- Email: [email protected]
Psychoeducation: improving outcomes in bipolar disorder
European Psychiatry 20 (2005) 359–364 http://france.elsevier.com/direct/EURPSY/
Original article
Psychoeducation: improving outcomes in bipolar disorder Francesc Colom a,*, Dominic Lam b,* a
b
Bipolar Disorders Program, IDIBAPS, Barcelona Stanley Medical Research Center, Barcelona, Spain Henry Wellcome Building (PO77), Psychology Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Available online 19 August 2005
Abstract Background. – A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients. Methods. – A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords. Results. – Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients’ health beliefs and illness-awareness. Conclusions. – The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents. © 2005 Published by Elsevier SAS. Keywords: Bipolar disorder; Psychoeducation; Cognition; Psychotherapy
1. Introduction: why psychoeducation? Bipolar illness is a severe, chronic and recurrent condition that represents a major health problem resulting in economic burden and high mortality rates [2,15,28,40]. The efficacy of some psychological treatments in preventing relapses has lead to a relevant paradigm shift in the treatment of bipolar disorder, switching from an exclusively pharmacological therapeutic approach, to a combined yet hierarchical model in which pharmacotherapy plays a central role, and psychological interventions help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Most of the psychotherapy studies recently published report positive results on * Corresponding authors. Tel.: +34 93 227 5401; fax: +34 93 207 5678 (F. Colomb); tel.: +44 20 7848 0885; fax: +44 20 7848 5006 (D. Lam). E-mail address: [email protected] (F. Colom). 0924-9338/$ - see front matter © 2005 Published by Elsevier SAS. doi:10.1016/j.eurpsy.2005.06.002
maintenance when used as an adjuvant treatment, and efficacy in the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contained important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of lifestyle regularity — and exploring patients’ health beliefs and illness-awareness. Psychoeducation also seems to be a key intervention in the enhancement of treatment adherence and improvement of long-term outcome in several medical conditions such as cardiac illness [27], diabetes [33] and asthma [14]. Psychoeducation is simply a key element of a good medical practice and covers a fundamental right of our patients: the right to be informed about their illness. But psychiatric disorders— especially those that may lead to a lack of insight or illness-
360
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
awareness—are, due to their intimate nature where behavior and decision-making are often altered, the field that may benefit more from this intervention. 2. Psychoeducation: an evidence-based approach Despite the considerable variability of proposed approaches and paradigms to psychological treatments—from psychoanalysis and humanist approaches to behavioral therapy—many of the therapeutic proposals have not been tested, and therefore, should not be considered for routine treatment unless further supportive evidence has been established [8]. Fortunately, in the last few years, we have moved to a phase of consolidation of well-tested approaches, with most studies indicating a high efficacy of psychoeducationbased programs in the prevention of relapses [10,35]. The pioneering studies in the field, carried out by Peet and Harvey, reported some changes in patients’ attitudes towards lithium [17,34]. Unfortunately, little attention was paid to major outcome measures such as relapses. In Europe, the studies of Eduard van Gent showed a significant decrease of noncompliant behavior and hospitalizations amongst psychoeducated patients [41]. The Barcelona Bipolar Disorders Program has shown the efficacy of group psychoeducation in preventing all types of bipolar episodes—manic or hypomanic, mixed and depressive—and increasing time to relapse at the 2-year follow-up [11]. Depressed patients may tend to only get negative aspects of psychoeducational information and may have serious cognitive difficulties that may hinder the learning processes needed in psychoeducation. Manic patients can be disruptive and do not absorb the information because of distractibility and other cognitive disturbances. Hence, psychoeducation should be always performed during euthymia; in this study, patients were required to have maintained an euthymic state (Young Mania Rating Scale [YMRS] < 6, Hamilton Rating Scale for Depression [HAMD] < 8) for at least 6 months prior to entering the study. The study had a reasonably large sample size (n = 120) and a random allocation of subjects to either a treatment condition (psychoeducation plus standard pharmacological treatment) or non-intervention (non-structured meetings plus standard pharmacological treatment) [10]. The psychoeducational group consisted of 8–12 patients, twenty 90-min sessions under the direction of two trained psychologists. The content, which followed a medical model with a directive style, encouraged participation and focused on the illness rather than on psychodynamic issues. At the end of the 2 year follow-up, the number of hospitalizations per patient was lower for the psychoeducation group, although the number of patients who required hospitalization did not change significantly. This can be interpreted as psychoeducation having good attributes for avoiding the impact of the “revolving door” phenomena in the bipolar population. Interestingly, a recent sub analysis of the study data shows that psychoeducation may even be useful in those complex
patients fulfilling criteria for a comorbid personality disorder [12]. This might be particularly interesting if we consider on the one hand the poor outcome of comorbid bipolar patients [4,13,26,42] and on the other hand the complexity of its treatment [5,9]. Thus, psychoeducation may be especially useful for the more difficult-to-treat bipolar patients. The Barcelona Bipolar Disorders Program group tried to replicate the Archives’ study, paying attention to the specific role of psychoeducative elements beyond the simple — but indispensable — enhancement of treatment adherence [11]. This was a randomized clinical trial using the same 21-session program, but included only 50 bipolar I patients who fulfilled criteria for being considered as treatment compliant (elicited by compliance-focused interviews with the patients and his/her first-degree relatives or partner, and plasma concentrations of mood stabilizers) [11]. The trial was designed to clarify whether the influence of psychoeducation goes beyond the improvement of treatment adherence, and positive results were seen: the effect size was similar to the Archives’ study, as were the results. Time to relapse was longer for psychoeducated patients and, at the end of the 2 year follow-up, 92% of subjects in the control group fulfilled criteria for recurrence, versus 60% in the psychoeducation group (P < 0.01). The number of total recurrences and the number of depressive episodes were significantly lower in psychoeducated patients. There is also good evidence for the efficacy of a psychoeducation-focused family intervention from the studies performed by the Colorado group guided by David Miklowitz. Miklowitz et al. carried out a randomized study among 101 bipolar patients who were stabilized on maintenance drug therapy and were randomized to receive either 21 sessions of family-focused psychoeducational treatment (n = 31) or two family education sessions and follow-up crisis management (n = 70), both treatments delivered over a 9 month period [30]. After a 2 year follow-up, patients assigned to the longer psychosocial treatment had fewer relapses, longer times to relapse, significantly lower non-adherence rates than patients assigned to the shorter intervention and even some improvement in certain mood symptoms. Thus, professionals may expect to see great treatment benefits from use of this integral approach, especially when combined with other individual therapies [29]. 3. Topics to be addressed in a psychoeducational program Psychoeducation of bipolar patients should include information about the high recurrence rates associated with the illness, drugs and their potential side-effects, early detection of prodromal symptoms and symptoms management, the importance of avoiding illicit substances and alcohol, the importance of maintaining routines, stress management and some concrete information about issues such as pregnancy and bipolar disorder, suicide risk, stigma, social problems related to the illness, etc. (Table 1).
