PB-PG-0609-16166 – NIHR Research for Patient Benefit Programme – Final report Project title: Early identification and treatment of young people at high risk of recurrent mood disorders: a feasibility study Authors: Professor Jan Scott - Newcastle University Dr Paul McArdle - Northumberland, Tyne and Wear NHS Foundation Trust Dr Thomas Meyer - University of Newcastle upon Tyne Dr Aditya Sharma - Northumberland, Tyne and Wear NHS Foundation Trust Dr Iain Macmillan - Northumberland, Tyne and Wear NHS Foundation Trust Plain language summary Despite 15-25 years being the peak age of onset for recurrent depression or bipolar disorders (BD), recognition of mood disorders (and differentiating them from transient distress) and/or the introduction of appropriate treatment are frequently delayed. This study examined ways to identify young people at high risk of repeated episodes of mood disorder and to work out whether they would get recurrent depression or BD. Also, we developed a therapy that could be offered to young people with ‘emerging mood disorders’ and we talked to those who are at 'above average' risk of getting these problems, to ask their views about future services or interventions. As well as working on our study, we collaborated with teams doing similar research in Australia, the USA, France, Norway and Germany. Interestingly, it appears that there are many common findings internationally. For example, even at a very early stage in the development of recurrent mood disorders, young people are already significantly impaired in their day to day functioning. Furthermore this problem is worsened if the young person tries to cope with their mood problems by using harmful amounts of alcohol or illicit drugs. We found that 20-30% of mood disorders developed into BD and this was most likely to occur in those with a family history of BD, with cyclothymia (a personality style characterised by fluctuating cycles of up and down moods), who had experienced depressions at an earlier age, and/or if they had recently experienced some milder symptoms of mania (that were similar to those seen in mania, but that did not add up to the full diagnosis). Young people who were at risk of BD because they had a parent with BD wanted both help to cope with the times when their parent was unwell, as well as help to learn how to cope better with any stress they experienced themselves. The young people were also clear that if they were ‘at risk’ of BD (but did not actually have BD), they were more likely to accept a psychological therapy rather than the medications used to treat those people who definitely have a BD diagnosis. We reviewed the types of therapies available for young people at risk of BD or with an emerging mood disorder and have adapted the approaches to include sleep hygiene, emotional coping, physical health and reduction of harmful use of drugs and alcohol. Overall, the study has delivered a screening tool for BD and a therapy acceptable to these young people. Keywords bipolar, at risk, early intervention, screening, mood disorders, CBT, identification, prospective Summary of research findings Study Aim 1: Retrospectively assess the number of and presentation of clinically diagnosed cases of mood disorders across a range of NHS settings over the preceding 2 years. We were unable to answer the first goal exactly as initially planned (see next section for details),but we agreed with the RfPB manager on the following approach- 1. We would ask the NHS data managers to give ‘ball park’ figures on the prevalence of key symptoms related to bipolar disorders across 16-25 year olds. We would then try to construct clinical histories for a range of levels of symptoms e.g. individuals with single reports of depression, individuals with persistent recordings of depression, individuals identified as having depressive episodes, etc. 2. We would undertake a systematic review of the literature to address the original question we had posed. With regard to item 1, we found that 70% of 16-25 year olds report depressive symptoms on at least one occasion, about 48% have persistent reports of depression and about 39% probably meet criteria for depression. Over one year, about 50% of these individuals were discharged, and about 30% dropped out of the services. Crude estimates suggested transition to BD was as frequent in those who were discharged as those who were in continuous treatment (we do not have enough data to know about dropouts). However, the reliability and validity of these data were insufficient to allow publication at this stage. Also, the data managers have not been able to give more detailed prior histories due to time issues and pressure of other work (please note we offered to pay for out of hours work, but this was deemed inappropriate, as the managers felt this work did fit within the terms of reference of department work. As such, it was listed as work to be done when time was available- but there have been many issues with the ‘roll out’ of RIO across the Trust and at the time of writing the work is incomplete. The data managers have stated they will still try to hep to do this work and McCardle is liaising about the options). With regard to item 2, the systematic review showed that alcohol and substance use may be associated with early onset of mood symptoms and the presence of subthreshold bipolar symptoms increases the risk of developing harmful substance use (i.e. the problems are bi-directional). This suggests screening in youth drug and alcohol services should be considered. The review also showed that the best predictors of transition to BD in young people are: cyclothymia with a family history of BD and/or a prior history of one or more depressive episodes and evidence of subthreshold manic symptoms. (These findings are now confirmed by the data from the current study). Importantly, a childhood history of ADHD or of...