آموزش روانی مختصر برای اختلال دو قطبی: تاثیر بر کیفیت زندگی در افراد جوان در 6 ماه پیگیری از یک مطالعه کنترل شده تصادفی

Abstract There are scarce follow-up studies evaluating the role of psychoeducation in the treatment of bipolar disorder, especially in a young sample, with a recent diagnosis and that probably received a few previous interventions. This was a randomized clinical trial with young adults aged 18–29 years, who had been diagnosed with bipolar disorder through the Structured Clinical Interview for DSM (SCID). The evaluation of quality of life was carried out using the Medical Outcomes Survey 36-Item Short-Form Health Survey (MOS SF-36). All participants were randomized into two groups: combined intervention (psychoeducation plus medication) and treatment-as-usual (medication). The sample consisted of 61 patients divided in two groups (29 usual treatment; 32 combined intervention). The quality of life domains did not reveal statistically significant differences when comparing baseline, post-intervention and 6-month follow-up evaluations, which indicates that there is no difference between combined intervention and usual intervention regarding quality of life improvement. Both groups presented improvements in quality of life domains, except General Health and Bodily Pain, at post-intervention. Moreover, this improvement persisted at 6-month follow-up, except for the Role Physical Health domain, which remained reduced. Combined Psychoeducation plus pharmacological intervention is so effective in improving quality of life perception as it is pharmacological only intervention.

1. Introduction Bipolar disorder (BD) is chronic, recurrent and characterized by mood oscillation episodes. (Sadock and Sadock, 2007) It is considered an important public health problem, since it has been associated with impairments regarding socioeconomic matters, quality of life (Hilty et al., 1999 and Goetzel et al., 2003), and elevated mortality rates (Angst et al., 2002). Mood disorders are very prevalent in the population over 18 years of age. A multicenter study found a prevalence of mood disorders in the previous year of 24.7%, in a sample of individuals between 18 and 34 years of age, and 20.5% in developing countries (Kessler et al., 2010). A Brazilian study performed in the city of São Paulo, found a prevalence of lifetime mood disorders of 18.5%, in a sample of individuals aged 18 years or more (Andrade et al., 2002). Epidemiological studies indicate that the prevalence of bipolar disorder range from 1.1% to 3.8% (Hoertel et al., 2013, Kozloff et al., 2010 and Subramaniam et al., 2013). Quality of life is defined by the World Health Organization (WHO) as “an individual׳s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (Fleck et al., 1999). Moreover, quality of life is an important indicator of health and it may be significantly compromised even in populations of young individuals. This information is corroborated by one population-based study carried out with young adults in the south of Brazil, which revealed impairments on quality of life of patients with mood disorders (Jansen et al., 2013). A cohort study indicated lower quality of life scores in individuals with current psychiatric symptoms, including bipolar disorder, when compared to individuals without current symptoms (Rubio et al., 2013). Psychoeducation for BD offers the patient the possibility of improving their awareness about the disorder, increases medication adherence, reduces the possibilities of new mood episodes, and improves quality of life (Figueiredo et al., 2009). In this sense, it aims to promote knowledge that will help the patient to better understand and cope with the disorder, culminating in a better context for pharmacological and behavioral treatment. Studies that tested the effect of 21 group sessions of psychoeducation demonstrate the effectiveness of this intervention. One study using this form of intervention with patients from 18 to 65 years old verified that, at one-year follow-up, there were lower indexes of hospitalization, as well as smaller numbers of hospitalization days in patients that had received the intervention, when compared to control patients (Candini et al., 2013). Another study using the same number of group sessions, with patients with a mean age of 40 years, indicates that patients who had been psychoeducated demonstrated less hypomanic and depressive episodes, lower duration (days) of episode and improved general functioning at 5-years follow-up, when compared to patients who had received psychoeducation (Colom et al., 2009). Findings from a clinical trial with six sessions of group psychoeducation, with patients from 19 to 62 years of age, evidenced an improvement in medication adherence from 40% to 86.7% in patients who had received psychoeducation, whereas patients from the control group presented a diminishment in medication adherence from 38.9% to 24.2% (Eker and Harkın, 2012). To our knowledge, a few studies have tested the efficacy of individual psychoeducation. One study with eight sessions of individual psychoeducation with patients from 18 to 60 years of age verified that psychoeducated patients demonstrated better medication adherence, improvement in all levels of quality of life, and lower rates of relapse and hospitalization, when compared to control individuals, in a 18-months follow-up study (Javadpour et al., 2013). Follow-up studies that evaluate the impact of psychoeducation on the quality of life of patients with bipolar disorder are scarce (Javadpour et al., 2013). Even though studies have verified impairments associated to the age of onset of the disorder, and identified that the early onset of the disorder implicates in a higher number of episodes, suicide attempts, panic attacks, higher duration of depressive episode, substance abuse, and severe mania with psychotic symptoms (Azorin et al., 2013 and Coryell et al., 2013), we did not find any study in literature that evaluated the effect of psychoeducation in a young population. Therefore, it is considered necessary to study the efficacy of interventions targeting bipolar disorder in a sample with small exposition time to the disorder. Thus, the aim of this study was to evaluate the impact of psychoeducation on quality of life in young adults from 18 to 29 years of age, presenting bipolar disorder, both at post-intervention and at 6-month follow-up.

