Psychoeducation and other
psychological approaches
for Bipolar Disorders
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
Syndromal and
Functional Recovery
Should Be the Goal of
Integrative Treatment
Effect Sizes of Psychosocial Treatments
Psychotherapy
Outcome/Endpoint
Effect
Size
NNT∞
Psychoeducation (Perry et al, 1999)1
Manic relapse
.30
4
Psychoeducation (Perry et al, 1999)1
Depressive relapse
.16
-
Psychoeducation (Colom et al, 2003)2
Relapse during treatment phase
.22
5
Psychoeducation (Colom et al, 2003)2
Relapse during 2-year follow-up phase
.32
4
Case management (Simon et al, 2005)3
Number of weeks without manic symptoms
.14
-
Cognitive therapy (Lam et al 2003)4
Relapse/recurrence over 1 year
.32
4
Cognitive therapy (Scott et al, 2001)5
Relapse/recurrence over 18 months
.45
3
Family-focused therapy (Miklowitz et al, 2003)6
Relapse/recurrence over 2 years
.17
6
Interpersonal and social rhythm therapy (Frank et al,
2005)7
Relapse/recurrence over 2 years
.57*
4*
*For those with < 4 comorbid diagnoses
∞ NNT = number needed to treat
1Perry
A, et al. BMJ 1999;318:149-153.
F et al. Arch Gen Psychiatry 2003;60:402-407.
3Simon GE, et al. Psychol Med 2005;35:13-24.
4Lam DH, et al. Arch Gen Psychiatry 2003;60:145-152.
2Colom
5Scott
J, et al. Psychol Med 2001;31:459-467.
DJ, et al. Arch Gen Psychiatry 2003;60:904-912.
7Frank E, et al. Arch Gen Psychiatry 2005;62:996-1004.
6Miklowitz
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
.601 5.098
.292
1.75
ACUTE EPISODE
Fixed Combined (5)
.703
.582
.851
.000
Random Combined (5)
.711
.569
.890
.003
0.1
Scott J, Vieta E & Colom F (2007)
1
10
Psychoeducation for BD…
 Is NOT:
– Just information
– Just good medical practice
– Just crisis management
– “Convincing” the patient
– Giving a booklet or a website
address to your patients
– Self help
 BUT:
– Training
– Providing patient’
empowering tools
– Enhancing coping
strategies
– Encouraging informed
proactiveness
– Agreeing on reasonable
targets
– Promoting self-care
The Modern Patient-Physician
Relationship Is Becoming Horizontal
Evolving Patient-Physician Relationship
Paternalism
Partnership
One-on-one strategies
Team approaches
Knowledge gap
Educational empowerment
“Doctors orders”
Mutual decision-making
Intervention
Prevention
Magee M, D’Antonio M. The Best Medicine. New York: Spencer Books; 2001.
Magee M. Relationship Based Health Care in the United States, United Kingdom, Canada, Germany, South Africa, and Japan. Presented at the World Medical
Association Annual Meeting. Helsinki, September 11, 2003.
The proper setting
The utopic setting for succeeding in the
implementation of psychoeducation
 Open-door policy.
– Less prescheduled appointments but total flexibility for
unscheduled visits or in-call availability.
– Psychoeducation encourages the patient to have a
proactive attitude in dealing with his disorder and so the
therapist should have the same proactive and flexible
attitude.
(Colom, British Journal of Psychiatry, 2011)
Why group setting?







Allows modeling
Allows training
Supportive
Against stigma
Enhances insight
Increasessocial network
Cheaper
Composing a psychoeducation group
 Beetween 8 and 12 outpatients. Better to start with 16.
 Balance gender.
 Balance bipolar subtype.
 No more than two ages subgroups.
 Therapist & co-therapists.
 Suitable schedule.
 90 minutes per session.
 Written material.
Who should deliver
psychoeducation?
