1. 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
sam
ciber
Centro de Investigación Biomédica En Red
de Salud Mental

2. Syndromal and Functional Recovery Should Be the Goal of Integrative Treatment

3. Effect Sizes of Psychosocial Treatments4*
.57*
Relapse/recurrence over 2 years
Interpersonal and social rhythm therapy (Frank et al, 2005)7 4
.32
Relapse during 2-year follow-up phase
Psychoeducation (Colom et al, 2003)2 6
.17
Family-focused therapy (Miklowitz et al, 2003)6 3
.45
Relapse/recurrence over 18 months
Cognitive therapy (Scott et al, 2001)5
Relapse/recurrence over 1 year
Cognitive therapy (Lam et al 2003)4 -
.14
Number of weeks without manic symptoms
Case management (Simon et al, 2005)3 5
.22
Relapse during treatment phase
.16
Depressive relapse
Psychoeducation (Perry et al, 1999)1
.30
Manic relapse
NNT∞
Effect Size
Outcome/Endpoint
Psychotherapy
*For those with < 4 comorbid diagnoses ∞ NNT = number needed to treat
1Perry A, et al. BMJ 1999;318:
2Colom F et al. Arch Gen Psychiatry 2003;60:
3Simon GE, et al. Psychol Med 2005;35:13-24.
4Lam DH, et al. Arch Gen Psychiatry 2003;60:
5Scott J, et al. Psychol Med 2001;31:
6Miklowitz DJ, et al. Arch Gen Psychiatry 2003;60:
7Frank E, et al. Arch Gen Psychiatry 2005;62: 3

4. 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
ACUTE EPISODE
1.75
.601
5.098
.292
Fixed Combined (5)
.703
.582
.851
.000
Random Combined (5)
.711
.569
.890
.003
0.1 1 10
Outcome According to Time Since Last Episode
Scott J, Vieta E & Colom F (2007)

5. 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

6. The Modern Patient-Physician Relationship Is Becoming Horizontal
Evolving Patient-Physician Relationship
Partnership
Team approaches
Educational empowerment
Mutual decision-making
Prevention
Paternalism
One-on-one strategies
Knowledge gap
“Doctors orders”
Intervention
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.

7. The proper setting

8. 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)

12. Why group setting? Allows modeling Allows training Supportive
Against stigma
Enhances insight
Increasessocial network
Cheaper

13. 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.

14. Who should deliver psychoeducation?

15. 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

16. Psychoeducation
enhancement
Adherence
identification
warning signs
Early
regularity
Habits
Substance misuse
avoidance
Illness awareness

17. Psychoeducation
Illness awareness

18. Chronicity and recurrence
Hospitalization,
treatment with antipsychotics
Split with Sandra M
Cocaine
Holidays in Morocco
I meet Sandra.
I go out every night H
Chronicity and recurrence
Euthymia
Treatments
Subthreshold cycling
Lithium d
Consequences
Antidepressants
Depression. Lost job. D
Triggering factors

23. Psychoeducation
enhancement
Adherence

24. “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 Available at:
American Medical Association. The Patient’s Role in Improving Adherence. Available at:
Magee M. Attacking Chronic Diseases in Developing Countries. . Available at:

25. Treatment Adherence in Euthymic Bipolar Patients
Colom F, et al. J Clin Psychiatry 2000;61(8):

26. 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
Patients (%)
Morselli et al 2002

27. Combination Therapy Average Number of Medications in 258 Bipolar Outpatients Followed Up Prospectively for 1 Year 60
20.9% 50
18.2%
17.1% 40
12.0%
12.0%
Number of Patients 30
Long-term follow-up data indicate that patients with bipolar disorder receive, on average, over 4 different medications each year. The use of combination therapy in patients with bipolar disorder appears to be increasing in the treatment of bipolar disorder [Frye et al, 2000] and in all phases of treatment, combination therapy is usually the rule rather than the exception.
Many of the agents used in bipolar disorder (such as lithium, the atypical antipsychotics, and anticonvulsants, such as divalproex) may have complementary mechanisms of action that bring enhanced benefits when used in combination. However, potentially, there is an increased risk of side effects when any combination of agents is used. Although in practice this is not always observed, the use of agents that have undergone study for use in combination should be favored. Combination-therapy studies are therefore necessary, informative, and closer to real-world clinical practice.
References Frye MA, Ketter TA, Leverich GS, et al. The use of combination therapy in patients with bipolar disorder appears to be increasing. J Clin Psychiatry. 2000;61:9-15.
Post RM, Denicoff KD, Leverich GS, et al. Morbidity in 258 bipolar outpatients followed for 1 year with daily prospective ratings on the NIMH life chart method. J Clin Psychiatry. 2003;64: 20
6.6%
6.6% 10
3.1%
1.9%
0.8%
0.8% 1 2 3 4 5 6 7 8 9 10
Total Number of Medications
Post RM, et al. J Clin Psychiatry. 2003;64(6):

28. 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.

