehensive assessment and treatment at inpatient (4-6 weeks), day-patient (2-6 months) and outpatient levels (>1 year), though patients may enter or leave the programme at any point, thus allowing for full recovery and identifying early recurrence given the typical duration of at least 9-12 months for full functional recovery.
ST EDMUNDSBURY MDU
The 4-6 week inpatient programme incorporates psychoeducation, group psychotherapy and behavioural activation through lectures, stress management, goal setting, psychological and occupational group therapies that all inpatients attend from admission (Table 1). Themes include illness definition, epidemiology, co-morbidity, goal setting, lifestyle change, adherence, modalities of psychotherapy and pharmacotherapy.
The programme is supplemented by weekly psychotherapy, cognitive behavioural therapy and mindfulness groups, which are by referral only at the first multidisciplinary team (MDT) meeting. Individual treatment consists of twice-weekly consultant review, daily supportive therapy, and individual psychotherapy which includes psychodynamic therapy, schema therapy, compassion focussed therapy, cognitive behavioural therapy, interpersonal therapy, family/couple therapy sessions and individual occupational therapy regarding structure and roles, social work assessments, and graded exercise via physiotherapy for prominent fatigue symptoms. Patients are also encouraged to discuss treatment with team pharmacists.
After intensive inpatient treatment, many patients leave hospital with at least residual symptoms, increasing risk of relapse and chronicity without ongoing support and treatment and as such patients are referred to specific mood disorder daypatient programmes over the first 6-months post-discharge, supplementing individual community outpatient psychological and psychiatric care. Day patient programmes, involve treatment of anxiety related to depression (Acceptance and Commitment Therapy and Mindfulness), poor self-esteem, social withdrawal and negative cognitions and schema (Healthy Self Esteem and Behavioural Activation), interpersonal obstacles (Roles and Transition), and emotional over control and self-criticism (Radical Openness and Compassion Focused Therapy) (Table 2).
Suitability for specific programmes and any deterioration during programmatic care is discussed at MDT meetings therefore allowing a seamless, continuous link between inpatient, daypatient and outpatient services. Typically for difficult to treat depression, a care plan would involve a relatively short admission comprising intensive individual psychological, educational, and psychopharmacological treatment followed by a comprehensive daypatient and outpatient follow-up of approximately one year to promote full functional recovery.
In our MDU we have incorporated a detailed standardised initial MDT assessment, comprehensive group psychotherapeutic and psychoeducational programmes both at inpatient and daypatient levels, and lengthy continuity of care. Mean length of stay (33 days) is much shorter than described in other units, largely to reserve admission to initiate a care plan and to alleviate high levels of distress rather than achieve remission. Patients with refractory depression often suffer from Cluster C personality disorders and dependant/avoidant personality traits and may benefit more from intensive daypatient and outpatient support.
All 137 first-episode patients referred with depression over the first 2 years of operation of the St Edmundsbury MDU were longitudinally followed-up for 2 years. Patients referred were largely pharmacologically treatment-resistant (75%) and a third were chronically depressed (>2 years). By discharge from the service 74% had received individual therapy, 67% had attended at least one day-patient programme and patients received more intensive pharmacological treatment. With intensive, continuous treatment, outcomes were good with 83% recovering overall and with less time spent with syndromal and sub-syndromal depressive symptoms over follow-up that in comparative studies.
Despite the significant economic costs and disability associated with depression specialised treatment of this illness remains understudied. Intensive, continuous, specialised treatment is likely to impact favourably on outcome and functioning.
References available on request
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