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
361
Table 1 Sessions of the psychoeducation program [10,11] Contents of the Barcelona 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, carbamazepine and valproate 11. Pregnancy and genetic counseling 12. Psychopharmacology 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. Life-style regularity 19. Stress management techniques 20. Problem-solving techniques 21. Final session
Psychoeducation is aimed at providing bipolar patients with a theoretical and practical approach towards understanding and coping with the consequences of illness in the context of a medical model, turning “the” illness into “their” illness, thereby attempting to make the patient understand the complex relationship amongst symptoms, personality, interpersonal environment, medication side-effects, and becoming responsible (but never guilty) when faced with the illness. This allows them to actively collaborate with the physician in some aspects of the treatment. De-stigmatization and improvement of illness-awareness plays a crucial role in the beginning of the bipolar psychoeducation, as patients may have pre-existing ideas about their illness that may be pushing them to denial. Understanding denial and learning the biological causes of the illness constitute an essential part of the first sessions. Another important issue is the distinction between causes (biological) and triggering factors. This issue will be crucial for establishing a good treatment adherence later on in the course of the illness. One of the main targets of psychoeducation concerns the enhancement of treatment adherence, which is usually very poor in bipolar patients, even when euthymic [9]. This may be viewed negatively, by some professionals of other fields of psychiatry. Nevertheless, the truth is that poor compliance has often a lot to do with misinformation or ignorance amongst relatives and the public, as shown by the results of the BEAM survey by Paolo Morselli et al. [32]. This survey completed by the GAMIAN advocacy forum questioned the patients’ main concerns about how bipolar disorder affected their lives and the issues regarding taking their prescribed drugs (Fig. 1). The most frequently cited reasons for non-compliance of treatment were “feeling dependent”, “feeling that taking medications is slavery”, “feeling afraid”, concern about long-term
Fig. 1. Concerns about medication, following the BEAM survey [32].
side effects, and “feeling ashamed”. It is noticeable that all these reasons are related to a lack of information, whilst other reasons traditionally considered by psychiatrists, such as side effects, were cited by less than 5% of patients. Thus, information is never enough to improve treatment compliance [7]. Other specific interventions for compliance, such as the Concordance model by Scott, are also useful for improving compliance [38]. Although it cannot be assured that every single factor is indispensable for the success of psychoeducation, the combination of them all has shown good prophylactic results. 4. Early detection and relapse prevention Despite the use of mood stabilizers, a significant proportion of bipolar patients suffer from frequent relapses [25]; some continue to be re-hospitalized [3]. Non-adherence to medication is part of the reasons for the failure of drugs to protect bipolar patients. However, some patients reported to have adhered consistently to prophylactic medication, still experienced relapses. In view of these findings, the National Institute of Mental Health Workshop on the Treatment of Bipolar Disorders concluded that there was an urgent need to develop new pharmacological and psychological treatments for bipolar patients [36]. Clinically it is observed that mania can fuel itself and depression can spiral down. During an early stage of mania, patients may not be totally aware that increased sociability, reemergence of feelings of sociability and confidence, and decreased need for sleep may be part of prodromal symptoms of mania. Likewise, during the prodromal stage of depression, patients may not know what the prodromal symptoms of depression are. In either case, even when patients are aware of these prodromal symptoms, they may not have any skills to cope with them. It is hoped that a combined approach of prophylactic medication plus an early intervention approach of helping bipolar patients to recognize and curb prodromal symptoms may prevent full-blown bipolar episodes. 5. Inherent problems in defining prodromes in mental health In medicine, prodromes are defined as the early signs and symptoms that herald a full episode. However, the presenta-
362
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
tion of such first symptoms can be more idiosyncratic and is probably the result of a complex mixture of biology, psychological make-up and past experiences. Prodromal symptoms can also be strikingly different, or similar to the full-blown episode but of less intense quality. Furthermore, the concept of prodrome can be circular in bipolar disorder: if unusual experiences lead to an episode, these unusual experiences are defined as bipolar prodromes but if the same unusual experiences do not lead to an episode, they cannot be defined as prodromal. With this limitation in mind, the term prodromes is used pragmatically in this paper, as a shorthand for the early warnings that patients may be at the early stages of a bipolar episode. Several naturalistic studies have found that bipolar patients were able to report prodromes [1,18,23,31,39]. Across these studies, there is good agreement about the most common prodromes of mania. These are: decreased need for sleep; increased activities/energy and sociability; racing thoughts; increased self worth; sharper senses; increased optimism; and irritability. However, there is less agreement about the common prodromes of depression. A significant proportion of bipolar patients were found to have difficulty in detecting depression prodromes, particularly those with significant residual depression symptoms. Patients found it difficult to determine when residual symptoms might become prodromal symptoms. However, across studies the most common prodromes for bipolar depression were: loss of interest in activities or people; not able to put worries or anxieties aside; interrupted sleep; and, feeling sad or wanting to cry. Lam, Wong and Sham reported that bipolar patients were able to report common prodromes reliably over 18 months [24]. Furthermore, the study found that patients’ coping abilities with manic prodromes at baseline correlated with their current levels of social functioning at baseline. The study also predicted patients’ levels of functioning, manic symptoms and relapses 18 months later. Since mania prodromes may precede a full bipolar syndrome by weeks [31,39], their early detection and intervention are particularly important if mild changes in mood states are not to spiral into more severe and prolonged conditions. It becomes logical to explore whether educating patients to detect and cope better with prodromes may prevent relapses. Two recent randomized controlled studies of early detection and intervention of bipolar episodes will be reviewed [22,35].