3. Results 3.1. Impact of psychoeducation on quality of life in patients with BD The young adults from the combined psychoeducation plus medication group significantly improved in five quality of life domains, at post-intervention evaluation, which are: Physical Functioning (t=−2.03, d.f.=31, p=0.051), Vitality (t=−2.37, d.f.=31, p=0.024), Social Functioning (t=−2.00, d.f.=31, p=0.054), Role Emotional (t=−2.78, d.f.=31, p=0.009), and Mental Health (t=−2.64, d.f.=31, p=0.013). This improvement persisted meaningful at 6-month follow-up; however, patients presented a greater impairment related to Role Physical Health (t=3.03, d.f.=31, p=0.05). The individuals who received the usual treatment (medication only) presented a significant improvement in three quality of life domains: Role Physical Health (t=−2.20, d.f.=28, p=0.036), Social Functioning (t=−2.57, d.f.=28, p=0.016) and Mental Health (t=−2.20, d.f.=28, p=0.036). This improvement persisted meaningful at 6-month follow-up, except for the Role Physical Health (t=4.31, d.f.=28, p<0.001), in which patients presented a decreased score when compared to post-intervention, and for the General Health(t=−3.03, d.f.=28, p=0.05), in which there was an improvement considering the post-intervention and follow-up period ( Table 3). Table 3. Impact of psychoeducation on quality of life in bipolar patients, by intention-to-treat analysis. Variables Combined intervention p-Value Usual treatment p-Value QoL domains Role Physical Healtha Baseline 73.13±20.89 71.21±21.74 Post-intervention 76.25±20.00 0.086 77.59±23.25 0.036 6-month follow-up 63.72±28.31 0.005 52.76±32.39 <0.001 Physical Functioninga Baseline 27.34±35.56 31.90±33.34 Post-intervention 38.28±37.56 0.051 42.24±40.15 0.179 6-month follow-up 40.63±37.97 0.703 49.14±43.03 0.212 General Healtha Baseline 51.97±21.40 58.17±23.77 Post-intervention 53.69±16.69 0.446 56.34±14.85 0.586 6-month follow-up 57.22±22.55 0.135 63.21±20.14 0.005 Vitalitya Baseline 35.78±22.18 34.48±21.85 Post-intervention 42.03±21.32 0.024 42.07±27.37 0.099 6-month follow-up 42.81±23.42 0.767 45.69±25.90 0.307 Social Functioninga Baseline 38.67±20.66 33.19±24.84 Post-intervention 45.31±20.76 0.054 46.55±29.49 0.016 6-month follow-up 45.70±24.72 0.904 50.00±31.87 0.433 Role Emotionala Baseline 13.54±25.20 20.69±30.10 Post-intervention 30.21±37.25 0.009 33.33±41.78 0.133 6-month follow-up 33.33±37.86 0.414 40.23±45.76 0.339 Mental Healtha Baseline 37.13±20.25 33.93±20.61 Post-intervention 44.75±22.39 0.013 42.90±26.83 0.036 6-month follow-up 44.63±23.81 0.956 47.59±27.14 0.241 Bodily Paina Baseline 54.41±28.92 59.21±26.29 Post-intervention 58.47±26.50 0.243 57.24±23.41 0.766 6-month follow-up 55.09±25.01 0.163 58.38±25.84 0.746 a There was no significant difference between groups at baseline, post-intervention and at 6-month follow-up. Table options Quality of life domains did not present significant differences regarding the evaluations at baseline, post-intervention, and at follow-up, which indicates that there is no difference between the usual treatment and the combined intervention regarding improvements related to quality of life (Table 3). Both interventions presented improvements on quality of life domains at post-intervention, except General Health and Bodily Pain. This improvement persisted at 6-month follow-up, except Role Physical Health, which was diminished at follow-up. Moreover, there was a significant improvement regarding general health at follow-up (Fig. 2). Mean quality of life scores at baseline, post-intervention and at 6-month ... Fig. 