精神療法穩定日常生活對雙極性異常病患是有益的


  December 27, 2007 —來自賓州匹茲堡大學醫學院的Ellen Frank醫師,在美國神經藥理學第46屆年會上討論兩項研究結果,個體間與社會節律治療穩定睡眠、覺醒以及進食時間可以改善雙極性異常病患預後。
  
  Frank醫師向Medscape精神學表示,臨床上的應用是,不見得一定要提供全套的個體間與社會節律治療療程,在美國,截至目前,僅有少數人受過這樣的訓練,任何一位治療雙極性異常病患的臨床醫師都可以鼓勵他們規律化自己的生活,特別是規律地起床、睡覺與進食。
  
  【個體間與社會節律治療】
  Frank醫師表示,罹患雙極性異常或再發性單極性異常的病患,其生物時鐘是特別敏感的,以致於干擾他們日常規律與睡眠覺醒週期的事件可能會誘發疾病的發生;我們假設,協助病患以非常規律地起床、睡覺、進食時間與其他可以保護這些精緻生物時鐘的日常生活,且將重點放在可能會擾亂日常規律生活的變化,與避免極端的改變,這樣的治療是可以保護病患不要發病的。
  
  他們研發出一種稱為”個體間與社會節律治療”,這項治療包括了社會節律治療,加上Klerman與Weissman研發的個體間精神治療;社會節律治療目標在於協助病患發展並維持規律的日常生活,個體間精神治療針對四種個體間問題,包括喪親、生活角色的重大變化、與重要人士的重大爭執(特別是與其同住的人士)、以及個體間關係缺陷。
  
  Frank醫師表示,我們現在於兩項研究中證實這樣的做法是有好處的。
  
  第一項研究是一隨機分派研究,收納了175位罹患第一型雙極性病患,這項研究結果顯示,相較於接受密集臨床治療的病患,那些接受急性個體間與社會節律治療的病患,在兩年的後續追蹤中,下一次躁鬱或憂鬱發作的時間顯著較長(Frank E等人,Arch Gen Psychiatry 2005;62:996-1004)。
  
  在第二項研究中,個體間與社會節律療法是三種密集精神治療中的一環,這些治療的預後比聯合照護好,這項研究是一項為期一年的隨機分派研究,且是Systematic Treatment Enhancement Program for Bipolar Disorder(STEP-BD)試驗的一部份(Miklowitz,等人Arch Gen Psychiatry 2007;64:419-426),總共有293位罹患第一或第二型雙極性異常與憂鬱症,且正在接受藥物治療療程的門診病患,他們被隨機分派接受高達30次的密集精神治療,分別是個體間與社會節律療法、家庭療法或是認知行為治療,或是接受三次的聯合照護治療;相較於接受行為治療照護的病患,接受密集精神治療的病患達到憂鬱症狀消退的時間較快。
  
  【雙極性異常的動物模式】
  在一項相關發表中,達拉斯德州南西大學醫學中心的Colleen McClung博士報導,一種生物時鐘基因突變的小鼠,其行為表現與躁鬱症病患的症狀相似,這成為研究雙極性異常疾病上一個有用的模式;Frank醫師表示,以病患進行的研究與這個動物模式之間有很強的連結。
  
  【實際上可行的改變、容易實踐】
  Frank醫師表示,建立並維持規律日常生活需要訓練,但相較於達成並維持飲食、運動等健康相關的改變簡單,特別是家庭成員或同住伴侶的支持。
  
  病患通常會說:你在讓我的生活變得索然無味;我們可能會說:只要你在每天晚上幾乎都同樣的時間上床睡覺、且在每天早上幾乎同樣的時間起床,你可以得到許多你想要的、有趣的且令人興奮的經驗;她表示,他們發現理解這項訊息、且能夠採取行動改變的病患,對於他們所見到的改變感到高興。
  
  【夜貓子,而不是早起的人】
  在另一項發表中,同樣來自匹茲堡大學醫學院的Vishwajit L. Nimgaonkar醫師討論到罹患雙極性異常的病患為什麼比一般大眾的生理時鐘要來得慢,這強化了Frank醫師的研究發現;她表示,我們學到的一件事情是,如果罹患雙極性異常病患沒有使他們早起的家人或工作需求,那讓他們維持原本自然的時程會是比較好的,因為至少他們可以得到足夠的睡眠。
  
  她歸納出,只要這不會干擾到工作或是家庭成員的義務,罹患雙極性異常病患應該被鼓勵維持與其自身自然生理時鐘一致的日常生活規律。
  
  STEP-BD研究由國家精神衛生研究院贊助。無相關資金上的往來。

Psychotherapy to Stabilize Dai

By Marlene Busko
Medscape Medical News

December 27, 2007 — Interpersonal and social rhythm therapy to stabilize sleep, wake, and meal times improved outcomes in bipolar patients in 2 studies discussed by Ellen Frank, MD, from the University of Pittsburgh School of Medicine, in Pennsylvania, in a presentation at the American College of Neuropsychopharmacology 46th Annual Meeting.