Therapist Charachteristics
 Training: 12 hours ... and 3 years
 Previous clinical experience with bipolar
patients
 Rather an expert on a disorder than on a
technique
 Previous experience with patients groups
 Interpersonal skills
 Common sense
 Sense of humour
Adherence
enhancement
Early
warning signs
identification
Illness
awareness
Psychoeducation
Substance
misuse
avoidance
Habits
regularity
Psychoeducation
Illness
awareness
Hospitalization,
treatment with antipsychotics
M
Cocaine
Split with Sandra
Holidays in Morocco
I meet Sandra.
I go out every night
H
Chronicity and recurrence
Euthymia
Subthreshold cycling
d
Treatments
Consequences
Antidepressants
Depression. Lost job.
D
Lithium
Triggering factors
17
18
19
20
21
22
23
Psychoeducation
Adherence
enhancement
“In developed countries,
adherence among patients
suffering chronic diseases
averages only 50 percent.”
– World Health Organization 2003
Adherence to Long-Term Therapies: Evidence for Action
Adherence to Long-Term Therapies: Evidence for action. World Health Organization 2003. Available at: http://www.who.int/chronic_conditions/adherencereport/en/.
American Medical Association. The Patient’s Role in Improving Adherence. Available at: http://www.ama-assn.org/ama/pub/article/12202-8427.html.
Magee M. Attacking Chronic Diseases in Developing Countries. . Available at: http://www.healthpolitics.com/program_info.asp?p=prog_55.
Treatment Adherence in
Euthymic Bipolar Patients
13%
N=200
27%
60%
Good Compliance
Medium Compliance
Colom F, et al. J Clin Psychiatry 2000;61(8):549-555.
Poor Compliance
BEAM survey: reasons why patients are
concerned about taking medication (% patients)
Feel ashamed
Feel dependent
It is slavery
I am a little afraid
It is unhealthy
Fear of long-term side effects
Medication not really needed
Side effects
My physical condition
Treatment is useless
Got pregnant
0
5
Patients (%)
10
15
20
25
Morselli et al 2002
Combination Therapy
Average Number of Medications in 258 Bipolar Outpatients
Followed Up Prospectively for 1 Year
60
20.9%
Number of Patients
50
17.1%
18.2%
40
12.0% 12.0%
30
20
6.6%
6.6%
10
0
3.1%
0.8%
0
1
2
3
4
5
6
7
Total Number of Medications
Post RM, et al. J Clin Psychiatry. 2003;64(6):680-690.
8
1.9%
9
0.8%
10
Compliance
“The extent to which a patient follows medical instructions”
Adherence
“The extent to which a person’s behavior – taking medication, following a diet,
and/or executing lifestyle changes – corresponds with agreed
recommendations from a health care provider”
Haynes RB. Determinants of compliance: the disease and the mechanics of treatment. Baltimore:
Johns Hopkins University Press; 1979.
Adherence to Long-Term Therapies: Evidence for action. World Health Organization 2003.
Lithium Levels During Psychoeducation
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
-6 months
N=49
Baseline
* p<0,05 * p<0,01
N=120
Colom F, et al. Bipolar Disord, 2005.
N=44
*
*
*
6 months 12 months 18 months 24 months
Psychoeducation
Control Group
Psychoeducation
Early
warning signs
identification
Efficacy of Teaching Bipolar Patients Early Detection
of Prodromal Signs
1.0
Exp-M
Cumulative survival
Control-M
Exp-D
0.8
Control-D
0.6
0.4
0
20
40
Weeks
Exp-M=experimental group, manic; Exp-D=experimental group, depressive.
Perry A et al. BMJ. 1999;318:149-153.
60
80
Ernie:
•Likes jokes
•Talkative
•Hyperactive
•Sleeping problems
Ernie
Depressive
prodromes:
•Likes quiet
environment
•Enjoys
reading for
hours
•Doesn’t like
jokes or
surprises
•Needs a lot of
sleep
Bert:
•Likes quiet
environment
•Enjoys
reading for
hours
•Doesn’t like
Bertjokes or
Hypomanic
surprises
prodromes:
•Needs a lot of
•Likes
jokes
sleep
•Talkative
•Hyperactive
•Sleeping
problems
Looking for Early Warning Signs in BD
 A prodrom should be
–A behaviour
–Operative
–Different from the
usual behavioral
span
–Well-known
–Subtle
Is it a valid early warning sign??
