papel de la psicoterapia en el tratamiento del trastorno … · trastorno bipolar dr. francesc...
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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
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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.
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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.
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Tested psychotherapies: effect on episodes
Intensive Care (Miklowitz et al., 2007)
MANIA DEPRESSION
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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)
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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)
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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
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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
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Systematic care: effects on mania
2-year intervention
S.C. N= 199
TAU N= 215
P=.04
(Simon et al., Arch Gen Psychiatry 2006)
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Systematic care: effects on depression
2-year intervention
S.C. N= 199
TAU N= 215
P=.04
(Simon et al., Arch Gen Psychiatry 2006)
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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.
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Tested psychotherapies: prophylaxis
Family-Focused Psychoeducation (Miklowitz et al., 2003)
MANIA DEPRESSION
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Family-focused psychoeducation
(Miklowitz et al., Arch Gen Psychiatry 2003)
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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
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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)
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CBT in bipolar disorder: 2-year follow-up
(Lam et al., Am J Psychiatry, 2005)
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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
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Illness awareness
Substance misuse
avoidance
Habits
regularity
Early
warning signs
identification
Adherence
enhancement
Psychoeducation
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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)
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Group psychoeducation
0 100 200 300
Est
imat
ed S
urv
ival
Fu
nct
ion
12 + 3 sessions (Castle et al., 2010)
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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
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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.
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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
*
* * *
*
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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