29. Lithium Levels During Psychoeducation* * *
* p<0,05 * p<0,01
N=120
Colom F, et al. Bipolar Disord, 2005.

30. Psychoeducation
identification
warning signs
Early

31. Efficacy of Teaching Bipolar Patients Early Detection of Prodromal Signs
1.0
Exp-M
Control-M
Exp-D
0.8
Control-D
Cumulative survival
0.6
0.4 20 40 60 80
Weeks
Exp-M=experimental group, manic; Exp-D=experimental group, depressive.
Perry A et al. BMJ. 1999;318: 31

32. Ernie:
Likes jokes
Talkative
Hyperactive
Sleeping problems
Bert:
Likes quiet environment
Enjoys reading for hours
Doesn’t like jokes or surprises
Needs a lot of sleep
Ernie Depressive prodromes:
Likes quiet environment
Enjoys reading for hours
Doesn’t like jokes or surprises
Needs a lot of sleep
Bert Hypomanic prodromes:
Likes jokes
Talkative
Hyperactive
Sleeping problems

33. Looking for Early Warning Signs in BD
A prodrom should be
A behaviour
Operative
Different from the usual behavioral span
Well-known
Subtle

34. Is it a valid early warning sign??
« I sleep less »
« I sleep less than 6 hours »

35. Is it a valid early warning sign??
« I increase my smoking »
« I smoke more than 15 cigarrettes »

36. Is it a valid early warning sign??
« I feel sexually aroused »
« I click on porn websites »

37. 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 »

38. « 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.

39. 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

40. Psychoeducation
regularity
Habits

41. Habits regularity in bipolar disorder
(Shen et al., 2008)

43. Habits Sleeping habits Sleeping hygiene Physical exercise
General health
Work & Stress
Family Issues
Problem solving

44. Substance misuse
avoidance
Psychoeducation

45. Substance use Avoid “policeman” attitudes
Stress importance on avoidance of “softer” drugs
Alcohol
Caffeine
Cannabis
Cigarretes withdrawal management

46. Psychological interventions for bipolar disorder: are all the same?
Francesc Colom, MSc, PsyD, PhD
Bipolar Disorders Program
IDIBAPS-CIBERSAM
Catalonia

47. 1° AXIS: POLARITY (The PENDULUM)

48. 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

49. Predominant Polarity MPP DPP UPP
≥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

50. Predominant Polarity 2/3 of total episodes of the same pole
(Colom et al., 2006) 50

51. Two possible ways of classifying bipolar treatments...
Balanced stabilizer
Prevention
of Mania
(but not depression)
Prevention
of Depression
(buyt not mania)

52. 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 52

53. Polarity Index of medicaments used in maintenance treatment of BD
PI = 1
QUE
1.14
LI 1.39
OLZ2.98
ZIP
3.91
ARI
4.38
RLAI
12.09
Predominantly Antidepressive PI
Predominantly Antimanic PI
Popovic et al., European Neuropsychopharmacology, 2012
LAM
VPA 0.49
OXC 53

54. Popovic et al., 2013; 1Colom 2003; 2Lam 2003; 3Lam 2005; 4Meyer, 2011
NNT
Mania
Depression
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
0.89
Popovic et al., 2013; 1Colom 2003; 2Lam 2003; 3Lam 2005; 4Meyer, 2011 54

55. NNT
Mania
Depression
Any episode
Polarity
Index
Enhanced relapse prevention4 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 55

56. Polarity Index for Adjunctive Psychotherapies in maintenance treatment of BD
Enhanced relapse prevention4
Family-focused therapy5
Caregiver group psychoeduc.7
Brief technique-driven interv.6
CBT8
CBT2
CBT3
Psychoeducation¹
Popovic et al., 2013

57. 2º AXIS: severity (The Pit)

58. Proposed Staging Model for Bipolar Disorder
Kapczinski et al, submitted

59. 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
Severity

60. Late
Medium
Early
D-prevention
M-prevention
At risk

61. Efficacy of Teaching Bipolar Patients Early Detection of Prodromal Signs
1.0
Exp-M
Control-M
Exp-D
0.8
Control-D
Cumulative survival
0.6
0.4 20 40 60 80
Weeks
Exp-M=experimental group, manic; Exp-D=experimental group, depressive.
Perry A et al. BMJ. 1999;318: 61

