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Psychoeducation and other psychological approaches

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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 Treatments
4* .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)

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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

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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)

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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.

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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 Group
EW (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

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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 Group
EW (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-prevention
EW (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

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

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98 CBT FFT FFT-HR Functional Remed. Late Ad hoc Medium CBT/Psyched Early
EW (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

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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

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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

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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

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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


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