Improving care for Treatment Resistant Depression Prednisolone Suppression Test predicts response to intensive treatment 7 Poor naturalistic prognosis 1 Tertiary treatment works 2 -acutely -long term -reduced local service use -reduced self harm Clinical predictors of response -Maudsley Staging Model 3 Predictors of relapse -Social support -Residual symptoms 4 -Carer stress 5 Biological disturbance -HPA axis overdrive 6 1. Fekadu et al, J Aff Disord 2009; 2. Wooderson et al, J Aff Disord 2011; 3. Fekadu et al, J Clin Psychiatry 2009; 4. Fekadu et al, Can J Psychiatry 2011; 5. Rane et al, Psychol Med, 2011; 6. Markopoulou et al, Psychoneuroendocrinol, 2009; 7. Juruena et al, Br J Psychiatry 2009

Improving care for Chronic Fatigue Syndrome -Consistent findings of: - low basal cortisol - reduced cortisol reactivity - enhanced negative feedback control 1 -Many factors interact to cause HPA change 1 -Low cortisol contributes to symptoms 1,2 1. Papadopoulos & Cleare, Nature Reviews: Endocrinol. 2011; 2. Cleare et al, Lancet, 1999; 3. Roberts et al, J Aff Disord, 2009; 4. Roberts et al, 2010, Psychol Med. CBT can reverse these changes overall 3 -But patients with lowest cortisol levels respond less well to CBT treatment 4 -This may be a biological marker of a need for different or longer treatments

Improving care for Bipolar Depression Clinically cant distinguish unipolar from bipolar depression However, treatment approaches very different Expansion of bipolarity spectrum – when to treat as unipolar? Cortisol reactivity distinguishes bipolar and unipolar depression 1 1. Markopoulou et al, presented at ISAD 2012 Antidepressants may work via glucocorticoid receptors May be a rationale for lack of good efficacy of antidepressants in bipolar depression Suggests alternative approaches