6. Psychological treatments to improve outcome in bipolar disorder Bipolar disorder is a complex illness. The effectiveness of any treatment program would probably largely depend on its ability to target selective problems in specific phases of the illness. Psychotherapy is generally accepted as minimally effective during an acute phase of the illness [21,22]. Like other recently published evidence-based psychological treatment for bipolar disorder [10,29], both studies discussed
below are combined treatment of mood stabilizers and psychological therapy. The two studies described here taught patients to detect prodromes early and promote good coping. Therapy required patients to learn to carry out regular and intensive monitoring of early signs. As discussed above, patients who have residual symptoms might have particular difficulties in detecting depression prodromes. They require extra training to discriminate residual symptoms from prodromal symptoms by learning to monitor not just prodromes, but the trend in which their mood is going. Other patients who prefer to be in a state of high arousal and aspire to being slightly high may choose to ignore early prodromes [20]. Often close personal knowledge of patients and good therapeutic reports are required in order to be collaborative and discuss the pros and cons of being aroused, chaotic behavior and risk of relapses. 6.1. Identifying early symptoms of relapse The simple intervention study by Perry et al. enrolled 69 patients who had experienced two or more bipolar episodes, one of which was in the previous 12 months [35]. Sixtynine patients were randomized into treatment-as-usual groups (TAU) of mood stabilizers and outpatient follow-up, or TAU plus psychological treatment. Psychological treatment consisted of seven to 12 sessions with a psychology assistant. Patients identified three symptoms at the warning stage when they would start monitoring their mood closely. They were also helped to identify three symptoms when they would contact health professionals for treatment. The overall results over the 18 months of the study period showed that, compared with TAU alone, psychological treatment reduced manic episodes by 30% and increased the time to the first manic recurrence (log rank = 7.04, df = 1, P < 0.01). However, there was no effect on depressive recurrence despite increased antidepressant use in the treatment group. An improvement in social functions, particularly social functions at work, was detected. Lam et al. [22] reported a randomized, controlled study using a cognitive therapy (CT) to help prevent relapses and promote social functioning. One hundred and three bipolar I patients were randomized into a CT group or a control group. Patients were required to be suffering from frequent relapses despite the prescription of commonly used mood stabilizers. Because of the relapse prevention nature of the study, patients enrolled were not in a severe episode of mania or depression. Both the control and the CT group received mood stabilizers and regular psychiatric follow-up. In addition, the CT group received 12–20 (mean 14) sessions of CT during the first 6 months and two booster sessions in the second 6 months. CT programs in this study are more complex than the schemes used in the study by Perry et al. In addition to traditional CT for unipolar depression, the CT in this study consisted of psychoeducation using a diathesis-stress model of the illness in order to enhance medication compliance. Furthermore, patients were taught the cognitive model of how thinking and behavior can affect mood. Hence, patients were taught that
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
behavior such as sensation seeking and taking on more tasks can fuel the mania, whilst ruminating with negative thoughts and inactivity can worsen the depression. Cognitive behavioral skills were used to help patients to monitor mood and prodromes, and to modify behavior in order to prevent the progression from the prodromal phase into a full-blown episode. Some bipolar patients have very extreme goal-attainment attitudes [20]. Examples are: “If I try hard enough I should be able to excel in anything I attempt,” and “A person should do well in everything he attempts.” As a result of these attitudes they are often behaviorally engaged in achievement activities at the expense of a good routine of regular meals, adequate sleep and exercise. As a way of coping, they often engage in very driven behavior of overworking to “make up for lost time.” Hence, therapists use traditional CT techniques to target these dysfunctional attitudes in order to promote less driven behavior and a good daily routine. Results of the study showed that over the 12-month period, significantly fewer patients in the CT group had bipolar episodes (Wald X2 = 9.0, P < 0.01) or bipolar admissions (Wald X2 = 6.7, P < 0.03) after controlling for number of previous episodes. Furthermore, patients in the CT group also had significantly fewer days in a bipolar episode (t = 3.56, P < 0.01). The CT group also showed less mood symptoms on the monthly mood questionnaires (P = 0.04). The CT group also reported better medication compliance after covarying for baseline medication compliance (Wald X2 = 4.3, P < 0.02).
7. Discussion The findings of these two studies support the conclusion that psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. The intervention program in the study by Perry et al. [35] was simpler and consisted of purely identifying early warnings and seeking early medical help. However, it achieved a significant effect in preventing manic episodes. Lam et al. used a more complex intervention [22]. It was not easy to identify the active ingredients in that study. Therapists were also highly trained clinical psychologists and hence the effect may have been more beneficial; as one patient wrote: “...realizing that I have a serious mental illness and that I need to take medication is a first step. The discrete surveillance of mood and efforts to deal with early prodromes allows me to assume a measure of control and hence develop a sense of security against the possible social and professional consequences of undetected illness.” Medication helped to stabilize the patient but the early detection of prodromes and effective coping can add to the treatment regimen to increase its efficacy. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidencebased psychoeducation programs and newer pharmacological agents. Recently, the use of psychoeducation as an
363
adjuvant prophylactic tool has been acknowledged by several prestigious treatment guidelines broadening and updating the treatment paradigms of bipolar disorder [6,16]. We should keep this in mind in our everyday clinical practice with bipolar patients especially because the benefits — in terms of fewer relapses and hospitalizations — are very clear and the costs very low. Undoubtedly, the usefulness of psychoeducation for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and it provides us with information, a strong tool to manage despair and fear. Unfortunately, many professionals fail to use psychoeducation to theirs and their patient’s advantage. Further research is needed in order to ascertain the role of other psychological interventions in the treatment of acute phases — especially bipolar depression — but it is already known that psychological treatments are efficacious in the prevention of suicide [37], which, by itself may justify the inclusion of some cognitive, supportive and/or interpersonal therapies during the acute depressive phases. To the best of our knowledge, no evidence-based information on the use of psychological approaches in (hypo)mania is available. Elation may not be a good target for psychotherapy, especially as drugs work well and rapidly, so no complementary therapy is required. Psychoeducation does not work as a monotherapy, but it is, to date, one of the few treatments guaranteeing class “A” and “B” effect as an adjuvant mood-stabilizer, according to the nomenclature of Ketter and Calabrese [19]. We are, therefore, obliged not to withhold this excellent treatment from our patients. Acknowledgements Dr. Colom’s work was supported in part by unrestricted grants from the Stanley Medical Research Institute (Bethesda, USA), Fundacio Marato TV3 and Red CIEN IDIBAPSISCIII RTIC C03/06. References [1]
[2]
[3]
[4]
[5]
[6]
Altman ES, Rea MM, Mintz J, Miklowitz DJ, Goldstein MJ, Hwang S. Prodromal symptoms and signs of bipolar relapse: a report based on prospectively collected data. Psychiatry Res 1992;41:1–8. Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34–38 years. J Affect Disord 2002;68: 167–81. Angst J, Gamma A, Sellaro R, Lavori PW, Zhang H. Recurrence of bipolar disorders and major depression: a life-long perspective. Eur Arch Psychiatry Clin Neurosci 2003;253:236–40. Bieling PJ, MacQueen GM, Marriot MJ, Robb JC, Begin H, Joffe RT, et al. Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms. Bipolar Disord 2003;5:14–21. Black DW, Winokur G, Hulbert J, Nasrallah A. Predictors of immediate response in the treatment of mania: the importance of comorbidity. Biol Psychiatry 1988;24:191–8. Calabrese JR, Kasper S, Johnson G, Tajima O, Vieta E, Yatham LN, et al. International consensus group on bipolar I depression treatment guidelines. J Clin Psychiatry 2004;65:571–9.
