Transcript Recaídas en el trastorno bipolar Meta

Risk factors for relapse in bipolar disorder:
conclusions stemming from an observational study
Benedikt L Amann
FIDMAG Research Foundation,
Barcelona, Spain
Conflicts of interest
I. Speaker for BMS, Otsuka, Janssen
II. Grants: Stanley Research Medical Institute, Ministery of
Health Spain (ISCIII), Spanish and European EMDR Associations
III. PI Research contract Ministery of Health, Spain (until 2018)
IV. No shares or stocks of pharmaceutical industry
Is there any need to look for
risk factors in BD?
Psychosocial interventions in BD
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Psychoeducation
Cognitive-Behavioral Therapy
Family Interventions
Interpersonal and Social Rhythm Therapy
Schema-focused Therapy
Functional remediation
Mindfulness
Reinares et al, 2014
Relapse rate in bipolar disorder
Meta-analysis of 1500 Bipolar I and II patients
Observational, naturalistic studies
Amann and Radua, submitted 2015
What are ignored risk factors?
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Subsyndromal symptoms
Adherence/insight
Comorbidities
Life events/trauma
Subsyndromal symptoms
Meta-analysis of 1500 Bipolar I and II patients
Observational, naturalistic studies
Treatment options:
1. Lamotrigine and lithium (Frye et al, 2006)?
2. Aripiprazole (Schweitzer et al, 2013)?
3. EMDR (Novo et al, 2014)?
4. Functional remediation therapy (Solé et al, 2014)?
5. Mindfulness (Lahera et al, 2014)?
Green: remission; red: subsyndromal symptoms
Amann y Radua, submitted 2015
BD II
• Largely ignored from a scientific point of view
• Less trials than in BDI
• BD II patients as impaired as BDI subjects
Sole et al, 2014
BD II
Meta-analysis of 1500 Bipolar I and II patients
Observational, naturalistic studies
Evidence
-Quetiapine (RCT) (> in depressive phases)
-LTG (RCT)
-Lithium?
-Valproate?
-Antidepressants?
-Acetilcysteine?
-OXC?
-Interpersonal Rhythm Therapy (depression)?
Brown: BDI; pink: BDII
Amann y Radua, in preparation 2015
Swartz et al, 2009; Swartz and Thase, 2011, Magalahes et al, 2011,
Vieta et al, 2011; Muzina et al, 2011; Suppes et al, 2013; Amsterdam
et al, 2013, Young et al, 2014
Adherence
Lack of insight
Treatment adherence in euthymic
bipolar patients
N=200
13%
27%
60%
Good Adherence
Partial Adherence
Poor Adherence
Colom et al, J. Clin. Psychiatry 2000
Adherence
Results from an observational study of 300 bipolar I and II patients
Simhandl, König and Amann, 2014
Interventions to improve adherence
Psychosocial
interventions
ADHERENCE
 CBT
 Psychoeducation for patients and
family
 Larger and more frequent visits
 EMDR protocol
Pharmacological
interventions
 Adjust dosage
 Simplify pharmacologcial strategies
 LAI
Comorbidites in our observational, naturalistic study
All
Bipolar I (n=159)
Bipolar II (n=118)
Alcohol use
disorders
55 (19.9%)
24 (15.1%)
31 (26.3%)
0.031 *
Physical
comorbidities
185 (66.5%)
99 (61.9%)
86 (72.9%)
0.073
Psychiatric
comorbidities
Anxiety: 43 (15.5%) Anxiety: 10 (6.3%)
Pers dis: 33 (11.9%) Pers. dis.: 11 (6.9%)
Anxiety: 33 (28.0%)
Pers. dis.: 22 (18.6%)
P
<0.001 *
0.005 *
Amann, Radua, Simhandl, König, in preparation 2015
AUDs provoke more depressive episodes in BDI
Possibly personality disorder
Simhandl, Radua, König, Amann, 2015 , ANJP, accepted
Comorbidities
Physical Comorbidities
All
Bipolar I (n=159)
Bipolar II (n=118)
P
Smoking: 130 (52.4%)
Smoking: 79 (57.7%)
Smoking: 51 (45.9%)
0.087
Metabolic disease: 61 (22.0%)
Metabolism: 29 (18.2%)
Metabolism: 32 (27.1%)
0.11
Cardiovascular: 52 (18.8%)
Cardiovascular: 29 (18.2%)
Cardiovascular: 23 (19.5%)
0.91
Thyroid disease: 52 (18.8%)
Thyeoidea: 35 (22.0%)
Thyeoidea: 17 (14.4%)
0.15
Neurological: 21 (7.6%)
Neurological: 9 (5.7%)
Neurological: 12 (10.2%)
0.24
Metabolism: lipids, obesity, DM
Cardiovascular: HTA, CV, COPD
Thyroids: Hyper-, Hypothyreodism Struma nod., Adenome, Strumektomie
Neurologisch: Enc Diss, Migraine
Amann, Radua, Simhandl, König, in preparation 2015
Do comorbidities influence the course of the illness?
