PAPEL DE LA PSICOTERAPIA EN EL TRATAMIENTO DEL TRASTORNO BIPOLAR

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1 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 GSK Sanofi Tecnifar X X X X Shire X Otros: Ars Médica, Cambridge University Press, Columna, Giovanni Fioriti Ed, La Esfera de los Libros, Panamericana Becas: Science and Innovation Ministry, Spain. CIBERSAM.

3 Meta Analysis of Eight Published Trials Citation Total Effect Lower Upper P Value Lam et al. (2000) Cochran (1984) Scott et al. (2001) Frank et al. (1999) Perry et al. (1999) Lam et al. (2003) Miklowitz et al. (2003) Colom et al. (2003) Fixed Combined (8) Random Combined (8) Logarithmic Scale of Odds Ratio Scott J & Colom F. Psychiatr Clin North Am 2005;28(2):

4 Tested psychotherapies: effect on episodes MANIA DEPRESSION 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 (Miklowitz et al., Am J Psychiatry, 2007)

6 Outcome According to Time Since Last Episode Phase of Disorder Effect Lower Upper P Value EUTHYMIA (Individual) EUTHYMIA (Group) EPISODE IN LAST YEAR EPISODE IN LAST MONTH ACUTE EPISODE Fixed Combined (5) Random Combined (5) Scott J, Vieta E & Colom F (2007)

7 Tested psychotherapies: prophylaxis MANIA DEPRESSION Early warning signs (Perry et al., 1999) Systematic care (Simon et al., 2006) Family-Group Psychoeducation (Reinares et al., 2008)

8 Cumulative survival Efficacy of Teaching Bipolar Patients Early Detection of Prodromal Signs 1.0 Exp-M Control-M Exp-D 0.8 Control-D Weeks Exp-M=experimental group, manic; Exp-D=experimental group, depressive. Perry A et al. BMJ. 1999;318:

9 Systematic care: effects on mania 2-year intervention S.C. N= 199 TAU N= 215 P=.04 (Simon et al., Arch Gen Psychiatry 2006)

10 Systematic care: effects on depression 2-year intervention S.C. N= 199 TAU N= 215 P=.04 (Simon et al., Arch Gen Psychiatry 2006)

11 Patients Recurrences During 15-month Follow-up after Family Psychoeducation % *p=0.011 N= *p=0.017 p= ,1 37,5 29,8 17,5 p= ,6 0 Mood episode Mania/hipomania Depression Mixed Control (n=56) Intervention (n=57) Reinares M et al. Bipolar Disord

12 Tested psychotherapies: prophylaxis MANIA DEPRESSION Family-Focused Psychoeducation (Miklowitz et al., 2003)

13 Family-focused psychoeducation (Miklowitz et al., Arch Gen Psychiatry 2003)

14 Tested psychotherapies: prophylaxis MANIA DEPRESSION Patient group psychoeducation (Colom et al., 2003; 2009; Castle et al, 2010) IPSRT (Frank et al., 2005) CBT (Lam et al., 2003)

15 Cum Survival CBT in Bipolar Disorders: 1-year follow-up 1.2 Survival Function at mean of covariates ALLOC therapy control Time of first bipolar episode (weeks) (Lam et al., Arch Gen Psychiatry 2003)

16 CBT in bipolar disorder: 2-year follow-up (Lam et al., Am J Psychiatry, 2005)

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

19 % Patients Efficacy of Psychoeducation: Time to recurrence of mood episode (2-year outcome) 100 N=120 p< Treatment group (N=60) Control group (N=60) 6 Months 12 Months 18 Months 24 Months Time to Recurrence Colom et al. Arch Gen Psychiatry. 2003;60:

20 Estimated Survival Function Group psychoeducation sessions (Castle et al., 2010)

21 Percent Cumulative mean no. per patient at 24 months Percent Percent Relapses During and After Psychoeducation (2-year Follow-up) Manic Relapse P= Mixed Relapse 60 P= P= P= Treatment phase 24-months follow-up 0 Treatment phase 24 months follow-up Depressive Relapse P< Hospitalizations P< P= Treatment phase 24 months follow-up Control group Treatment group Colom F et al. Arch Gen Psychiatry. 2003;60:

22 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 Lithium Levels During Psychoeducation -6 months Baseline 6 months 12 months 18 months 24 months * p<0,05 * p<0,01 N=120 Colom F, et al. Bipolar Disord 2005;7(Suppl 5): * * * Psychoeducation Control Group

23 Mean Number of Episodes (5-year Follow-up) Psychoeducation group Control group * * * * * Total episodes Mania Hypomania Mixed Depression *P<.05 psychoeducation vs control. Colom F et al. Br J Psychiatry. 2009

24 Costs Between Groups ( ) Psychoeducation-Control Outpatient Visits 699 Emergency Visits -311 Prescribed Medication 450 Inpatient Service Total Outpatient Cost 2230 Total Cost -3330

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