Abordaje terapéutico del alcoholismo en el trastorno bipolarterapéutico... · Abordaje...

Abordaje terapéutico del

alcoholismo en el trastorno bipolar

Antoni Gual & Pol Bruguera Addictions Unit.

Psychiatry Dept. Neurosciences Institute.

Hospital Clínic de Barcelona. IDIBAPS.

tgual@clinic.cat

Índice

• Nuevos conceptos en el ámbito del alcohol

• Impacto del alcohol en el TB

• Evaluación diagnóstica

• Abordaje terapéutico

• Conclusiones

Nuevos conceptos Impacto Diagnóstico Tratamiento

Índice

• Conclusiones

Epidemiología

• EU: Cerca de 11 millones de alcohólicos entre 18-64 años en el 2005 (Rehm et al., 2012)

• US: National Epidemiologic Survey on Alcohol and Related Conditions; (Hasin et al., 2007)

Prevalence of: lifetime 12-month

Alcohol Abuse 17,8% 4,7%

Alcohol Dependence 12,5% 3,8%

Therapeutic Goals

WHO – ICD 10

• Hazardous drinking

• Harmful drinking

• Alcohol dependence

APA – DSM-IV TR

• Alcohol abuse

• Alcohol dependence

Abstinence

Reduction

Given the empirical evidence, the DSM-V Substance Use Disorders Workgroup recommends:

• To combine abuse and dependence into a single disorder

• With graded clinical severity: mild, moderate and severe

• Two criteria required to make a diagnosis

• Specify Physiological Dependence (Tolerance / Withdrawal)

ALCOHOL USE DISORDER (DSM V)

Severity specifiers:

• Mild: 2-3 criteria

• Moderate: 4-5 criteria

• Severe: 6 or more criteria

Physiological Dependence:

• tolerance and/or withdrawal

DSM 5: Alcohol use disorder (AUD)

Abstinence

Reduction

NO YES Nuevos conceptos Impacto Diagnóstico Tratamiento

Consumo Excesivo Continuado (CEC) Heavy Use Over Time (HUOT)

Why use HUOT ?

• HUOT is responsible for the changes in the brain and other physiological characteristics of SUD

• HUOT is responsible for intoxication and for the withdrawal and tolerance phenomena regarded as central to current definitions of addiction or dependence

• HUOT is responsible for the main social consequences of SUD, such as problems in fulfilling social roles

• HUOT is responsible for the majority of the substance-attributable burden of disease and mortality

• HUOT as a definition better fits the empirical data and may diminish stigmatization and avoids pointing attention away from highest-risk categories

Why use HUOT ?

Índice

• Conclusiones

Impacto del alcoholismo en el TB

• Alta comorbilidad

• Mayor severidad

• Mayor complejidad en el tratamiento

• Alta comorbilidad • Can affect up to 54,6% in BD I and 51,8% in BD II (NESARC; Bega et al. 2011)

• Increases the likelihood of co-occurring lifetime diagnosis of mania (OR 12.03 for men and OR 5.3 for women) (Kessler RC et al., 1997)

• Mayor severidad

• Mayor severidad • Nonadherence (Baldessarini et al., 2008) (Perlis et al., 2010)

• More comorbid nicotine and drug dependence. (Oquendo et al., 2010)

• More cognitive impairement. ( Van Gorp et al., 1998, Levy et al., 2012)

• Violent behavior (Salloum et al., 2002)

• Higher rates of suicide attempts, (Feinman and Dunner, 1996; Sublette et al.,

2009, Oquendo et al., 2010)

• Mayor severidad

• Mayor complejidad en el tratamiento – Higher rates of hospitalization (Reich et al., 1974)

– Mood episode recurrences (Tohen et al., 1990), (Winokur et al., 1995) (Strakowski

et al., 1998), (DelBello et al., 2007), (Kessing, 1999), (Goldstein et al., 2006)

– More likely to switch or to have a rapid cycling course of disease. (Ostacher et al., 2010), (Strakowski et al., 2005), (Cruz et al., 2008) , (McKowen et al., 2005)

• Review of 23 studies

• Alcohol did not prolong mood episodes of any type (3/5 studies)

• High levels of alcohol intake increase the risk of a mood recurrence (6/11

studies)

• Increased alcohol use preceded the development of new mood episodes

(5/7 studies)

• AUDs were associated with higher rates of rapid-cycling (4/5 studies)

Alcohol use destabilizes the course of illness over the long run

Índice

• Conclusiones

Cuestionario autoadministrable que explora:

• Cantidad y frecuencia de consumo

• Problemas relacionados con el consumo de alcohol

• Sintomatología de dependencia y consecuencias del consumo

Válido y fiable

• Sensibilidad: 51% - 97%

• Especificidad: 78% - 96%

AUDIT-C

0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1

1-Specificity

nsitiv

AUDIT_3

AUDIT_4

AUDIT_10

Females

0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1

1-Specif icity

Sensitiv

AUDIT_3

AUDIT_4

AUDIT_10

No se encontraron diferencias en el funcionamiento del cuestionario

AUDIT-C frente al AUDIT para la detección del consumo de riesgo en

hombres ni en mujeres

AUDIT-C

1. ¿Con qué frecuencia consume alguna bebida alcohólica?

