Psychotherapy online: Bridging the gap between recommendations and reality

IF 5 2区 医学 Q1 CLINICAL NEUROLOGY
Ralph Kupka, Manja Koenders, Susan Zyto
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引用次数: 0

Abstract

There is a simple, layman's version of bipolar disorder: an episodic mental illness with seriously disturbing manic and depressive episodes, and after recovery long periods of euthymia in which all is well again. Medication is effective in the acute symptomatic treatment, and maintenance pharmacotherapy prevents future episodes, if prescribed and taken indefinitely. Psychoeducation will increase insight and awareness of the characteristics of the illness, and thereby facilitate acceptance, self-management, and treatment compliance.

Anyone who has to deal with bipolar illness, either as a patient, a family member, a caregiver, or a professional, knows that the reality is far more complex. If this is true for the acute management and pharmacotherapy, it is even more for the time after the storm has calmed down. Subsyndromal residual symptoms and mood instability, subtle but annoying cognitive impairments, occupational and interpersonal problems as a result of past manic behavior, an injured self-image, and doubts about what to expect in the future, may all have a negative impact on psychosocial functioning and emotional wellbeing. Highly prevalent comorbid psychiatric conditions like anxiety disorders, personality disorders, and substance abuse further complicate this situation.

Of the psychological approaches, psychoeducation is now a well-established intervention which is part of standard treatment. In addition, family-focused therapy (FFT), cognitive behavioral therapy (CBT), and interpersonal and social rhythm therapy (IPSRT) are also recommended in most clinical guidelines, in combination with pharmacotherapy. A major concern is: while most treated patients with bipolar disorder will receive pharmacotherapy, and many will have had some form of psychoeducation, how many do get one of these recommended psychotherapies? How many psychologists and psychotherapist have an interest in bipolar disorder, let alone will be trained in these specific interventions? Bipolar disorder has long been viewed as a highly biologically rooted psychiatric illness, where pharmacotherapy is the cornerstone of acute curative and long-term preventive treatment. Moreover, dare psychotherapists treat a person with an anxiety or personality disorder, when she/he also suffers from bipolar disorder? The recently established ISBD Psychological Interventions Taskforce1 is a welcome initiative to improve this situation, as is this special issue of Bipolar Disorders Journal.

Tremain et al.2 address several important issues that underscore the potential for psychological treatment in addition to pharmacotherapy and clinical management of mood episodes.

First, we have to extend treatment of bipolar disorder beyond symptomatic recovery. Van der Voort et al.3 showed that functional recovery in recurrent depressive and bipolar disorder seriously lags behind recovery of a depressive episode. This means that much has to be done in the so-called ‘inter-episodic interval’, and there is a shift of focus from pharmacotherapy to psychosocial interventions.

Second, even if clinicians focus on both symptomatic and functional recovery, for patients overall quality of life may be even a more important outcome. In a recent survey among patients in the Netherlands about meaningful treatment goals, quality of life was rated more important than complete symptomatic recovery.

Third, in contrast to what is often thought, psychological treatment can also be helpful for patients in a more advanced stage of bipolar disorder.

And finally, and maybe most importantly, the paper shows the potential of digital interventions. The Task Force points out that the availability of psychological treatment is limited when still relatively few psychologists are involved in the treatment of bipolar disorder. This will be particularly problematic in areas remote from specialized mental health centers, where patients cannot have access to weekly or bi-weekly psychotherapy. One way to solve this will be offering treatments in an interactive online format, since there is increasing evidence that digital psychological interventions can be as effective as an in-person approach.2, 4, 5 In that way, adequately trained health professionals can operate from specialized mood centers where this expertise is present. Another benefit of digital interventions is that psychoeducational or psychotherapy groups fill up more readily. There is no longer a need to wait until enough patients have been referred within a specific health center if the treatment is open for all patients from a much larger catchment area. Digital interventions are very promising and more research is needed to understand who benefits and in what way the intervention needs to be designed or adapted to yield the best effects. This may help to fill one of the many gaps between what we recommend and what we (can) do to improve the perspective of those living with bipolar disorder.