62. Adjusted hazard ratio 0.79 (95% CI 0.45–1.38)
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

63. Late EW
(Ind)
Medium
Early
D-prevention
M-prevention
At risk

64. Family-focused psychoeducation
(Miklowitz et al., Arch Gen Psychiatry 2003)

65. FFT Delays Rehospitalization Longer Than Individual Treatment
UCLA FFT Study (N=53)
Cumulative Survival Rate
39 Weeks
X2 (1) = 3.87, P <.05
Rea, Tompson, Miklowitz et al. J Consult Clin Psychol ; 71:

66. Patients’ Recurrences During 15-month Follow-up after Family Psychoeducation%
*p=0.011
N=113
*p=0.017
p=0.211
p=0.468
Reinares M et al. Bipolar Disord

67. Impact of staging on family psychoeducation
Stage I
N= 113
Advanced Stages
Reinares et al, 2010

68. FFT Late Medium Early At risk D-prevention M-prevention Group
F-Psyched EW
(Ind)
FFT
Medium
Early
D-prevention
M-prevention
At risk

69. CBT in Bipolar Disorders: 1-year follow-up
(Lam et al., Arch Gen Psychiatry 2003)

70. CBT in bipolar disorder: 2-year follow-up
(Lam et al., Am J Psychiatry, 2005)

71. CBT Not Effective in Acutely Ill Patients With Multiple Episodes
Recurrences (%)
Time (wk)
At risk (n)
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: 71

72. 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)

73. Cumulative proportion without episode
A randomized controlled trial of cognitive behavioural group therapy for bipolar disorder
1.0
50 euthymic BP I or II
TAU vs. TAU + CBGT
ITT: no differences re time to relapse (total, manic, or depressive)
TAU
CBGT
0.8
0.6
Cumulative proportion without episode
0.4
0.2
Dc - bw
0.0 20 40 60 80
Weeks
CBGT, cognitive behavioural group therapy
TAU, treatment as usual
Gomes Psychother Psychosom. 2011;80:144.

75. % recurrence by treatment group and number of previous episodes
Early input is better
% recurrence by treatment group and number of previous episodes
Dc - bw
CBT, cognitive behavioural therapy
TAU, treatment as usual
N=253
Scott Br J Psychiatry. 2006;188:313.

76. CBT FFT Late Medium Early At risk D-prevention M-prevention GroupEW
(Ind)
FFT
Group
F-Psyched
Medium
Early
D-prevention
M-prevention
At risk

77. Mean Number of Episodes (5-year Follow-up)* * * * *
*P<.05 psychoeducation vs control.
Colom F et al. Br J Psychiatry 77

78. Time Spent Ill (5-year Follow-up)
Days
P<.05
P<.005
P<.005
Colom F et al. Br J Psychiatry 78

79. 102 Bipolar outpatients type I & II
IS STRUCTURED GROUP PSYCHOEDUCATION FOR BIPOLAR PATIENTS EFFECTIVE IN ORDINARY MENTAL HEALTH SERVICES?
A CONTROLLED TRIAL IN ITALY
102 Bipolar outpatients type I & II
Exclusion criteria
Axis I comorbidity
Mental retardation (QI <70)
Organic brain damage or deafness
1 year follow-up
Psychoed.
group
(n=57)
Controls
(n=45)
p-value
N° of hospitalisations
Mean (ds)
0.11 (0.36)
0.47 (0.69)
.001
N° of days of hospitalisation
1.75 (7.0)
10.16 (16.8)
SURVIVAL CURVES FOR HOSPITALISATION
N° of people hospitalised
Psychoed. Group (5 out of 57)
Controls (16 out of 45)
Candini et al., 2013

81. Colom et al., Acta Neuropsychiatrica, 2010
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

82. Impact of staging on family psychoeducation
Stage I
N= 113
Advanced Stages
Reinares et al, 2010

83. % recurrence by treatment group and number of previous episodes
Early input is better
% recurrence by treatment group and number of previous episodes
Dc - bw
CBT, cognitive behavioural therapy
TAU, treatment as usual
N=253
Scott Br J Psychiatry. 2006;188:313.