Amann, Radua, König and Simhandl, 2015 in preparation
Life events and PTSD
PTSD increases:
Suicide attempts
RC
More manic symptoms
Quarantinni et al. 2010
Less QoL
Life events:
Negative: Loss of job, end of a relationship, Loss of a person,
Accident, admission to hospital, personal crisis, law case or violence
Positive: wedding, birth etc
50.5% had no life event
31.5% 1 life event
30.6% > than 1 life events
> in BDII
Conclusions
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RCTs are the best methodological standards but only half of the
story
Polypharmacy y comorbidities are the rule in BD but observational
studies are scarce, especially >4 years.
Still face high relapse rates in BD (BDII>BDI)
Exist various risk factors causing a poorer outcome for bipolar
subjects.
Risk factors include adherence, subsyndromal symptoms, physical
comorbidities (especially thyroids dysfunction), AUDs and life
events.
EMDR might be a candidate totreat traumatized bipolar patients.
Results of observational studies should be more taken into account
for individual treatment plans but also in guidelines.
Thanks for your attention!
[email protected]
www.irbd.org
Thanks for your attention
[email protected]
Recaídas en el trastorno bipolar
Meta-análisis de 1375 pacientes con TB I y II
Estudios prospectivos naturalistas
Radua y Amann, en preparación 2013
Recaídas en el trastorno bipolar
Meta-análisis de 1375 pacientes con TB I y II
Estudios prospectivos naturalistas
Marrón: TBI; rosa: TBII
Radua y Amann, en preparación 2013
Recaídas en el trastorno bipolar
Meta-análisis de 1375 pacientes con TB I y II
Estudios prospectivos naturalistas
Verde: remisión; rojo: síntomas subsindromales
Radua y Amann, en preparación 2013
Differences BD I and BD II in relaps
Simhandl et al
Too many relapses in BD
*318 bipolar I and II patients
*Consecutevily admitted
* 4-y prospective, naturalistic follow up
*Comorbidities
*70% relapsed within 4 years
*230 days until next affective relapse
*Lithium better
Simhandl C, König B, Amann BL, Journal of Clinical Psychiatry 2013
Relapse in BD
Simhandl et al, 2013
CBT as relapse prevention in BD
Meyer and Hautzinger, 2012
Polypharmacy
Are comorbidities frequent?
All patients
BD I
BD II
Physical comorbidities: Thyroids, diabetes, lipoproteins and cholesterol,
migrains, cardiovascular deseases, obesity, hypertension, EPOC, asthma, neoplasms,
arthritis, epilepsy, GIT diseases.
More helps more?
Simhandl, König and Amann, 2014
A 30 year old servere bipolar I
patient with psychotic symtpoms
who stabilized finally with:
1. aripiprazol 45 mg
2. clozapine 400 mg
3. amitriptyline 75 mg
4. tranxilium 30 mg
What to do to decrease polypharmacy?
• Stop medication as well
• Adjust dosage and check levels of drugs
• Do not forget lithium
• Watch out for other risk factors
- which might provoke polypharmacy
- and/or a poor response
High relapse rates in BD
“The natural length of affective episodes has probably
not changed over the past 120 years…
The recurrence of bipolar disorder was always the
rule; it now seems to be established that there is
some initial shortening of intervals/cycles, followed
by an irregular persistent recurrence...”
Comorbidities