cures incomprehension, alleviates stigma, deals effectively with guilt, and prevents learned helplessness. Psychoeducation replaces guilt by responsibility, helplessness by proactive care, and denial by awareness.
What Is Psychoeducation? Training Psychoeducation is rather an information-based behavioral training aimed at adjusting lifestyle to cope with bipolar disorder for improved outcome, including enhancement of illness awareness treatment adherence early detection of relapse avoidance of potentially harmful factors such as illegal drugs and sleep deprivation.
main components Barcelona Psychoeducation Program Illness Awareness Adherence Enhancement Substance Misuse Avoidance Early Warning Signs Detection Lifestyle Regularity (and Miscellanea)
Sessions of the Barcelona Psychoeducation Program Introduction What is bipolar illness? Etiological and triggering factors Symptoms (I): Mania and hypomania Symptoms (II): Depression and mixed episodes Course and outcome Treatment (I): Mood stabilizers Treatment (II): Antimanic agents Treatment (III): Antidepressants Serum levels: Lithium, carabamazepine, and valproate Pregnancy and genetic counseling Psychopharmacology versus alternative therapies Risks associated with treatment withdrawal Alcohol and street drugs: Risks in bipolar illness Early detection of manic and hypomanic episodes Early detection of depressive and mixed episodes What to do when a new phase is detected Regularity Stress management techniques Problem-solving techniques Farewell
Illness Awareness helping to refocus the patient on the biological nature of his or her condition and the need for pharmacological treatment Patients generally learn quite quickly, though, to feel comfortable within the medical model of the illness, which may be much more helpful to deal with stigma and guilt
What is bipolar disorder? concept of bipolar disorder dispel the numerous myths about it, stressing the biological nature of the disorder attempting to overcome its social stigma
Etiological and triggering factors explain the biological nature of the disorder “causal” concept of the disorder—underscored as biological the “triggering” concept—which can be either biological or environmental.
Symptoms Mania and hypomania Symptoms Depression and mixed episodes Course and outcome : focus on the chronic and recurring character of bipolar disorder, further emphasizing the difference between causal and triggering factors
Adherence Enhancement Almost a half of patients stop taking medication without indication from their psychiatrists, even during euthymia The reasons for nonadherence are quite unspecific and patient-dependent, although substance and personality comorbidities play a major role. Medication withdrawal is the most common cause of relapse among bipolar patients. The risk of hospitalization is four times higher among the patients who do not duly comply with their maintenance treatment. Mortality, especially by suicide, is also higher in nonadherent patients. Nonadherence is usually underestimated by clinicians. Lack of adherence is often explained by irrational fears, prejudice, and misinformation
Poor adherence can be defined as the inability of the patient to follow some or all of the instructions given by his or her psychiatrist and psychologist, including drug prescription and the facilitation of health- promoting behaviors or habits
Substance Misuse Avoidance lifetime prevalence for co-occurring alcohol use disorders reaching almost 60 percent of bipolar I patients and a 38 percent lifetime prevalence of any drug use disorder nearly half of bipolar II patients have a comorbid substance use disorder. risk for a bipolar patient to suffer a substance-related problem is sixfold higher than that of the general population
Substance use is associated with a poorer outcome: Increased episodes of depression increased adherence problems delayed symptomatic recovery
Alcohol may trigger depression, increase anxiety, worsen sleep, reduce impulse control, cause cognitive impairment, increase aggressiveness, and the appearance of psychotic symptoms and mania. Marijuana may cause an amotivational syndrome characterized by great apathy; it may also trigger depression and mania, interfere with sleep, increase anxiety, and psychotic symptoms. Cocaine and hallucinogens all by themselves can trigger any type of episode and also rapid cycling, anxiety, aggressiveness, psychotic symptoms, poor sleep, and cognitive impairment. The danger of coffee is mainly its ability to alter sleep structure and increase anxiety. cigarette smoking,
five important points stop smoking: is generally not a good idea to try to quit smoking during an episode. The best time to quit smoking is during periods of long- duration euthymia (6 months of euthymia or more). Do not try to stop suddenly. The use of substitutes is recommended (nicotine chewing gum or patch) to avoid the withdrawal syndrome, which may give rise to anxiety and irritability. The use of anticraving drugs such as bupropion is absolutely contraindicated in bipolar patients who are not depressed, as they are antidepressants and might eventually destabilize the disorder.
integrated group therapy IGT has shown its usefulness in decreasing the days of substance use and other measures regarding the severity of the substance disorder but not the outcome of bipolar disorder.