« I sleep less »
« I sleep less
than 6 hours »
Is it a valid early warning sign??
« I increase my
smoking »
« I smoke more
than 15
cigarrettes »
Is it a valid early warning sign??
« I feel sexually
aroused »
« I click on
porn
websites »
Is it a valid early warning sign??
« Increased self-
esteem » or
« I am joyfull and
happier »
« I do more than
10 phone calls a
day »
« Pre-emergency plan »
 After ticking three or more boxes, the
patient contacts his moodwatch and they
decide together if the therapist should or
should not be contacted.
 It is helpful to have a pre-agreement stating
that, if the moodwatch is sure that an
episode is starting, he has the right to
contact the therapist.
Emergency plan
The patient should contact the
therapeutic team as soon as possible
The patient should start with the
« agreed behaviors » as soon as
possible
We may have pre-arranged « rescue
medications » for some patients
Psychoeducation
Habits
regularity
Habits regularity in bipolar disorder
(Shen et al., 2008)
Habits
 Sleeping habits
 Sleeping hygiene
 Physical exercise
 General health
 Work & Stress
 Family Issues
 Problem solving
Psychoeducation
Substance misuse
avoidance
Substance use
 Avoid “policeman” attitudes
 Stress importance on avoidance of “softer” drugs
– Alcohol
– Caffeine
– Cannabis
 Cigarretes withdrawal management
Psychological interventions for
bipolar disorder: are all the same?
Francesc Colom, MSc, PsyD, PhD
Bipolar Disorders Program
IDIBAPS-CIBERSAM
Catalonia
1° AXIS: POLARITY
(THE PENDULUM)
Predominant Polarity
 Operational description of a clinical impression
 2/3 of past episodes of a given polarity
 Validated with more than 1000 patients1, 2, 3
 Included in ISBD Nomenclature Taskforce recommendations4
 ...But neglected by DSM-5 despite all its clinical and
therapeutic implications
1. Colom et al., 2006; 2. Rosa et al., 2008; 3. Yang et al., 2013; 4.Tohen et al., 2009
Predominant Polarity
≥2/3 of a patient's past episodes fulfilling DSM-IV criteria
for Depression or Mania/ Hypomania
MPP
DPP
UPP
Colom et al., JAD, 2006
Predominant Polarity
40
44
56
With PP
2/3
Without PP
of total episodes of the same pole
60
Depressive PP
(Hypo)manic PP
(Colom et al., 2006)
Two possible ways of classifying bipolar
treatments...
Prevention
of Depression
(buyt not mania)
Balanced stabilizer
Prevention
of Mania
(but not depression)
Polarity Index
A measure of the relative prophylactic efficacy of drugs used in bipolar
disorder maintenance treatment
NNT depression
Polarity Index=
NNT mania
PI = 1
Predominantly
Antidepressive PI
Predominantly Antimanic PI
Popovic et al., 2012
Polarity Index of medicaments used
in maintenance treatment of BD
PI = 1
QUE
1.14
Predominantly
Antidepressive PI
LAM
0.40
VPA 0.49
OXC
0.62
LI
1.39
OLZ2
ZIP ARI
RLAI
.98
3.91 4.38
12.09
Predominantly
Antimanic PI
Popovic et al., European
Neuropsychopharmacology, 2012
NNT
Mania
NNT
Depression
NNT
Any episode
Polarity
Index
Psychoeducation¹
7.5
5.5
4.6
0.73
CBT2
9.6
3.2
4.8
0.33
CBT3
5.7
3.6
4.9
0.63
CBT4
19
5.4
4.8
0.89
Popovic et al., 2013; 1Colom 2003; 2Lam 2003;
3Lam 2005; 4Meyer, 2011
NNT
Mania
NNT
Depression
NNT
Any episode
Polarity
Index
Enhanced relapse
prevention4
40
40
20
1
Family-focused therapy5
4
5.6
5.3
1.40
Brief technique-driven
interventions6
3.9
13.1
11.3
3.36
Caregiver group
psychoeducation7
5.0
8.9
4.2
1.78
Popovic et al., 2013; 4Lobban 2010; 5Miklowitz
2003; 6Perry 1999; 7Reinares
Polarity Index for Adjunctive Psychotherapies in
maintenance treatment of BD
PI = 1
Enhanced
relapse
prevention4
Familyfocused
therapy5
Caregiver group
psychoeduc.7
Brief techniquedriven interv.6
CBT8
CBT2 CBT3 Psychoeducation¹
Popovic et al., 2013
2º AXIS: SEVERITY
(THE PIT)
Proposed Staging Model for Bipolar Disorder
Kapczinski et al, submitted
Two possible ways of classifying bipolar
treatments...