364 [7] [8]
[9]
[10]
[11]
[12]
[13]
[14] [15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364 Colom F, Vieta E. Non-adherence in psychiatric disorders: misbehavior or clinical feature? Acta Psychiatr Scand 2002;105:161–3. Colom F, Vieta E, Martinez A, Jorquera A, Gastó C. What is the role of psychotherapy in the treatment of bipolar disorder? Psychother Psychosom 1998;67:3–9. Colom F, Vieta E, Martinez-Arán A, Reinares M, Benabarre A, Gasto C. Clinical factors associated to treatment non-compliance in euthymic bipolar patients. J Clin Psychiatry 2000;61:549–54. Colom F, Vieta E, Martínez-Arán A, Reinares M, Goikolea JM, Benabarre A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003;60:402–7. Colom F, Vieta E, Reinares M, Martínez-Arán A, Torrent C, Goikolea JM, et al. Psychoeducation efficacy in bipolar disorders beyond compliance enhancement. J Clin Psychiatry 2003;64:1101–5. Colom F, Vieta E, Sánchez-Moreno J, Reinares M, Martínez-Arán A, Torrent C, et al. Psychoeducation in bipolar patients with comorbid personality disorders. Bipolar Disord 2005;6:294–8. Dunayevich E, Sax KW, Keck Jr. PE, McElroy SL, Sorter MT, McConville BJ, et al. Twelve-month outcome in bipolar patients with and without personality disorders. J Clin Psychiatry 2000;61:134–9. Durna Z, Ozcan S. Evaluation of self-management education for asthmatic patients. J Asthma 2003;40:631–43. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large US employers in 1999. J Occup Environ Med 2003;45:5–14. Goodwin GM, for the British Association for Psychopharmacology. Evidence-based guidelines for treating recommendations from British Association for Psychopharmacology. J Psychopharmacol 2003;17: 149–73. Harvey NS, Peet M. Lithium maintenance: effects of personality and attitude on health information acquisition and compliance. Br J Psychiatry 1991;158:200–4. Keitner GI, Solomon DA, Ryan CE, Miller IW, Mallinger A, Kupfer DJ, et al. Prodromal and residual symptoms in bipolar l disorder. Compr Psychiatry 1996;37:362–7. Ketter TA, Calabrese JR. Stabilization of mood from below versus above baseline in bipolar disorder: a new nomenclature. J Clin Psychiatry 2002;63:146–51. Lam D, Wright K, Sham P. Sense of hyper-positive self and response to cognitive therapy for bipolar disorder. Psychol Med 2005;35:69– 77. Lam DH, Jones S, Hayward P, Bright J. Cognitive therapy for bipolar disorder: a therapist’s guide to the concept, methods and practice. Wiley and Son Ltd; 1999. Lam DH, Watkins E, Hayward P, Bright J, Wright K, Kerr N, et al. A randomised controlled study of cognitive therapy of relapse prevention for bipolar affective disorder — outcome of the first year. Arch Gen Psychiatry 2003;60:145–52. Lam DH, Wong G. Prodromes, coping strategies, insight and social functioning in bipolar affective disorders. Psychol Med 1997;27: 1091–100.
[24] Lam DH, Wong G, Sham P. Prodromes, coping strategies and course of illness in bipolar affective disorders — a naturalistic study. Psychol Med 2001;31:1397–402. [25] Lavori PW, Dawson R, Mueller TI, Warshaw M, Swartz A, Leon A. Analysis of course of psychopathology: transitions among states of health and illness. Int J Methods Psychiatr Res 1996;6:321–34. [26] Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck Jr. PE, McElroy SL, et al. Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003;64:506–15. [27] Linden W. Psychological treatments in cardiac rehabilitation: review of rationales and outcomes. J Psychosom Res 2000;48:443–54. [28] López AD, Murray CJ. The global burden of disease. Nat Med 1998; 4:1241–3. [29] Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath RL. A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 2003;60:904–12. [30] Miklowitz DJ, Richards JA, George EL, Frank E, Suddath RL, Powell KB, et al. Integrated family and individual therapy for bipolar disorder: results of a treatment development study. J Clin Psychiatry 2003;64:182–91. [31] Molnar GJ, Feeney MG, Fava GA. Duration and symptoms of bipolar prodromes. Am J Psychiatry 1998;145:1576–8. [32] Morselli PL, Elgie R. The BEAM survey: Information on current and past treatment of bipolar disorder generated by a patient questionnaire. Bipolar Disord 2002;4(Suppl. 1):131. [33] Olmsted MP, Daneman D, Rydall AC, Lawson ML, Rodin G. The effects of psychoeducation on disturbed eating attitudes and behavior in young women with type 1 diabetes mellitus. Int J Eat Disord 2002;32:230–9. [34] Peet M, Harvey NS. Lithium maintenance: 1. A standard education program for patients. Br J Psychiatry 1991;158:197–200. [35] Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999; 318:149–53. [36] Prien RF, Potter WZ. NIMH workshop report on treatment of bipolar disorder. Am J Psychiatry 1990;146:840–8. [37] Rucci P, Frank E, Kostelnik B, Fagiolini A, Mallinger AG, Swartz HA, et al. Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. Am J Psychiatry 2002;159:1160–4. [38] Scott J, Tacchi MJ. A pilot study of concordance therapy for individuals with bipolar disorders who are non-adherent with lithium prophylaxis. Bipolar Disord 2002;4:386–92. [39] Smith JA, Tarrier N. Prodromal symptoms in manic-depressive psychosis. Soc Psychiatry Psychiatr Epidemiol 1992;27:245–8. [40] Tsai SY, Kuo CJ, Chen CC, Lee HC. Risk factors for completed suicide in bipolar disorder. J Clin Psychiatry 2002;63:469–76. [41] Van Gent EM. Follow-up study of 3 years group therapy with lithium treatment. Encephale 2000;26:76–9. [42] Vieta E, Colom F, Corbella B, Martinez-Aran A, Reinares M, Benabarre A, et al. Clinical correlates of psychiatric comorbidity in bipolar I patients. Bipolar Disord 2001;3:253–8.
