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INTRODUCTION: Patients with bipolar disorder (BD) are frequently exposed to traumatic events which worsen disease course, but this study is the first multicentre randomised controlled trial to test the efficacy of a trauma-focused adjunctive psychotherapy in reducing BD affective relapse rates. MATERIALS AND METHODS: This multicentre randomised controlled trial included 77 patients with BD and current trauma-related symptoms. Participants were randomised to either 20 sessions of trauma-focused Eye Movement Desensitization and Reprocessing (EMDR) therapy for BD, or 20 sessions of supportive therapy (ST). The primary outcome was relapse rates over 24-months, and secondary outcomes were improvements in affective and trauma symptoms, general functioning, and cognitive impairment, assessed at baseline, post-treatment, and at 12- and 24-month follow-up. The trial was registered prior to starting enrolment in clinical trials (NCT02634372) and carried out in accordance with CONSORT guidelines. RESULTS: There was no significant difference between treatment conditions in terms of relapse rates either with or without hospitalisation. EMDR was significantly superior to ST at the 12-month follow up in terms of reducing depressive symptoms (p=0.0006, d=0.969), manic symptoms (p=0.027, d=0.513), and improving functioning (p=0.038, d=0.486). There was no significant difference in dropout between treatment arms. CONCLUSIONS: Although the primary efficacy criterion was not met in the current study, trauma-focused EMDR was superior to ST in reducing of affective symptoms and improvement of functioning, with benefits maintained at six months following the end of treatment. Both EMDR and ST reduced trauma symptoms as compared to baseline, possibly due to a shared benefit of psychotherapy. Importantly, focusing on traumatic events did not increase relapses or dropouts, suggesting psychological trauma can safely be addressed in a BD population using this protocol.
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Background: Post-traumatic stress disorder (PTSD) is an established comorbidity in Bipolar Disorder (BD), but little is known about the characteristics of psychological trauma beyond a PTSD diagnosis and differences in trauma symptoms between BD-I and BD-II. Objective: (1) To present characteristics of a trauma-exposed BD sample; (2) to investigate prevalence and trauma symptom profile across BD-I and BD-II; (3) to assess the impact of a lifetime PTSD diagnosis vs. a history of trauma on BD course; and (4) to research the impacts of sexual and physical abuse. Methods: This multi-center study comprised 79 adult participants with BD with a history of psychological trauma and reports baseline data from a trial registered in Clinical Trials (https://clinicaltrials.gov; ref: NCT02634372). Clinical variables were gathered through clinical interview, validated scales and a review of case notes. Results: The majority (80.8%) of our sample had experienced a relevant stressful life event prior to onset of BD, over half of our sample 51.9% had a lifetime diagnosis of PTSD according to the Clinician Administered PTSD scale. The mean Impact of Event Scale-Revised scores indicated high levels of trauma-related distress across the sample, including clinical symptoms in the PTSD group and subsyndromal symptoms in the non-PTSD group. Levels of dissociation were not higher than normative values for BD. A PTSD diagnosis (vs. a history of trauma) was associated with psychotic symptoms [2(1) = 5.404, p = 0.02] but not with other indicators of BD clinical severity. There was no significant difference between BD-I and BD-II in terms of lifetime PTSD diagnosis or trauma symptom profile. Sexual abuse significantly predicted rapid cycling [2(1) = 4.15, p = 0.042], while physical abuse was not significantly associated with any clinical indicator of severity. Conclusion: Trauma load in BD is marked with a lack of difference in trauma profile between BD-I and BD-II. Although PTSD and sexual abuse may have a negative impact on BD course, in many indicators of BD severity there is no significant difference between PTSD and subsyndromal trauma symptoms. Our results support further research to clarify the role of subsyndromic PTSD symptoms, and highlight the importance of screening for trauma in BD patients.
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INTRODUCCIÓN: La Hospitalización a Domicilio (HAD) se inició en nuestra zona a finales de 2007, actualmente consta de 3 unidades, 30 camas y tiene una cobertura territorial del 80%. La modalidad de ingreso es mixto, evitación de ingreso y alta precoz. OBJETIVO: analizar los resultados de HAD en los últimos 10 años en cuanto a eficacia y eficiencia. MÉTODO: Análisis retrospectivo de los pacientes ingresados en HAD (enero 2009-Diciembre 2018) para definir tipología de paciente y procedencia, evaluar indicadores de estancia media, retorno al hospital, reingreso a los 30 días, mortalidad y coste comparado con hospitalización convencional. RESULTADOS: Se han realizado 6.033 altas. El 86% de los pacientes ingresaron por un proceso médico con predominio de las enfermedades del aparato respiratorio (43,7%). La modalidad de evitación de ingreso supuso el 79% de los ingresos en HAD. La estancia media en HAD fue de 7,1 días y el retorno al hospital por complicaciones del 4,1%. La mortalidad fue del 2,3% y los reingresos por cualquier motivo en los 30 días siguientes al alta de HAD del 12,2%, ambos inferiores a los resultados de las unidades de hospitalización de Medicina Interna. La gravedad según el sistema de clasificación APRDRG de los pacientes ingresados en HAD fue significativamente superior a la encontrada en la Unidad de Corta Estancia pero menor que en las unidades de hospitalización de Medicina Interna, tal como era de esperar. El coste de estructura por día de estancia en HAD fue, aproximadamente, 3 veces inferior al de hospitalización convencional. CONCLUSIONES: HAD ha sido una alternativa útil a la hospitalización convencional, principalmente para patología médica de pacientes que precisando ingreso, no necesitaban toda la infraestructura hospitalaria
INTRODUCTION: Hospital at Home (HAH) started in our area at the end of 2007; currently it consists of 3 units, 30 beds and 80% territorial coverage. It has two main aims: to avoid unnecessary hospital admission and to allow early discharge. OBJECTIVE: to analyze the results of HAH in the last 10 years in terms of effectiveness and efficiency. METHOD: Retrospective analysis of patients discharged in HAH (January 2009-December 2018) to define patient typology and source of admission, to evaluate indicators of length of stay, return to hospital, 30-day readmission rate, mortality rate, severity according to the APRDRG classification system and cost compared to conventional hospitalization. RESULTS: 6,033 patients have been discharged. 86% of patients were admitted through a medical process with a predominance of respiratory diseases (43.7%). The modality of Hospital admission avoidance was 79% of the admissions in HAH. The average length of stay in HAH was 7.1 days; the return to the hospital due to complications was 4.1%. Mortality rate was 2.3%, and the 30-day readmission rate was 12.2 %, both lower than the average of the Internal Medicine units. The severity according to the APRDRG classification system of patients admitted in HAH was significantly higher than in the Short Stay Hospital Unit but less than conventional hospitalization in Internal Medicine Units, as expected. The cost of structure per day of stay in HAH is approximately 3 times lower than conventional hospitalization. CONCLUSIONS: HAH has been a useful alternative to conventional hospitalization, mainly for medical pathology of patients who, requiring admission, did not need the entire hospital infrastructure
