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

Becas: Science and Innovation Ministry, Spain. CIBERSAM.

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 EffectLower Upper P Value

Scott J & Colom F. Psychiatr Clin North Am 2005;28(2):371-384.

Tested psychotherapies: effect on episodes

Intensive Care (Miklowitz et al., 2007)

MANIA DEPRESSION

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)

Outcome According to Time Since Last Episode

Phase of Disorder Effect LowerUpper 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

Scott J, Vieta E & Colom F (2007)

Tested psychotherapies: prophylaxis

Early warning signs (Perry et al., 1999)

Systematic care (Simon et al., 2006)

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

MANIA DEPRESSION

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

Cum

ula

tive s

urv

ival

Exp-M

Control-M

Exp-D

Control-D0.8

0.6

604020

Systematic care: effects on mania

2-year intervention

S.C. N= 199

TAU N= 215

P=.04

(Simon et al., Arch Gen Psychiatry 2006)

Systematic care: effects on depression

2-year intervention

S.C. N= 199

TAU N= 215

P=.04

(Simon et al., Arch Gen Psychiatry 2006)

66

37,541,1

3,6

42

17,5

29,8

00

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

%

Reinares M et al. Bipolar Disord. 2008.

Tested psychotherapies: prophylaxis

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

MANIA DEPRESSION

Family-focused psychoeducation

(Miklowitz et al., Arch Gen Psychiatry 2003)

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)

MANIA DEPRESSION

CBT in Bipolar Disorders: 1-year follow-up

Survival Function at mean of covariates

Time of first bipolar episode (weeks)

6050403020100-10

Cu

m S

urv

iva

l

1.2

1.0

.8

.6

.4

.2

ALLOC

therapy

control

(Lam et al., Arch Gen Psychiatry 2003)

CBT in bipolar disorder: 2-year follow-up

(Lam et al., Am J Psychiatry, 2005)

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 Months18 Months12 Months6 Months

% P

atie

nts

100

80

60

40

20

Treatment group (N=60)

Control group (N=60)

N=120p<.003

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

Efficacy of Psychoeducation: Time to

recurrence of mood episode (2-year outcome)

Group psychoeducation

0 100 200 300

Est

imat

ed S

urv

ival

Fu

nct

ion

12 + 3 sessions (Castle et al., 2010)

0

20

40

60

80

100

Cu

mu

lati

ve

me

an

no

. p

er

pa

tie

nt

at

24

mo

nth

s

Control group Treatment group

Manic Relapse

Relapses During and After

Psychoeducation (2-year Follow-up)

HospitalizationsDepressive 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

Pe

rce

nt

0

20

40

60

80

100

Treatment phase 24-months follow-up

Pe

rce

nt

0

20

40

60

80

100

Treatment phase 24 months follow-up

Pe

rce

nt

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

Colom F, et al. Bipolar Disord 2005;7(Suppl 5):32-36.

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

*

* * *

*

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

Total Cost -3330