在线心理治疗:缩小建议与现实之间的差距。
双相情感障碍有一个通俗易懂的说法:这是一种发作性精神疾病,会出现令人严重不安的躁狂和抑郁发作,康复后会有很长一段时间的 "安乐期",一切都会恢复正常。药物治疗对急性期的对症治疗是有效的,而维持性药物治疗则可以预防未来的发作,但必须遵医嘱并无限期服用。心理教育可以提高人们对躁狂症特征的洞察力和认识,从而促进对躁狂症的接受、自我管理和治疗依从性。任何需要面对躁狂症的人,无论是患者、家属、护理人员还是专业人士,都知道现实情况要复杂得多。如果说急性期的管理和药物治疗是如此,那么在暴风雨平息之后,情况就更加复杂了。亚躁狂症的残留症状和情绪不稳定、细微但恼人的认知障碍、因过去的躁狂行为而导致的职业和人际关系问题、受伤的自我形象以及对未来预期的怀疑,都可能对心理社会功能和情绪健康产生负面影响。焦虑症、人格障碍和药物滥用等精神疾病的高发并发症使情况更加复杂。此外,以家庭为中心的疗法(FFT)、认知行为疗法(CBT)以及人际和社会节奏疗法(IPSRT)也被大多数临床指南推荐与药物疗法结合使用。一个值得关注的主要问题是:虽然大多数接受治疗的双相情感障碍患者都会接受药物治疗,许多患者也会接受某种形式的心理教育,但有多少患者接受了这些推荐的心理疗法?有多少心理学家和心理治疗师对躁郁症感兴趣,更不用说接受过这些特定干预措施的培训了?长期以来,躁郁症一直被视为一种具有高度生物学根源的精神疾病,药物治疗是急性治疗和长期预防治疗的基石。此外,当一个人同时患有焦虑症或人格障碍时,心理治疗师还敢于对其进行治疗吗?最近成立的国际躁郁症协会(ISBD)心理干预工作组1 和本期《躁郁症杂志》(Bipolar Disorders Journal)特刊都是为改善这一状况而采取的值得欢迎的举措。Tremain 等人2 提出了几个重要问题,强调了心理治疗在药物治疗和情绪发作临床管理之外的潜力。Van der Voort 等人3 的研究表明,复发性抑郁症和双相情感障碍的功能恢复严重滞后于抑郁发作的恢复。这意味着在所谓的 "发作间歇期 "需要做很多工作,并且需要将重点从药物治疗转移到社会心理干预上。其次,即使临床医生同时关注症状和功能的恢复,对患者而言,整体生活质量可能是更重要的结果。第三,与人们通常认为的不同,心理治疗对处于双相情感障碍晚期的患者也有帮助。最后,也许也是最重要的一点,该文件展示了数字化干预措施的潜力。特别工作组指出,当参与躁郁症治疗的心理学家仍然相对较少时,心理治疗的可用性就受到了限制。这在远离专业心理健康中心的地区尤其成问题,因为那里的患者无法获得每周或每两周一次的心理治疗。解决这一问题的方法之一是提供在线互动形式的治疗,因为越来越多的证据表明,数字化心理干预可以与面对面的方法同样有效。数字化干预的另一个好处是,心理教育或心理治疗小组更容易满员。如果治疗向更大范围内的所有患者开放,就不再需要等到特定医疗中心内有足够多的患者转诊。数字化干预措施前景广阔,需要开展更多研究,以了解谁能从中受益,以及需要以何种方式设计或调整干预措施才能产生最佳效果。这可能有助于填补我们的建议与我们(能够)为改善双相情感障碍患者的视角所做的工作之间的差距。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Bipolar Disorders
Bipolar Disorders 医学-精神病学
CiteScore
8.20
自引率
7.40%
发文量
90
审稿时长
6-12 weeks
期刊介绍: Bipolar Disorders is an international journal that publishes all research of relevance for the basic mechanisms, clinical aspects, or treatment of bipolar disorders and related illnesses. It intends to provide a single international outlet for new research in this area and covers research in the following areas: biochemistry physiology neuropsychopharmacology neuroanatomy neuropathology genetics brain imaging epidemiology phenomenology clinical aspects and therapeutics of bipolar disorders Bipolar Disorders also contains papers that form the development of new therapeutic strategies for these disorders as well as papers on the topics of schizoaffective disorders, and depressive disorders as these can be cyclic disorders with areas of overlap with bipolar disorders. The journal will consider for publication submissions within the domain of: Perspectives, Research Articles, Correspondence, Clinical Corner, and Reflections. Within these there are a number of types of articles: invited editorials, debates, review articles, original articles, commentaries, letters to the editors, clinical conundrums, clinical curiosities, clinical care, and musings.
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