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PAPEL DE LA PSICOTERAPIA EN EL TRATAMIENTO DEL TRASTORNO BIPOLAR

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PAPEL DE LA PSICOTERAPIA

EN EL TRATAMIENTO DEL

TRASTORNO BIPOLAR

Dr. Francesc Colom PsyD, MSc, PhD

Bipolar Disorders Program IDIBAPS- CIBERSAM -Hospital Clínic

Barcelona, University of Barcelona

Centro de Investigación Biomédica En Red de Salud Mental

(2)

Declaración de conflictos de interés:

Francesc Colom, PsyD, MSc PhD

Compañía Speaker Advisor

BMS X Eli-Lilly X MSD-Merck X Astra Zeneca X X Sanofi X Pfizer X GSK X Sanofi X Tecnifar X Shire X

Otros: Ars Médica, Cambridge University Press, Columna, Giovanni Fioriti Ed, La Esfera de los Libros, Panamericana

(3)

Meta Analysis of Eight Published Trials

Lam et al. (2000) 25 .04 .00 .31 .00 Cochran (1984) 28 .12 .02 .78 .02 Scott et al. (2001) 42 .38 .09 1.55 .17 Frank et al. (1999) 40 2.12 .51 8.77 .29 Perry et al. (1999) 69 .54 .19 1.56 .25 Lam et al. (2003) 103 .26 .11 .62 .00 Miklowitz et al. (2003) 101 .46 .19 1.11 .08 Colom et al. (2003) 120 .41 .20 .86 .02 Fixed Combined (8) 528 .39 .27 .56 .00 Random Combined (8) 528 .38 .22 .66 .00 0.1 1 10

Logarithmic Scale of Odds Ratio

Citation Total Effect Lower Upper P Value

(4)

Tested psychotherapies: effect on episodes

Intensive Care (Miklowitz et al., 2007)

(5)

Intensive Psychosocial Intervention: effects

on functioning in bipolar depression

IPT (30 sessions) vs.

Collaborative Care (3 sessions)

IPT N= 84

CC N= 68

F.U.= 9 months

P=.04

(6)

Outcome According to Time Since Last Episode

Phase of Disorder Effect Lower Upper P Value

EUTHYMIA (Individual) .583 .407 .836 .002

EUTHYMIA (Group) .639 .436 .936 .018

EPISODE IN LAST YEAR .654 .388 1.101 .081 EPISODE IN LAST MONTH .839 .617 1.140 .255

ACUTE EPISODE 1.75 .601 5.098 .292

Fixed Combined (5) .703 .582 .851 .000

Random Combined (5) .711 .569 .890 .003

0.1 1 10

(7)

Tested psychotherapies: prophylaxis

Early warning signs (Perry et al., 1999) Systematic care (Simon et al., 2006)

Family-Group Psychoeducation (Reinares et al., 2008)

(8)

Efficacy of Teaching Bipolar Patients

Early Detection of Prodromal Signs

1.0

0.4

Exp-M=experimental group, manic; Exp-D=experimental group, depressive. Perry A et al. BMJ. 1999;318:149-153. 0 80 Weeks C umulati ve s ur vival Exp-M Control-M Exp-D Control-D 0.8 0.6 60 40 20

(9)

Systematic care: effects on mania

2-year intervention

S.C. N= 199

TAU N= 215

P=.04

(10)

Systematic care: effects on depression

2-year intervention

S.C. N= 199

TAU N= 215

P=.04

(11)

66 37,5 41,1 3,6 42 17,5 29,8 0 0 10 20 30 40 50 60 70 80

Mood episode Mania/hipomania Depression Mixed

Control (n=56) Intervention (n=57)

*p=0.011

*p=0.017 p=0.211

p=0.468 N=113

Patients’ Recurrences During 15-month

Follow-up after Family Psychoeducation

%

(12)

Tested psychotherapies: prophylaxis

Family-Focused Psychoeducation (Miklowitz et al., 2003)

(13)

Family-focused psychoeducation

(14)

Tested psychotherapies: prophylaxis

Patient group psychoeducation

(Colom et al., 2003; 2009; Castle et al, 2010) IPSRT (Frank et al., 2005)

CBT (Lam et al., 2003)

(15)

CBT in Bipolar Disorders: 1-year follow-up

Survival Function at mean of covariates

Time of first bipolar episode (weeks)

60 50 40 30 20 10 0 -10 C u m S u rvi va l 1.2 1.0 .8 .6 .4 .2 ALLOC therapy control

(16)

CBT in bipolar disorder: 2-year follow-up

(17)

Sessions of the Psychoeducative Program

1. Introduction

2. What is bipolar illness?

3. Causal and triggering factors 4. Symptoms (I): Mania and

hypomania

5. Symptoms (II): Depression and mixed episodes

6. Course and outcome

7. Treatment (I): mood stabilizers 8. Treatment (II): antimanic agents 9. Treatment (III): antidepressants 10. Serum levels: lithium,

carabamazepine and valproate

11. Pregnancy and genetic counselling

12. Pychopharmacology vs. Alternative therapies

13. Risks associated with treatment withdrawal

14. Alcohol and street drugs: risks in bipolar illness

15. Early detection of manic and hypomanic episodes

16. Early detection of depressive and mixed episodes

17. What to do when a new phase is detected?

18. Regularity

19. Stress management techniques 20. Problem-solving techniques 21. Final session

(18)

Illness awareness Substance misuse avoidance Habits regularity Early warning signs identification Adherence enhancement

Psychoeducation

(19)

Time to Recurrence

24 Months 18 Months 12 Months 6 Months

% Patient

s

100

80

60

40

20

Treatment group (N=60)

Control group (N=60)

N=120

p<.003

Colom et al. Arch Gen Psychiatry. 2003;60:402-407.

Efficacy of Psychoeducation: Time to

(20)

Group psychoeducation

0 100 200 300

Est

im

at

ed

Sur

vival

Fun

ct

ion

(21)

0 20 40 60 80 100 C u m u la tiv e m e a n n o . p e r p a tie n t a t 2 4 m o n th s

Control group Treatment group

Manic Relapse

Relapses During and After

Psychoeducation (2-year Follow-up)

Hospitalizations Depressive Relapse

Mixed Relapse

Colom F et al. Arch Gen Psychiatry. 2003;60:402-407.

P=.13 P=.003 P=.01 P<.001 P=.19 P=.003 P<.05 0 20 40 60 80 100

Treatment phase 24 months follow-up

P e rc e n t 0 20 40 60 80 100

Treatment phase 24-months follow-up

P e rc e n t 0 20 40 60 80 100

Treatment phase 24 months follow-up

P e rc e n t

(22)

Lithium Levels During

Psychoeducation

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

-6 months Baseline

6 months 12 months 18 months 24 months

Psychoeducation

Control Group

*

*

*

* p<0,05 * p<0,01 N=120

(23)

Mean Number of Episodes

(5-year Follow-up)

0 1 2 3 4 5 6 7 8 9

Total episodes Mania Hypomania Mixed Depression

Psychoeducation group Control group

*P<.05 psychoeducation vs control.

Colom F et al. Br J Psychiatry. 2009

*

* * *

(24)

Costs Between Groups (€)

Psychoeducation-Control

-6000 -5000 -4000 -3000 -2000 -1000 0 1000 2000 3000 Outpatient Visits 699 Emergency Visits -311 Prescribed Medication 450 Inpatient Service -5500

Total Outpatient Cost 2230

References

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