Original article
Psychoeducation: improving outcomes in bipolar disorder Francesc Colom a,*, Dominic Lam b,* a
b
Bipolar Disorders Program, IDIBAPS, Barcelona Stanley Medical Research Center, Barcelona, Spain Henry Wellcome Building (PO77), Psychology Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Available online 19 August 2005
Abstract Background. – A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients. Methods. – A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords. Results. – Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients’ health beliefs and illness-awareness. Conclusions. – The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents. © 2005 Published by Elsevier SAS. Keywords: Bipolar disorder; Psychoeducation; Cognition; Psychotherapy
1. Introduction: why psychoeducation? Bipolar illness is a severe, chronic and recurrent condition that represents a major health problem resulting in economic burden and high mortality rates [2,15,28,40]. The efficacy of some psychological treatments in preventing relapses has lead to a relevant paradigm shift in the treatment of bipolar disorder, switching from an exclusively pharmacological therapeutic approach, to a combined yet hierarchical model in which pharmacotherapy plays a central role, and psychological interventions help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Most of the psychotherapy studies recently published report positive results on * Corresponding authors. Tel.: +34 93 227 5401; fax: +34 93 207 5678 (F. Colomb); tel.: +44 20 7848 0885; fax: +44 20 7848 5006 (D. Lam). E-mail address: [email protected] (F. Colom). 0924-9338/$ - see front matter © 2005 Published by Elsevier SAS. doi:10.1016/j.eurpsy.2005.06.002
maintenance when used as an adjuvant treatment, and efficacy in the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contained important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of lifestyle regularity — and exploring patients’ health beliefs and illness-awareness. Psychoeducation also seems to be a key intervention in the enhancement of treatment adherence and improvement of long-term outcome in several medical conditions such as cardiac illness [27], diabetes [33] and asthma [14]. Psychoeducation is simply a key element of a good medical practice and covers a fundamental right of our patients: the right to be informed about their illness. But psychiatric disorders— especially those that may lead to a lack of insight or illness-
360
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
awareness—are, due to their intimate nature where behavior and decision-making are often altered, the field that may benefit more from this intervention. 2. Psychoeducation: an evidence-based approach Despite the considerable variability of proposed approaches and paradigms to psychological treatments—from psychoanalysis and humanist approaches to behavioral therapy—many of the therapeutic proposals have not been tested, and therefore, should not be considered for routine treatment unless further supportive evidence has been established [8]. Fortunately, in the last few years, we have moved to a phase of consolidation of well-tested approaches, with most studies indicating a high efficacy of psychoeducationbased programs in the prevention of relapses [10,35]. The pioneering studies in the field, carried out by Peet and Harvey, reported some changes in patients’ attitudes towards lithium [17,34]. Unfortunately, little attention was paid to major outcome measures such as relapses. In Europe, the studies of Eduard van Gent showed a significant decrease of noncompliant behavior and hospitalizations amongst psychoeducated patients [41]. The Barcelona Bipolar Disorders Program has shown the efficacy of group psychoeducation in preventing all types of bipolar episodes—manic or hypomanic, mixed and depressive—and increasing time to relapse at the 2-year follow-up [11]. Depressed patients may tend to only get negative aspects of psychoeducational information and may have serious cognitive difficulties that may hinder the learning processes needed in psychoeducation. Manic patients can be disruptive and do not absorb the information because of distractibility and other cognitive disturbances. Hence, psychoeducation should be always performed during euthymia; in this study, patients were required to have maintained an euthymic state (Young Mania Rating Scale [YMRS] < 6, Hamilton Rating Scale for Depression [HAMD] < 8) for at least 6 months prior to entering the study. The study had a reasonably large sample size (n = 120) and a random allocation of subjects to either a treatment condition (psychoeducation plus standard pharmacological treatment) or non-intervention (non-structured meetings plus standard pharmacological treatment) [10]. The psychoeducational group consisted of 8–12 patients, twenty 90-min sessions under the direction of two trained psychologists. The content, which followed a medical model with a directive style, encouraged participation and focused on the illness rather than on psychodynamic issues. At the end of the 2 year follow-up, the number of hospitalizations per patient was lower for the psychoeducation group, although the number of patients who required hospitalization did not change significantly. This can be interpreted as psychoeducation having good attributes for avoiding the impact of the “revolving door” phenomena in the bipolar population. Interestingly, a recent sub analysis of the study data shows that psychoeducation may even be useful in those complex
patients fulfilling criteria for a comorbid personality disorder [12]. This might be particularly interesting if we consider on the one hand the poor outcome of comorbid bipolar patients [4,13,26,42] and on the other hand the complexity of its treatment [5,9]. Thus, psychoeducation may be especially useful for the more difficult-to-treat bipolar patients. The Barcelona Bipolar Disorders Program group tried to replicate the Archives’ study, paying attention to the specific role of psychoeducative elements beyond the simple — but indispensable — enhancement of treatment adherence [11]. This was a randomized clinical trial using the same 21-session program, but included only 50 bipolar I patients who fulfilled criteria for being considered as treatment compliant (elicited by compliance-focused interviews with the patients and his/her first-degree relatives or partner, and plasma concentrations of mood stabilizers) [11]. The trial was designed to clarify whether the influence of psychoeducation goes beyond the improvement of treatment adherence, and positive results were seen: the effect size was similar to the Archives’ study, as were the results. Time to relapse was longer for psychoeducated patients and, at the end of the 2 year follow-up, 92% of subjects in the control group fulfilled criteria for recurrence, versus 60% in the psychoeducation group (P < 0.01). The number of total recurrences and the number of depressive episodes were significantly lower in psychoeducated patients. There is also good evidence for the efficacy of a psychoeducation-focused family intervention from the studies performed by the Colorado group guided by David Miklowitz. Miklowitz et al. carried out a randomized study among 101 bipolar patients who were stabilized on maintenance drug therapy and were randomized to receive either 21 sessions of family-focused psychoeducational treatment (n = 31) or two family education sessions and follow-up crisis management (n = 70), both treatments delivered over a 9 month period [30]. After a 2 year follow-up, patients assigned to the longer psychosocial treatment had fewer relapses, longer times to relapse, significantly lower non-adherence rates than patients assigned to the shorter intervention and even some improvement in certain mood symptoms. Thus, professionals may expect to see great treatment benefits from use of this integral approach, especially when combined with other individual therapies [29]. 3. Topics to be addressed in a psychoeducational program Psychoeducation of bipolar patients should include information about the high recurrence rates associated with the illness, drugs and their potential side-effects, early detection of prodromal symptoms and symptoms management, the importance of avoiding illicit substances and alcohol, the importance of maintaining routines, stress management and some concrete information about issues such as pregnancy and bipolar disorder, suicide risk, stigma, social problems related to the illness, etc. (Table 1).