2. Mean quality of life scores at baseline, post-intervention and at 6-month follow-up, by intention-to-treat analysis. *Significant difference between baseline and post-intervention, without significant difference between post-intervention and 6-month follow-up. **Significant difference between baseline and post-intervention and between post-intervention and 6-month follow-up. ***No significant difference between baseline and post-intervention, with significant difference between post-intervention and 6-month follow-up. ****No significant difference between baseline and post-intervention and between post-intervention and 6-month follow-up. Figure options The ANCOVA test was used to compare the effect of the intervention models considering the quality of life scores at baseline and the economic indicator as covariables. There was no difference between the groups regarding quality of life improvement at post-intervention and at 6-month follow-up: Role Physical Health at post-intervention (F=2.53, d.f.=1, p=0.119) and at 6-month follow-up(F=1.98, d.f.=1, p=0.166); Physical Functioning at post-intervention (F=0.04, d.f.=1, p=0.851) and at 6-month follow-up(F=0.08, d.f.=1, p=0.780); General Health at post-intervention (F=0.04, d.f.=1, p=0.835) and at 6-month follow-up (F=0.04, d.f.=1, p=0.836); Vitality at post-intervention (F=0.52, d.f.=1, p=0.474) and at 6-month follow-up (F=0.39, d.f.=1, p=0.537); Social Functioning at post-intervention (F=0.01, d..f=1, p=0.996) and at 6-month follow-up (F=0.62, d.f.=1, p=0.435); Role Emotional at post-intervention (F=0.39, d.f.=1, p=0.531) and at 6-month follow-up (F=0.24, d.f.=1, p=0.627); Mental Health at post-intervention (F=0.26, d.f.=1, p=0.614) and at 6-month follow-up (F=1.19, d.f.=1, p=0.282). 3.2. Impact of psychoeducation on symptom improvement Depressive symptoms were significantly reduced at post-intervention both in patients from the combined intervention (t=3.36, d.f.=31, p=0.002), as from the usual treatment (t=3.79, d.f.=28, p=0.001). Also, both groups maintained the improvement at follow-up. Manic symptoms, however, were not reduced in both intervention groups ( Table 4). Table 4. Impact of psychoeducation on depressive and manic symptoms remission in bipolar patients, by intention-to-treat analysis. Variables Combined intervention p-Value Usual Treatment p-Value Severity of symptoms Depressive symptomsa 0.002 0.001 Baseline 12.63±5.46 15.07±8.24 Post-intervention 9.41±5.56 10.86±5.70 6-month follow-up 10.06±5.96b 9.31±5.70b Manic symptomsa 0.102 0.892 Baseline 7.03±8.63 5.83±6.58 Post-intervention 4.66±5.83 5.62±4.40 6-month follow-up 4.69±5.64b 5.66±4.43b a There was no significant difference between groups at baseline, post-intervention and at 6-month follow-up. b There was no significant difference from post-intervention to 6-month follow-up. Table options The ANCOVA analysis comparing the interventions, considering the severity of depressive symptoms at baseline and the economic indicator as covariables, indicate that there is no difference between the groups regarding the improvement of depressive symptoms at post-intervention (F=0.06, d.f.=1, p=0.806), as well as at 6-month follow-up (F=0.99, d.f.=1, p=0.324). The ANCOVA analysis comparing the interventions, considering the severity of manic symptoms at baseline and the economic indicator as covariables, indicate that there is no difference between the interventions regarding the improvement of manic symptoms at post-intervention (F=2.16, d.f.=1, p=0.149), as well as at 6-month follow-up (F=2.94, d.f.=1, p=0.094).