Mood instability and bipolar disorder: a new target for new treatments. Guy Goodwin University of Oxford

Transcription

1 Mood instability and bipolar disorder: a new target for new treatments Guy Goodwin University of Oxford

2 Disclosures of interest Grants Honoraria Shares Paid positions Advisory boards Servier Angelini, Medscape, Pfizer, Servier, Shire, Sun. P1vital University of Oxford Compass pathways, Minerva, MSD, Lundbeck (/Otsuka or /Takeda), P1Vital, Servier and Shire

3 The central place of mood monitoring Pencil and paper diaries Personal but difficult to share Text messaging Self-awareness of symptoms Sense of protection Automatic digital collection of data Constantly updated patient record Easy to review

4 True Colours engages the patient: we send weekly text or messages to enable patients to self-report their symptoms using mood rating scales. True Colours reminds the patient: we send reminders when patients do not respond

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10 10 TrueColours: on line and interactive

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12 Mood instability is a common experience Adult Psychiatric Morbidity Survey (APMS) 2007 (n = 7403) population rate of 13.9% was found, more common in women than men Peak prevalence aged 16 24, gradually declining with age to 7% of 65- to 74-year-olds Marwaha et al. Psychiatry Res 2013; 205: 262 8

13 Do you have a lot of sudden mood changes? with the timescale being suffered this symptom over the last several years

14 Objectives Is variable mood a co-morbidity or a core symptom? Is variable mood a treatment target? Is diurnal physiology disturbed in Bipolar disorder and/or Borderline personality disorder? Is variable mood ripe for digital solutions?

15 Kessler et al

16 Kessler et al

17 Overlap of disorders still unusual Overlap of symptom dimensions, common

18 Mood instability UNSTABLE MOOD ADHD BPD BD ASPD

19 Mood disorder Bipolar I Defined by mania = mood elevation with impairment including psychotic features Bipolar II Defined by major depression PLUS hypomania = mood elevation, no impairment Bipolar NOS Unipolar depression Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts 70% of patients with borderline personality disorder may have remitted in 6 years In contrast, bipolar disorder is usually a life-long relapsing condition

20 Lord Kelvin ( ) on measurement

21 Is variable mood a measureable treatment target?

22 The potential of Smart phones Collect data Geolocation Movement: sleep/wake cycle Phone, text use Voice quality and speed Apps Mood monitoring Devices of all kinds Interactive programmes

23 Time (weeks) Recruitment Low-intensity monitoring (12 weeks) 1) Research phone + AMoSS Study App 2) Fitbit One 3) GeneActiv Smart Watch 4) True Colours weekly mood monitoring 5) Mood Zoom daily mood monitoring Option to continue for ~12 months High-intensity monitoring (1 week) (i) Blood pressure monitor and ear/oral thermometer (3 x per day) (ii) Proteus Patch (continuous, 3-7 days) (iii) Shimmer ECG (continuous, 2-3 days) (iv) Mood Zoom (current mood) 10 x per day (scheduled during a week convenient to the participant) Qualitative feedback

24 Automated Monitoring of Symptom Severity Energetic

25 Patient Reported Outcome Measures (PROMS) MZ questionnaire TC questionnaires ASRM (mania) QIDS (depression) GAD-7 (anxiety) EQ-5D (QoL)

26 Diurnal Rhythms in Subjective Measures of Mood (Carr et al in submission) BPD BD HC

27 Where does variable mood come Mood is regulated Homeostasis from? Failure of homeostasis = unstable mood Candidate biology The circadian system Clock plus sleep homeostat Is it normal in bipolar and borderline disorder?

28 ACTIGRAPHY AND HEART RATE : DIURNAL VARIATION

29 Diurnal desynchronisation

30 Borderline PD, not bipolar disorder shows diurnal disorder Patients presenting with Delayed sleep phase disorder (DSPD) showed evidence of personality disorder (Dagan et al J Psychosomatic Med 41; 357) NICE guideline The management of insomnia Obvious potential for more research and treatment

31 Variability in diurnal cycle

32 BPD SHOWS MOST VARIABLE DIURNAL PHYSIOLOGY BIPOLAR EFFECTS LARGELY SLEEP RELATED ACTIVITY SLEEP HEART RATE BORDERLINE EFFECTS IN ACTIVITY, SLEEP AND HR

33 CORRELATE MOOD VARIABILITY AND DIURNAL VARIABILITY HR v MOVE v SLEEP v

34 HR v MOVE v

35 Conclusions Diurnal physiology is disturbed in Borderline personality disorder Heart rate rhythm 3 hours delayed: higher HR Sleep 2 hours delayed from activity Variability in HR and sleep associated with variable mood, especially irritability Diurnal physiology is not SO disturbed in Bipolar disorder BUT, variability in sleep associated with variable mood in BD

36 Is variable mood ripe for a digital solution? The case of sleep

37 CBT inspired with focus on: 1) Your thoughts 2) Your daily schedule 3) Your lifestyle 4) Your bedroom On line Animated therapist Community of users Data collected

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42 OASIS trial Freeman, Sheaves, Goodwin et al Lancet 2017

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45 Thanks to John Geddes David Miklowitz Emily Holmes Kate Saunders Jonathan Price Will Stevens Maarten devos Amy Bilderbeck Jean Christensen Sarah Bell Lauren Atkinson Priyanka Panshal Oliver Carr

46 Conclusions Variable mood is a treatment target Diurnal physiology is disturbed in Borderline personality disorder Sleep is probably a key mediator in BD, not just a symptom ADHD? Variable mood is ripe for digital solutions Start with sleep?