Early Warning Signs Detection One useful comparison to help the patients understand the need for early detection and treatment of (hypo)mania is the avalanche Another key element of these sessions is the early intervention plan
“Tips” against a Hypomanic Switch What to do if a hypomanic, mixed, or manic phase is suspected Try to locate your psychiatrist or psychologist, even if by telephone, so that he or she can evaluate the relapse or tell you it is a nonpathological fluctuation. Increase the number of sleeping hours to a minimum of 10, even if you need the sleeping drugs the psychiatrist prescribed for the emergency plan. Often, sleeping long hours for 3 or 4 days will be enough to stop the beginning of an episode, if done in time. Limit the number of activities and eliminate the ones that are not absolutely essential. Normally the help of the support person will be needed to decide which activities are not essential. Remember that the only truly important thing is your health and avoiding relapses; this outweighs any job or social commitment. Spend a maximum of 6 hours being active. The rest of the day should be for resting or for relaxing, nonstimulating activities. You should behave as if you had the flu: Lots of bed rest, a little TV, few outings, and lots of tranquility
Never try to overcome your hyperactivity and increased energy by trying to exhaust yourself, doing lots of physical exercise to get tired. This is like trying to put out a fire with gasoline: The more activity you do, the more stimulated you will be, and the worse the episode will get. Physical exercise must be minimized. Reduce stimuli: Avoid exposure to highly stimulating environments (a discotheque, a demonstration, or a mall) and surround yourself with a relaxing environment (quiet, little light, and few people). Avoid stimulating beverages such as coffee, tea, cola drinks, and so- called energy drinks (containing taurine, ginseng, caffeine, or derivatives of these substances). Also avoid multivitamins because they sometimes contain some of these substances. Obviously, alcohol and other drugs should be avoided. Limit spending: Remove access to credit cards (your “lifeboat caregiver” can hold onto them until the threatened episode disappears) and postpone all purchases for at least 48 hours. Never make important decisions if you suspect you are starting to suffer symptoms of hypomania. Until the psychiatrist or psychologist rules out the existence of an episode, you should postpone all decision- making. Never give yourself permission to “go up a little more.” Remember that the higher you go, the harder you fall.
“Tips” against a Depressive Switch What to do if a depressed phase is suspected Try to reach your psychiatrist by phone. When a depressive phase starts or when you suspect this is happening, you should not change psychiatrists, as the psychiatrist on duty may overestimate your depressive symptoms without knowing that you have bipolar disorder, and this may lead to overuse of antidepressants. You should never self-medicate for depressive symptoms. Carry on taking the medication prescribed by the psychiatrist. Sleep 8 hours at most, as sleeping longer can worsen the depression. To limit sleeping time, it may be useful to schedule activities for the morning. Try to increase your activity level, even though this is just the opposite of what you want to do. Do not leave out any of your daily activities. It is very important to do some physical exercise; if you cannot go to the gym or go swimming, try to walk half an hour every day.
Do not make important decisions—these should be made only when you are fully lucid. They should not be influenced by the pessimism and despair characteristic of depressive states. If you make decisions at the beginning of a depression, then the decision is probably being made by the depression, not by you. Do not consume alcohol, marijuana, or cocaine to try to cheer yourself up or be more active: These substances will leave you even more depressed after a few hours. If you do not have anxiety problems, you can drink a couple of cups of coffee for stimulation. Try to put notions of inferiority and pessimism in perspective: They are just the result of biochemical changes in the brain. If you talk about them to a “lifeboat caregiver,” he or she will probably tell you that you are blowing up the importance of these notions. Try to keep to a regular schedule; many depressed people feel better in the afternoon, so they go to bed later and later, and end up with upside-down sleeping hours. It is best to go on living during the day and sleeping at night. Move up your visit to the psychologist; he or she will give you advice on how to deal with this initial relapse. If you have suicidal ideas, immediately let your therapist know about them: Remember they are always a symptom.
A valid warning sign must: Be behavioral Be regular for all episodes Be easily identifiable Be subtle Be operative Not lead to arguments Escalate to the symptom
Lifestyle Regularity : Sleeping habits/circadian rhythm general advice in psychoeducation is to sleep between 7 and 9 hours, avoid daytime sleep, and use sleep both as an indicator of relapse and as a helper to deal with oncoming episodes
Lifestyle Regularity Physical exercise doing physical exercise is highly recommended for bipolar patients, not only to improve general health but also to improve mood Physical exercise should not be done 3 to 4 hours before going to bed, as its stimulant properties may worsen the quality of sleep. Physical exercise should be stopped if a manic, hypomanic, or mixed relapse is suspected. Similarly, it should be increased if a depressive relapse is suspected. Physical exercise often implies some risk of dehydratation. This should be kept in mind especially with those patients on lithium, due to intoxication risk