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
361
Table 1 Sessions of the psychoeducation program [10,11] Contents of the Barcelona 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, carbamazepine and valproate 11. Pregnancy and genetic counseling 12. Psychopharmacology 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. Life-style regularity 19. Stress management techniques 20. Problem-solving techniques 21. Final session
Psychoeducation is aimed at providing bipolar patients with a theoretical and practical approach towards understanding and coping with the consequences of illness in the context of a medical model, turning “the” illness into “their” illness, thereby attempting to make the patient understand the complex relationship amongst symptoms, personality, interpersonal environment, medication side-effects, and becoming responsible (but never guilty) when faced with the illness. This allows them to actively collaborate with the physician in some aspects of the treatment. De-stigmatization and improvement of illness-awareness plays a crucial role in the beginning of the bipolar psychoeducation, as patients may have pre-existing ideas about their illness that may be pushing them to denial. Understanding denial and learning the biological causes of the illness constitute an essential part of the first sessions. Another important issue is the distinction between causes (biological) and triggering factors. This issue will be crucial for establishing a good treatment adherence later on in the course of the illness. One of the main targets of psychoeducation concerns the enhancement of treatment adherence, which is usually very poor in bipolar patients, even when euthymic [9]. This may be viewed negatively, by some professionals of other fields of psychiatry. Nevertheless, the truth is that poor compliance has often a lot to do with misinformation or ignorance amongst relatives and the public, as shown by the results of the BEAM survey by Paolo Morselli et al. [32]. This survey completed by the GAMIAN advocacy forum questioned the patients’ main concerns about how bipolar disorder affected their lives and the issues regarding taking their prescribed drugs (Fig. 1). The most frequently cited reasons for non-compliance of treatment were “feeling dependent”, “feeling that taking medications is slavery”, “feeling afraid”, concern about long-term
Fig. 1. Concerns about medication, following the BEAM survey [32].
side effects, and “feeling ashamed”. It is noticeable that all these reasons are related to a lack of information, whilst other reasons traditionally considered by psychiatrists, such as side effects, were cited by less than 5% of patients. Thus, information is never enough to improve treatment compliance [7]. Other specific interventions for compliance, such as the Concordance model by Scott, are also useful for improving compliance [38]. Although it cannot be assured that every single factor is indispensable for the success of psychoeducation, the combination of them all has shown good prophylactic results. 4. Early detection and relapse prevention Despite the use of mood stabilizers, a significant proportion of bipolar patients suffer from frequent relapses [25]; some continue to be re-hospitalized [3]. Non-adherence to medication is part of the reasons for the failure of drugs to protect bipolar patients. However, some patients reported to have adhered consistently to prophylactic medication, still experienced relapses. In view of these findings, the National Institute of Mental Health Workshop on the Treatment of Bipolar Disorders concluded that there was an urgent need to develop new pharmacological and psychological treatments for bipolar patients [36]. Clinically it is observed that mania can fuel itself and depression can spiral down. During an early stage of mania, patients may not be totally aware that increased sociability, reemergence of feelings of sociability and confidence, and decreased need for sleep may be part of prodromal symptoms of mania. Likewise, during the prodromal stage of depression, patients may not know what the prodromal symptoms of depression are. In either case, even when patients are aware of these prodromal symptoms, they may not have any skills to cope with them. It is hoped that a combined approach of prophylactic medication plus an early intervention approach of helping bipolar patients to recognize and curb prodromal symptoms may prevent full-blown bipolar episodes. 5. Inherent problems in defining prodromes in mental health In medicine, prodromes are defined as the early signs and symptoms that herald a full episode. However, the presenta-
362
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
tion of such first symptoms can be more idiosyncratic and is probably the result of a complex mixture of biology, psychological make-up and past experiences. Prodromal symptoms can also be strikingly different, or similar to the full-blown episode but of less intense quality. Furthermore, the concept of prodrome can be circular in bipolar disorder: if unusual experiences lead to an episode, these unusual experiences are defined as bipolar prodromes but if the same unusual experiences do not lead to an episode, they cannot be defined as prodromal. With this limitation in mind, the term prodromes is used pragmatically in this paper, as a shorthand for the early warnings that patients may be at the early stages of a bipolar episode. Several naturalistic studies have found that bipolar patients were able to report prodromes [1,18,23,31,39]. Across these studies, there is good agreement about the most common prodromes of mania. These are: decreased need for sleep; increased activities/energy and sociability; racing thoughts; increased self worth; sharper senses; increased optimism; and irritability. However, there is less agreement about the common prodromes of depression. A significant proportion of bipolar patients were found to have difficulty in detecting depression prodromes, particularly those with significant residual depression symptoms. Patients found it difficult to determine when residual symptoms might become prodromal symptoms. However, across studies the most common prodromes for bipolar depression were: loss of interest in activities or people; not able to put worries or anxieties aside; interrupted sleep; and, feeling sad or wanting to cry. Lam, Wong and Sham reported that bipolar patients were able to report common prodromes reliably over 18 months [24]. Furthermore, the study found that patients’ coping abilities with manic prodromes at baseline correlated with their current levels of social functioning at baseline. The study also predicted patients’ levels of functioning, manic symptoms and relapses 18 months later. Since mania prodromes may precede a full bipolar syndrome by weeks [31,39], their early detection and intervention are particularly important if mild changes in mood states are not to spiral into more severe and prolonged conditions. It becomes logical to explore whether educating patients to detect and cope better with prodromes may prevent relapses. Two recent randomized controlled studies of early detection and intervention of bipolar episodes will be reviewed [22,35].