Stage 4: Paliative care:
Diminish impact and alleviate some
symptoms
Stage 3: Remediation & rehabilitation:
Reduce burden, improve functioning
Stage 2: Maintenance treatments:
Reduce # episodes & # days spent ill
Stage 0/1: Preventive treatments:
Specific for offspring or for cyclothymia
Late
Medium
Early
D-prevention
M-prevention
At risk
Efficacy of Teaching Bipolar Patients Early Detection of
Prodromal Signs
1.0
Exp-M
Cumulative survival
Control-M
Exp-D
0.8
Control-D
0.6
0.4
0
20
40
Weeks
Exp-M=experimental group, manic; Exp-D=experimental group, depressive.
Perry A et al. BMJ. 1999;318:149-153.
60
80
Cluster RCT: PATIENTS & THERAPISTS RECRUITED FROM CMHTs
(ERP=12 teams; TAU=11 teams)
ERP
TAU
Adjusted hazard ratio 0.79 (95% CI 0.45–1.38)
Lobban, F. et al. The British Journal of Psychiatry 2010;196:59-63
Late
EW
(Ind)
Medium
Early
D-prevention
M-prevention
At risk
Family-focused psychoeducation
(Miklowitz et al., Arch Gen Psychiatry 2003)
FFT Delays Rehospitalization Longer Than Individual Treatment
Cumulative Survival Rate
UCLA FFT Study (N=53)
1,0
0,8
0,6
39 Weeks
0,4
0,2
Individually-focused treatment
Family-focused treatment
0,0
0
26
52
78
104
Weeks
X2 (1) = 3.87, P <.05
Rea, Tompson, Miklowitz et al. J Consult Clin Psychol. 2003 ; 71: 482-492.
130
156
182
Patients’ Recurrences During 15-month Follow-up after Family
Psychoeducation
%
80
N=113
*p=0.011
70
66
60
50
*p=0.017
42
40
p=0.211
41,1
37,5
29,8
30
17,5
20
p=0.468
10
3,6
0
0
Mood episode
Reinares M et al. Bipolar Disord. 2008.
Mania/hipomania
Depression
Control (n=56)
Intervention (n=57)
Mixed
Impact of staging on family
psychoeducation
Stage I
N= 113
Advanced Stages
Reinares et al, 2010
Late
EW
(Ind)
FFT
Medium
Early
D-prevention
M-prevention
At risk
CBT in Bipolar Disorders: 1-year follow-up
Survival Function at mean of covariates
1.2
1.0
.8
Cum Survival
.6
ALLOC
.4
therapy
.2
control
-10
0
10
20
30
40
50
60
Time of first bipolar episode (weeks)
(Lam et al., Arch Gen Psychiatry 2003)
CBT in bipolar disorder: 2-year follow-up
(Lam et al., Am J Psychiatry, 2005)
CBT Not Effective in Acutely Ill Patients With Multiple
Episodes
Recurrences (%)
100
TAU n=126
80
CBT n=127
60
40
20
0
Time (wk)
At risk (n)
0
253
8
204
16
168
24
146
32
131
40
117
48
102
56
94
64
84
72
Actuarial cumulative recurrence curves (Kaplan-Meier): intention-to-treat analysis of any recurrence.
CBT=cognitive-behavioral therapy; TAU=treatment as usual.
Scott J et al. Br J Psychiatry. 2006;188:313-320.