(0) nunca (1) una o menos veces al mes (2) 2 a 4 veces al mes

(3) 2 o 3 veces a la semana (4) 4 o más veces a la semana.

2. ¿Cuántas consumiciones de bebidas alcohólicas suele

realizar en una ocasión de consumo?

(0) 1 o 2 (1) 3 o 4 (2) 5 o 6 (3) 7 a 9 (4) 10 o

3. ¿Con qué frecuencia toma 6 o más bebidas alcohólicas en un

solo día?

(0) nunca (1) menos de una vez al mes (2) mensualmente

(3) semanalmente (4) a diario o casi a diario.

Punto de corte: 5 o mas

Timeline followback

• Retrospective assessment of drinking behaviour.

• Reliable and valid for a variety of populations for time frames of up to one year.

(Sobell & Sobell, 1992, 1996)

Reducción de consumos usando Brenda y TLFB (Sense study)

Change f

baseline in H

Change f

baseline in T

Monthly period Monthly period

HDDs TAC

Resultados del grupo placebo

• 150 individuals, half of them with comorbid (Axis I and/or Axis II)

psychiatric disorders engaged in residential treatment for substance use

disorders (SUDs).

• Validity was assessed comparing TLFB with the Addiction Severity Index

(ASI) and collateral reports.

• TLFB was significantly correlated with data from the ASI and collateral

reports of substance use.

• No significant differences were found between those with and without a

comorbid psychiatric disorder. The TLFB was equally valid for both groups.

Validity of the TLFB in comorbid patients

Índice

• Conclusiones

Abordaje terapéutico

• Estrategia terapéutica: secuencial, en paralelo o integrada

• Abordaje del consumo de riesgo en el paciente bipolar

• Tratamiento del TB comorbido con TUA

– Psicosocial

– Farmacológico

– Psicosocial

– Farmacológico

• Pilot study following screening for at-risk drinking

• 604 patients; 390 screened; 87 patients identified + brief alcohol

intervention.

• 63% follow-up at 6 months (n = 55)

Eficacia de la intervención breve a los 6 meses

Drinks per week Binge drinking

– Psicosocial

– Farmacológico

Fireside. Concepto.

Fireside. Resultados (basado en el TLFB)

Weiss et al., 2007. Am J Psychiatry

Integrated group therapy for SUD and BD

• Single-disorder paradigm

• Common features in the recovery and relapse process in the two disorders

• Relationship between the two disorders

(Weiss et al., 1999, 2000, 2007, 2009)

Weiss et al., 2007

Pharmacological Treatment

• Valproate

• Lithium and divalproex

• Naltrexone

• Disulfiram

• Acamprosate

• Quetiapine

• Olanzapine

Summary (Pettinati et al. 2013)

• Co-occurring bipolar and substance use disorders are difficult to treat

• Conducting research with this group can be particularly challenging.

• Pharmacotherapies have been studied in well-controlled trials. Patients with stabilized mood disorder were treated with a double-blind medication.

• The medications studied included two used for bipolar symptoms (quetiapine and valproate) and two for alcohol dependence (naltrexone and acamprosate)

• Adding a medication to reduce substance use to a pharmacotherapy for treating bipolar disorder did not consistently reduce substance use (except valproate).

• More research is needed before any firm conclusions can be drawn.

• Prevention and treatment of the substance use disorder is especially indicated for patients with an early age at onset of a bipolar disorder.

59 patients with BD and AUD in treatment with lithium carbonate and

psychosocial interventions were randomized into two groups; placebo

and valproate

Conclusiones

• Elevada comorbilidad. Mayor complejidad.

• Gran dificultad para generar evidencia

• Monitorizar consumos: TLFB/Audit C

• Intervenciones breves en bebedores de riesgo

• Tratamiento integrado

Muchas gracias!!

Abordaje terapéutico del

alcoholismo en el trastorno bipolar

Antoni Gual & Pol Bruguera Addictions Unit.

Psychiatry Dept. Neurosciences Institute.

Hospital Clínic de Barcelona. IDIBAPS.

tgual@clinic.cat

Abordaje terapéutico del alcoholismo en el trastorno bipolarterapéutico... · Abordaje...

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