6. Psychological treatments to improve outcome in bipolar disorder Bipolar disorder is a complex illness. The effectiveness of any treatment program would probably largely depend on its ability to target selective problems in specific phases of the illness. Psychotherapy is generally accepted as minimally effective during an acute phase of the illness [21,22]. Like other recently published evidence-based psychological treatment for bipolar disorder [10,29], both studies discussed
below are combined treatment of mood stabilizers and psychological therapy. The two studies described here taught patients to detect prodromes early and promote good coping. Therapy required patients to learn to carry out regular and intensive monitoring of early signs. As discussed above, patients who have residual symptoms might have particular difficulties in detecting depression prodromes. They require extra training to discriminate residual symptoms from prodromal symptoms by learning to monitor not just prodromes, but the trend in which their mood is going. Other patients who prefer to be in a state of high arousal and aspire to being slightly high may choose to ignore early prodromes [20]. Often close personal knowledge of patients and good therapeutic reports are required in order to be collaborative and discuss the pros and cons of being aroused, chaotic behavior and risk of relapses. 6.1. Identifying early symptoms of relapse The simple intervention study by Perry et al. enrolled 69 patients who had experienced two or more bipolar episodes, one of which was in the previous 12 months [35]. Sixtynine patients were randomized into treatment-as-usual groups (TAU) of mood stabilizers and outpatient follow-up, or TAU plus psychological treatment. Psychological treatment consisted of seven to 12 sessions with a psychology assistant. Patients identified three symptoms at the warning stage when they would start monitoring their mood closely. They were also helped to identify three symptoms when they would contact health professionals for treatment. The overall results over the 18 months of the study period showed that, compared with TAU alone, psychological treatment reduced manic episodes by 30% and increased the time to the first manic recurrence (log rank = 7.04, df = 1, P < 0.01). However, there was no effect on depressive recurrence despite increased antidepressant use in the treatment group. An improvement in social functions, particularly social functions at work, was detected. Lam et al. [22] reported a randomized, controlled study using a cognitive therapy (CT) to help prevent relapses and promote social functioning. One hundred and three bipolar I patients were randomized into a CT group or a control group. Patients were required to be suffering from frequent relapses despite the prescription of commonly used mood stabilizers. Because of the relapse prevention nature of the study, patients enrolled were not in a severe episode of mania or depression. Both the control and the CT group received mood stabilizers and regular psychiatric follow-up. In addition, the CT group received 12–20 (mean 14) sessions of CT during the first 6 months and two booster sessions in the second 6 months. CT programs in this study are more complex than the schemes used in the study by Perry et al. In addition to traditional CT for unipolar depression, the CT in this study consisted of psychoeducation using a diathesis-stress model of the illness in order to enhance medication compliance. Furthermore, patients were taught the cognitive model of how thinking and behavior can affect mood. Hence, patients were taught that
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
behavior such as sensation seeking and taking on more tasks can fuel the mania, whilst ruminating with negative thoughts and inactivity can worsen the depression. Cognitive behavioral skills were used to help patients to monitor mood and prodromes, and to modify behavior in order to prevent the progression from the prodromal phase into a full-blown episode. Some bipolar patients have very extreme goal-attainment attitudes [20]. Examples are: “If I try hard enough I should be able to excel in anything I attempt,” and “A person should do well in everything he attempts.” As a result of these attitudes they are often behaviorally engaged in achievement activities at the expense of a good routine of regular meals, adequate sleep and exercise. As a way of coping, they often engage in very driven behavior of overworking to “make up for lost time.” Hence, therapists use traditional CT techniques to target these dysfunctional attitudes in order to promote less driven behavior and a good daily routine. Results of the study showed that over the 12-month period, significantly fewer patients in the CT group had bipolar episodes (Wald X2 = 9.0, P < 0.01) or bipolar admissions (Wald X2 = 6.7, P < 0.03) after controlling for number of previous episodes. Furthermore, patients in the CT group also had significantly fewer days in a bipolar episode (t = 3.56, P < 0.01). The CT group also showed less mood symptoms on the monthly mood questionnaires (P = 0.04). The CT group also reported better medication compliance after covarying for baseline medication compliance (Wald X2 = 4.3, P < 0.02).
7. Discussion The findings of these two studies support the conclusion that psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. The intervention program in the study by Perry et al. [35] was simpler and consisted of purely identifying early warnings and seeking early medical help. However, it achieved a significant effect in preventing manic episodes. Lam et al. used a more complex intervention [22]. It was not easy to identify the active ingredients in that study. Therapists were also highly trained clinical psychologists and hence the effect may have been more beneficial; as one patient wrote: “...realizing that I have a serious mental illness and that I need to take medication is a first step. The discrete surveillance of mood and efforts to deal with early prodromes allows me to assume a measure of control and hence develop a sense of security against the possible social and professional consequences of undetected illness.” Medication helped to stabilize the patient but the early detection of prodromes and effective coping can add to the treatment regimen to increase its efficacy. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidencebased psychoeducation programs and newer pharmacological agents. Recently, the use of psychoeducation as an
363
adjuvant prophylactic tool has been acknowledged by several prestigious treatment guidelines broadening and updating the treatment paradigms of bipolar disorder [6,16]. We should keep this in mind in our everyday clinical practice with bipolar patients especially because the benefits — in terms of fewer relapses and hospitalizations — are very clear and the costs very low. Undoubtedly, the usefulness of psychoeducation for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and it provides us with information, a strong tool to manage despair and fear. Unfortunately, many professionals fail to use psychoeducation to theirs and their patient’s advantage. Further research is needed in order to ascertain the role of other psychological interventions in the treatment of acute phases — especially bipolar depression — but it is already known that psychological treatments are efficacious in the prevention of suicide [37], which, by itself may justify the inclusion of some cognitive, supportive and/or interpersonal therapies during the acute depressive phases. To the best of our knowledge, no evidence-based information on the use of psychological approaches in (hypo)mania is available. Elation may not be a good target for psychotherapy, especially as drugs work well and rapidly, so no complementary therapy is required. Psychoeducation does not work as a monotherapy, but it is, to date, one of the few treatments guaranteeing class “A” and “B” effect as an adjuvant mood-stabilizer, according to the nomenclature of Ketter and Calabrese [19]. We are, therefore, obliged not to withhold this excellent treatment from our patients. Acknowledgements Dr. Colom’s work was supported in part by unrestricted grants from the Stanley Medical Research Institute (Bethesda, USA), Fundacio Marato TV3 and Red CIEN IDIBAPSISCIII RTIC C03/06. References [1]
[2]
[3]
[4]
[5]
[6]
Altman ES, Rea MM, Mintz J, Miklowitz DJ, Goldstein MJ, Hwang S. Prodromal symptoms and signs of bipolar relapse: a report based on prospectively collected data. Psychiatry Res 1992;41:1–8. Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34–38 years. J Affect Disord 2002;68: 167–81. Angst J, Gamma A, Sellaro R, Lavori PW, Zhang H. Recurrence of bipolar disorders and major depression: a life-long perspective. Eur Arch Psychiatry Clin Neurosci 2003;253:236–40. Bieling PJ, MacQueen GM, Marriot MJ, Robb JC, Begin H, Joffe RT, et al. Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms. Bipolar Disord 2003;5:14–21. Black DW, Winokur G, Hulbert J, Nasrallah A. Predictors of immediate response in the treatment of mania: the importance of comorbidity. Biol Psychiatry 1988;24:191–8. Calabrese JR, Kasper S, Johnson G, Tajima O, Vieta E, Yatham LN, et al. International consensus group on bipolar I depression treatment guidelines. J Clin Psychiatry 2004;65:571–9.