Reality is a mess… but not that much
 Of the 253 patients, 89% (225) were either in
episode at baseline or had 2 or more of:
– Past history of >12 episodes
– Co-morbid axis I/II
– Current or past history of substance
abuse/dependence
– History of attempted suicide (severe)
– Forensic history
 Only 10% of patients in real-life clinical settings
present this way
(Scott and Colom., 2008)
Cumulative proportion without episode
A randomized controlled trial of cognitive
behavioural group therapy for bipolar disorder
1.0
TAU
CBGT
0.8
• 50 euthymic BP I or II
• TAU vs. TAU + CBGT
0.6
• ITT: no differences re
time to relapse (total,
manic, or depressive)
0.4
0.2
0.0
0
20
40
60
80
Weeks
CBGT, cognitive behavioural group therapy
TAU, treatment as usual
Gomes Psychother Psychosom. 2011;80:144.
Early input is better
% recurrence by treatment group and
number of previous episodes
CBT, cognitive behavioural therapy
TAU, treatment as usual
N=253
Scott Br J Psychiatry. 2006;188:313.
Late
FFT
Medium
EW
(Ind)
Group
F-Psyched
Early
D-prevention
M-prevention
At risk
Mean Number of Episodes
(5-year Follow-up)
9
Psychoeducation group
8
Control group
7
6
5
*
4
3
*
2
*
*
*
1
0
Total episodes
*P<.05 psychoeducation vs control.
Colom F et al. Br J Psychiatry. 2009.
Mania
Hypomania
Mixed
Depression
Time Spent Ill
(5-year Follow-up)
700
P<.001
Psychoeducation group (N=50)
600
Control group (N=49)
Days
500
P<.001
400
300
200
P<.05
P<.005
P<.005
100
0
Total
Colom F et al. Br J Psychiatry. 2009.
Mania
Hypomania
Mixed
Depression
IS STRUCTURED GROUP PSYCHOEDUCATION FOR BIPOLAR PATIENTS
EFFECTIVE IN ORDINARY MENTAL HEALTH SERVICES?
A CONTROLLED TRIAL IN ITALY
102 Bipolar outpatients type I & II
Psychoed.
group
1 year follow-up
(n=57)
Controls
p-value
(n=45)
N° of
hospitalisations
Mean (ds)
0.11 (0.36)
0.47 (0.69)
.001
1.75 (7.0)
10.16 (16.8)
.001
N° of days of
hospitalisation
Mean (ds)
Exclusion criteria
•Axis I comorbidity
•Mental retardation (QI <70)
•Organic brain damage or deafness
SURVIVAL CURVES FOR HOSPITALISATION
N° of people hospitalised
Psychoed. Group (5 out of 57)
Controls (16 out of 45)
Candini et al., 2013
Mean time spent in an episode (5-year follow-up)
PATIENTS WITH >15 EPISODES AT STUDY ENTRY
N.S.
N.S.
N.S.
N.S.
N.S.
Colom et al., Acta Neuropsychiatrica, 2010
Impact of staging on family
psychoeducation
Stage I
N= 113
Advanced Stages
Reinares et al, 2010
Early input is better
% recurrence by treatment group and
number of previous episodes
CBT, cognitive behavioural therapy
TAU, treatment as usual
N=253
Scott Br J Psychiatry. 2006;188:313.
Late
FFT
CBT
Group
Psyched
Medium
EW
(Ind)
Group
F-Psyched
Early
D-prevention
M-prevention
At risk
Unsolved areas
 Functional impairment
 (Ultra)High-risk individuals
 Therapy availability/implementation problems
 “Veteran” patients / paliative psychotherapy
 Dual pathology
 Physical health
Unsolved areas
 Functional impairment
 (Ultra)High-risk individuals
 Therapy availability/implementation problems
 “Veteran” patients / paliative psychotherapy
 Dual pathology
 Physical health
Why psychological treatments may not work
on patients with >11 previous episodes?