"The clinical implications are that without necessarily trying to provide patients with the full interpersonal and social rhythm therapy protocol, which so far only a small number of people in the United States are trained to do, any clinician treating someone with bipolar disorder can encourage them to lead lives characterized by regular routines, and in particular, regular wake times, bedtimes, and mealtimes," Dr. Frank told Medscape Psychiatry.

Interpersonal and Social Rhythm Therapy

Individuals with bipolar disorder or recurring unipolar disorder have particularly sensitive biological clocks, so that events that disrupt their daily routines and sleep-wake cycles are associated with new onsets of illness, said Dr. Frank. "We hypothesized that a treatment that helped patients lead lives with very regular wake times, bedtimes, mealtimes, and other routines could protect these delicate clocks, and paying attention to potential changes in routine and avoiding drastic changes could protect patients from new episodes."

They developed a treatment called "interpersonal and social rhythm therapy," in which social rhythm therapy is added to Klerman and Weissman's interpersonal psychotherapy. The social rhythm therapy attempts to help the patient develop and maintain regular daily routines. The interpersonal psychotherapy focuses on 4 interpersonal problem areas: bereavement, transition in a major life role, a major dispute with an important person (particularly someone with whom the patient lives), and interpersonal relationship deficits.

"We've now shown in 2 studies that there are benefits to this approach," said Dr. Frank.

The first study, a randomized controlled trial of 175 patients with bipolar I disorder, showed that compared with participants who received intensive clinical management, those who received acute interpersonal and social rhythm therapy had a significantly longer time before a new episode of mania or depression during a 2-year follow-up (Frank E et al. Arch Gen Psychiatry 2005;62:996-1004).

In the second study, interpersonal and social rhythm therapy was 1 of 3 intense psychotherapies that resulted in better outcomes than collaborative care, in a 1-year randomized study that was part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial (Miklowitz DJ et al. Arch Gen Psychiatry 2007;64:419-426). A total of 293 outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomized to up to 30 sessions of intensive psychotherapy with 1 of 3 methods — interpersonal and social rhythm therapy, family-focused therapy, or cognitive behavior therapy — or to 3 sessions of collaborative care treatment. Compared with patients treated with brief collaborative care, patients receiving intensive psychotherapy attained remission of depression within a shorter time.

Mouse Model of Bipolar Disease

In a related presentation, Colleen McClung, PhD, from the University of Texas Southwest Medical Center, in Dallas, reported that mice with a clock-gene mutation displayed behavior that was similar to symptoms of mania in patients, which makes this a useful model to study bipolar disease. There is a very strong link with patient studies and this animal model, said Dr. Frank.

Practical Change, Easy to Implement

Establishing and maintaining a regular routine take discipline but require less effort than making and keeping health-related changes in diet and exercise, especially with the support of family members or other people living with the patient, said Dr. Frank.

"Patients will often say, 'You are trying to make my life boring,' and we always say, 'You can have as many interesting and exciting experiences as you want, as long as you manage to get to bed at the same time pretty much every night and get up at the same time pretty much every morning,' " she said. They found that patients who understand this message and are able to make the changes are quite happy with the improvement that they see.

Night Owls, Not Morning Larks

In another presentation, Vishwajit L. Nimgaonkar, MD, also from the University of Pittsburgh School of Medicine, discussed how individuals with bipolar disorder are much more likely than people in the general population to have a body clock that runs late, which reinforces findings from Dr. Frank's studies. "One of the things that we learned . . . is that if individuals who have bipolar disorder don’t have family or work demands that require that they get up early, they are much better off staying on their own natural schedule, as long as they get enough sleep," she said.

"As long as it doesn't interfere with work or family obligations, individuals with bipolar disorder should be encouraged to have a regular routine that is consistent with their body's own natural clock," she summarized.

STEP-BD is sponsored by the National Institute of Mental Health. No financial disclosures were reported.

American College of Neuropsychopharmacology 46th Annual Meeting. December 9-13, 2007.

    
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