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
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
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 10Logarithmic Scale of Odds Ratio
Citation Total Effect Lower Upper P Value
Tested psychotherapies: effect on episodes
Intensive Care (Miklowitz et al., 2007)
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
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
Tested psychotherapies: prophylaxis
Early warning signs (Perry et al., 1999) Systematic care (Simon et al., 2006)
Family-Group Psychoeducation (Reinares et al., 2008)
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
Systematic care: effects on mania
2-year intervention
S.C. N= 199
TAU N= 215
P=.04
Systematic care: effects on depression
2-year intervention
S.C. N= 199
TAU N= 215
P=.04
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
%
Tested psychotherapies: prophylaxis
Family-Focused Psychoeducation (Miklowitz et al., 2003)
Family-focused psychoeducation
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)
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
CBT in bipolar disorder: 2-year follow-up
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
Illness awareness Substance misuse avoidance Habits regularity Early warning signs identification Adherence enhancement
Psychoeducation
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
Group psychoeducation
0 100 200 300Est
im
at
ed
Sur
vival
Fun
ct
ion
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
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
Mean Number of Episodes
(5-year Follow-up)
0 1 2 3 4 5 6 7 8 9Total episodes Mania Hypomania Mixed Depression
Psychoeducation group Control group
*P<.05 psychoeducation vs control.
Colom F et al. Br J Psychiatry. 2009
*
* * *
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 -5500Total Outpatient Cost 2230