364 [7] [8]
[9]
[10]
[11]
[12]
[13]
[14] [15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364 Colom F, Vieta E. Non-adherence in psychiatric disorders: misbehavior or clinical feature? Acta Psychiatr Scand 2002;105:161–3. Colom F, Vieta E, Martinez A, Jorquera A, Gastó C. What is the role of psychotherapy in the treatment of bipolar disorder? Psychother Psychosom 1998;67:3–9. Colom F, Vieta E, Martinez-Arán A, Reinares M, Benabarre A, Gasto C. Clinical factors associated to treatment non-compliance in euthymic bipolar patients. J Clin Psychiatry 2000;61:549–54. Colom F, Vieta E, Martínez-Arán A, Reinares M, Goikolea JM, Benabarre A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003;60:402–7. Colom F, Vieta E, Reinares M, Martínez-Arán A, Torrent C, Goikolea JM, et al. Psychoeducation efficacy in bipolar disorders beyond compliance enhancement. J Clin Psychiatry 2003;64:1101–5. Colom F, Vieta E, Sánchez-Moreno J, Reinares M, Martínez-Arán A, Torrent C, et al. Psychoeducation in bipolar patients with comorbid personality disorders. Bipolar Disord 2005;6:294–8. Dunayevich E, Sax KW, Keck Jr. PE, McElroy SL, Sorter MT, McConville BJ, et al. Twelve-month outcome in bipolar patients with and without personality disorders. J Clin Psychiatry 2000;61:134–9. Durna Z, Ozcan S. Evaluation of self-management education for asthmatic patients. J Asthma 2003;40:631–43. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large US employers in 1999. J Occup Environ Med 2003;45:5–14. Goodwin GM, for the British Association for Psychopharmacology. Evidence-based guidelines for treating recommendations from British Association for Psychopharmacology. J Psychopharmacol 2003;17: 149–73. Harvey NS, Peet M. Lithium maintenance: effects of personality and attitude on health information acquisition and compliance. Br J Psychiatry 1991;158:200–4. Keitner GI, Solomon DA, Ryan CE, Miller IW, Mallinger A, Kupfer DJ, et al. Prodromal and residual symptoms in bipolar l disorder. Compr Psychiatry 1996;37:362–7. Ketter TA, Calabrese JR. Stabilization of mood from below versus above baseline in bipolar disorder: a new nomenclature. J Clin Psychiatry 2002;63:146–51. Lam D, Wright K, Sham P. Sense of hyper-positive self and response to cognitive therapy for bipolar disorder. Psychol Med 2005;35:69– 77. Lam DH, Jones S, Hayward P, Bright J. Cognitive therapy for bipolar disorder: a therapist’s guide to the concept, methods and practice. Wiley and Son Ltd; 1999. Lam DH, Watkins E, Hayward P, Bright J, Wright K, Kerr N, et al. A randomised controlled study of cognitive therapy of relapse prevention for bipolar affective disorder — outcome of the first year. Arch Gen Psychiatry 2003;60:145–52. Lam DH, Wong G. Prodromes, coping strategies, insight and social functioning in bipolar affective disorders. Psychol Med 1997;27: 1091–100.
[24] Lam DH, Wong G, Sham P. Prodromes, coping strategies and course of illness in bipolar affective disorders — a naturalistic study. Psychol Med 2001;31:1397–402. [25] Lavori PW, Dawson R, Mueller TI, Warshaw M, Swartz A, Leon A. Analysis of course of psychopathology: transitions among states of health and illness. Int J Methods Psychiatr Res 1996;6:321–34. [26] Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck Jr. PE, McElroy SL, et al. Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003;64:506–15. [27] Linden W. Psychological treatments in cardiac rehabilitation: review of rationales and outcomes. J Psychosom Res 2000;48:443–54. [28] López AD, Murray CJ. The global burden of disease. Nat Med 1998; 4:1241–3. [29] Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath RL. A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 2003;60:904–12. [30] Miklowitz DJ, Richards JA, George EL, Frank E, Suddath RL, Powell KB, et al. Integrated family and individual therapy for bipolar disorder: results of a treatment development study. J Clin Psychiatry 2003;64:182–91. [31] Molnar GJ, Feeney MG, Fava GA. Duration and symptoms of bipolar prodromes. Am J Psychiatry 1998;145:1576–8. [32] Morselli PL, Elgie R. The BEAM survey: Information on current and past treatment of bipolar disorder generated by a patient questionnaire. Bipolar Disord 2002;4(Suppl. 1):131. [33] Olmsted MP, Daneman D, Rydall AC, Lawson ML, Rodin G. The effects of psychoeducation on disturbed eating attitudes and behavior in young women with type 1 diabetes mellitus. Int J Eat Disord 2002;32:230–9. [34] Peet M, Harvey NS. Lithium maintenance: 1. A standard education program for patients. Br J Psychiatry 1991;158:197–200. [35] Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999; 318:149–53. [36] Prien RF, Potter WZ. NIMH workshop report on treatment of bipolar disorder. Am J Psychiatry 1990;146:840–8. [37] Rucci P, Frank E, Kostelnik B, Fagiolini A, Mallinger AG, Swartz HA, et al. Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. Am J Psychiatry 2002;159:1160–4. [38] Scott J, Tacchi MJ. A pilot study of concordance therapy for individuals with bipolar disorders who are non-adherent with lithium prophylaxis. Bipolar Disord 2002;4:386–92. [39] Smith JA, Tarrier N. Prodromal symptoms in manic-depressive psychosis. Soc Psychiatry Psychiatr Epidemiol 1992;27:245–8. [40] Tsai SY, Kuo CJ, Chen CC, Lee HC. Risk factors for completed suicide in bipolar disorder. J Clin Psychiatry 2002;63:469–76. [41] Van Gent EM. Follow-up study of 3 years group therapy with lithium treatment. Encephale 2000;26:76–9. [42] Vieta E, Colom F, Corbella B, Martinez-Aran A, Reinares M, Benabarre A, et al. Clinical correlates of psychiatric comorbidity in bipolar I patients. Bipolar Disord 2001;3:253–8.