84. CBT FFT Late Medium Early At risk D-prevention M-prevention GroupEW
(Ind)
FFT
CBT
Group
Psyched
Group
F-Psyched
Medium
Early
D-prevention
M-prevention
At risk

85. Unsolved areas Functional impairment (Ultra)High-risk individuals
Therapy availability/implementation problems
“Veteran” patients / paliative psychotherapy
Dual pathology
Physical health

86. Unsolved areas Functional impairment (Ultra)High-risk individuals
Therapy availability/implementation problems
“Veteran” patients / paliative psychotherapy
Dual pathology
Physical health

87. 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)

88. Functional Impairment across Mood States*
D>M>E >C * 50 40
Functioning Assessment Short Test (FAST) * 30 * 20 10
Depression
(Hypo)mania
Euthymia
Healthy Controls
(Rosa et al., 2010)

89. Functional Impairment in Remitted Bipolar Patients
d=1.26, p<0.001
d=1.18, p<0.001
In order to avoid the interfering effects of acute mood symptoms on functioning, this study enrolled patients in remission and compared functioning in multiple domains with healthy controls.
We found that euthymic bipolar patients experienced not only lower global functioning than healthy controls, but they presented significant difficulties in five areas of functioning, such as autonomy, occupational functioning, cognitive functioning, financial issues and interpersonal relationships.
When the effect size analyses were performed, we observed that the occupational functioning, cognition and autonomy were the most affected domains.
d=0.65, p<0.001
d=0.88, p<0.001
d=0.91, p<0.001
d=0.33
d=0.35, p<0.004
(Rosa et al., 2008) 89 89

90. Cognitive Impairment in Bipolar Disorder
Bipolar patients show cognitive dysfunctions across different mood states, including remission
Patients with history of psychotic symptoms, bipolar I disorder, longer duration of illness and a high number of manic episodes are the ones who are more likely to show neuropsychological disturbances
Cognitive impairment has a strong impact on functioning
Early diagnosis and treatment would most likely be the best way to prevent cognitive dysfunctions and their impact on psychosocial outcome
Pese a que se ha estudiado más la m.verbal que la visual, actualmente los hallazgos apuntan déficits tanto en pacientes agudos como eutímicos.
Los déficit mnésicos pueden ser el resultado de dificultades en la codificación de la información debido a alteraciones de atención y concentración, lo que comporta problemas en la fijación del material.
Por otra parte, los déficit mnésicos más característicos se dan en relación a la organización de la información para facilitar su recuperación posterior.
No está clara la afectación de la memoria de reconocimiento.
Martínez-Arán, et al. Am J Psychiatry, 2004;161:

91. Psychoeducation and functional remediation
Changes in functional impairment scores before and after intervention in patients with bipolar disorder
Within-group effect sizes in functional improvement, by domain of the Functioning Assessment Short Test
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0 34 32 30 28 26 24 22 20
Leisure
Interpersonal*
Financial
Cognitive
Occupational*
Autonomy * *
Functioning Assessment Short Test†
Effect size
Functional remediation (n=77)
Psychoeducation (n=82)
Treatment as usual (n=80) ** 21
Time (weeks)
Functional remediation
Psychoeducation
Treatment as usual
*p<0.05, **p<0.005 compared with treatment as usual
†Higher scores indicate greater impairment
Torrent C, et al. Am J Psychiatry 2013 91

92. Functional remediation in BP-II patients
(Solé et al., Eur Neuropsy 2015)

93. CBT FFT Functional Remed. Late Medium Early At risk D-preventionEW
(Ind)
FFT
CBT
Group
Psyched
Group
F-Psyched
Medium
Early
D-prevention
M-prevention
At risk

94. Unsolved areas Functional impairment (Ultra)High-risk individuals
Therapy availability/implementation problems
“Veteran” patients / paliative psychotherapy
Dual pathology
Physical health

96. Family-Focused Therapy for individuals at bipolar risk
(Miklowitz et al., 2013)

98. CBT FFT FFT-HR Functional Remed. Late Ad hoc Medium CBT/Psyched EarlyEW
(Ind)
FFT
CBT
Group
Psyched
Group
F-Psyched
Ad hoc
CBT/Psyched
Medium
FFT-HR
Early
D-prevention
M-prevention
At risk

99. Unsolved areas Functional impairment (Ultra)High-risk individuals
Therapy availability/implementation problems
“Veteran” patients / paliative psychotherapy
Dual pathology
Physical health

101. :): 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.

102. *
Clinical trial.gov Identifier: NCT

107. :):
SIMPLe: General app function framework

108. Unsolved areas Functional impairment (Ultra)High-risk individuals
Therapy availability/implementation problems
“Veteran” patients / paliative psychotherapy
Dual pathology
Physical health

110. + :): + The SIMPLe Project What’s next? SIMPLeBand Smartphone data log
Weareables +
Passive information inclusion +

111. Rematch (Relapse prEvention through Mobile providers cAll deTailed records (CDRs)
Project

114. (Colom, 2012)

115. Newer potential targets for BD psychotherapy
Emotional hyperreactivity
Social cognition
Non-verbal strategies
BCT rather than CBT …

116. 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

117. Centro de Investigación Biomédica En Red
sam
ciber
Centro de Investigación Biomédica En Red
de Salud Mental