 Psychotherapy requires some good functioning on attention,
learning, executive functioning and memory, and all these
could be seriously damaged in veteran patients
 Lifestyle difficult to change
 Kindling/sensitization
OR…
 It may be imposiible to see differences from non-treated
patients because they have already learnt…
(Kapczinsky et al., Expert Rev Neurother, 2009)
Functioning Assessment Short Test (FAST)
Functional Impairment across Mood States
*
D>M>E >C
*
50
40
*
30
*
20
10
0
Depression
(Hypo)mania
Euthymia
Healthy Controls
(Rosa et al., 2010)
Functional Impairment in Remitted Bipolar Patients
20
d=1.26, p<0.001
18
16
FAST scores
14
d=1.18, p<0.001
12
10
8
d=0.65, p<0.001
6
d=0.91, p<0.001
d=0.88, p<0.001
4
d=0.33
d=0.35, p<0.004
2
0
total
autonomy
occupational
cognition
financial
issues
Interpersonal
leisure time
(Rosa et al., 2008)
Psychoeducation and functional remediation
Within-group effect sizes in functional
improvement, by domain of the Functioning
Assessment Short Test
0.8
34
0.7
32
0.6
30
Effect size
Functioning Assessment Short Test†
Changes in functional impairment scores
before and after intervention in patients
with bipolar disorder
28
26
24
Functional remediation (n=77)
Psychoeducation (n=82)
22
Treatment as usual (n=80)
20
0
Time (weeks)
**
0.5
Torrent C, et al. Am J Psychiatry 2013
*
0.4
0.3
0.2
21
0.1
0.0
*p<0.05, **p<0.005 compared with treatment as usual
†Higher scores indicate greater impairment
*
Leisure
Interpersonal*
Financial
Cognitive
Occupational*
Autonomy
Functional
remediation
Psychoeducation
Treatment
as usual
Functional remediation in BP-II patients
(Solé et al., Eur Neuropsy 2015)
Functional
Remed.
Late
FFT
CBT
Group
Psyched
Medium
EW
(Ind)
Group
F-Psyched
Early
D-prevention
M-prevention
At risk
Unsolved areas
 Functional impairment
 (Ultra)High-risk individuals
 Therapy availability/implementation problems
 “Veteran” patients / paliative psychotherapy
 Dual pathology
 Physical health
Family-Focused Therapy
for individuals at bipolar risk
(Miklowitz et al., 2013)
Functional
Remed.
Late
FFT
CBT
Ad hoc
CBT/Psyched
Group
Psyched
Medium
EW
(Ind)
Group
F-Psyched
FFT-HR
Early
D-prevention
M-prevention
At risk
Unsolved areas
 Functional impairment
 (Ultra)High-risk individuals
 Therapy availability/implementation problems
 “Veteran” patients / paliative psychotherapy
 Dual pathology
 Physical health
:):
The SIMPLe Project
Main aims
Develop a Smartphone application which could:
•Empower the self-management of the disorder and improve the outcome
through a personalized psychoeducation program.
While at the same time:
•Becoming a user-friendly device, suitable for daily use.
•Non-stigmatizing, discrete and non-invasive.
•Sensitive enough to detect mood changes and emergency situations.
•Providing tailored psychoeducational contents and encourage behavior change.
•Guarantee safety and confidentiality.
•Provide useful data for clinical and research purposes.
*
Clinical trial.gov Identifier: NCT02258711
:): SIMPLe: General app function framework
Unsolved areas
 Functional impairment
 (Ultra)High-risk individuals
 Therapy availability/implementation problems
 “Veteran” patients / paliative psychotherapy
 Dual pathology
 Physical health
:):
The SIMPLe Project
What’s next? SIMPLeBand
Passive information
inclusion
Smartphone data log
Weareables
Rematch (Relapse prEvention through Mobile
providers cAll deTailed records (CDRs)
Project
(Colom, 2012)
Newer potential targets for BD psychotherapy
 Emotional hyperreactivity
 Social cognition
 Non-verbal strategies
 BCT rather than CBT
…
Few episodes (0-6):
Prevention
Psychoeducation
CBT
Pharmacotherapy
Most patients:
Pharmacotherapy
Psychoeducation
(adherence empowerment)
>12 episodes or
Stage >3:
Paliative pharmacology
Functional remediation
Biophysical treatment
Centro de Investigación Biomédica En Red
de Salud Mental