Family-focused treatment for adolescents with bipolar disorder

Abstract

Background

Research has begun to elucidate the optimal pharmacological treatments for pediatric-onset bipolar patients, but few studies have examined the role of psychosocial interventions as adjuncts to pharmacotherapy in maintenance treatment. This article describes an adjunctive family-focused psychoeducational treatment for bipolar adolescents (FFT-A). The adult version of FFT has been shown to be effective in forestalling relapses in two randomized clinical trials involving bipolar adults.

Methods

FFT-A is administered to adolescents who have had an exacerbation of manic, depressed, or mixed symptoms within the last 3 months. It is given in 21 outpatient sessions of psychoeducation, communication enhancement training, and problem solving skills training. We describe modifications to the adult FFT model to address the developmental issues and unique clinical presentations of pediatric-onset patients.

Results

An open treatment trial involving 20 bipolar adolescents (11 boys, 9 girls; mean age 14.8±1.6) found that the combination of FFT-A and mood stabilizing medications was associated with improvements in depression symptoms, mania symptoms, and behavior problems over 1 year.

Limitations

These early results are based on a small-scale open trial.

Conclusions

Results from an ongoing randomized controlled trial will clarify whether combining FFT-A with pharmacotherapy improves the 2-year course of adolescent bipolar disorder. If the results are positive, then a structured manual-based psychosocial approach will be available for clinicians who treat adolescent bipolar patients in the community.

Introduction

This article describes a new form of psychosocial intervention for adolescent bipolar patients known as family-focused psychoeducational treatment (FFT-A). Family-focused treatment was originally developed for adult bipolar patients. It is given alongside pharmacotherapy during the post-episode phases of the illness. It has been remanualized for adolescent patients in the context of a collaborative treatment development study at the University of Colorado and the University of Pittsburgh Medical Center (NIMH Grant MH62555, 2001–2005; D. Miklowitz, Principal Investigator). First, we describe the research background of the FFT approach focusing on randomized clinical trials with adults. Next, we describe the clinical methods for applying FFT to adolescent patients. Finally, we present data on the clinical outcomes of adolescents participating in a 1-year open trial of FFT-A and pharmacotherapy.

Between 20% and 40% of bipolar adults have their first onset in childhood or adolescence (Joyce, 1984, Lish et al., 1994). About 20% of depressed children eventually develop bipolar disorder (Geller et al., 1994, Strober and Carlson, 1982), but its presentation in adolescence is often atypical and associated with other childhood disorders (Biederman et al., 2003, Bowring and Kovacs, 1992). The early-onset form of the disorder is related to greater familial loading, a less robust response to pharmacotherapy, and continued functional impairment in adulthood (Carlson et al., 1977, Lewinsohn et al., 2000, Strober et al., 1995, Welner et al., 1979).

Childhood and adolescent bipolar disorder is a major public health hazard: it is associated with high rates of suicide, hospitalizations, drug and alcohol abuse, conduct disorders, and a high potential for sexually transmitted diseases (Akiskal et al., 1985, Borchardt and Bernstein, 1995, Brent et al., 1988, Brent et al., 1993, Brent et al., 1994, Carlson, 1990, Rich et al., 1986, Rich et al., 1990, Strober et al., 1995, Welner et al., 1979). If bipolar children and teenagers are not treated early, they can fall behind, sometimes irreparably, in social, school, and work functioning. Family environments are placed under enormous strain from this disease in a young offspring (Papolos and Papolos, 1999). Despite increasing recognition of childhood and adolescent bipolar disorder and its pernicious course, the disorder continues to be under-recognized and under-treated (McClellan and Werry, 1997).

Pharmacotherapy is the cornerstone of the treatment of bipolar youth. Data from rigorously controlled medication trials in bipolar adolescents are limited, but recent reports indicate that mood stabilizers and atypical antipsychotics may have efficacy in the treatment of mood symptoms and substance abuse in bipolar youth (e.g., Geller et al., 1998, Kowatch et al., 2000, Delbello et al., 2002, Wagner et al., 2002). Nonetheless, most bipolar adolescents follow a relapse/remission course even when they do take mood stabilizers (McGlashan, 1988, Strober et al., 1995, Geller et al., 2002).

Adherence to medication regimens is also a significant problem among bipolar adolescents, perhaps even more than among adults. In fact, younger age is associated with poorer drug adherence in bipolar and recurrent unipolar depressed populations (Frank et al., 1985, Jamison and Akiskal, 1983). A recent open-label randomized trial (Kowatch et al., 2000) found that 31% of bipolar children and adolescents failed to comply with any mood stabilizer during 6 weeks of open treatment. As is true for adults, discontinuing maintenance medication leads to more rapid recurrences among childhood-onset patients (Strober et al., 1990).

Given these realities, the need for research on adjunctive psychosocial approaches is critical. Psychosocial interventions that improve the adolescent's adherence to drug treatments are likely to contribute substantially to improving the course of the illness. Through enhancing the adolescent's understanding of the disorder and skills for communicating and solving problems, psychosocial interventions may mitigate the negative effects of school, social, or family pressures on mood cycling.

Focusing on the family is a logical starting point because adolescents typically live with first-degree relatives who are responsible for their care. In turn, caregiving relatives often feel isolated in their struggles and request support for their efforts to manage their offspring's disorder. But there are other compelling arguments for tailoring psychosocial methods to the family unit.

First, family environmental factors are correlated with the course of recurrent mood disorders. Several studies have found that adult bipolar patients who have high expressed emotion (high-EE) relatives (parents or spouses with high levels of criticism, hostility, and/or emotional overinvolvement) or who have relatives who are critical and/or hostile in face-to-face verbal interactions with the patient (negative affective style) have poorer outcomes than bipolar patients in low expressed emotion or benign affective style environments (Honig et al., 1997, Miklowitz et al., 1988, Miklowitz et al., 2000, O'Connell et al., 1991, Priebe et al., 1989). Effect sizes for the EE/outcome relationship are larger for the major affective disorders than for schizophrenic disorders, in which EE has traditionally been studied (Butzlaff and Hooley, 1998). No studies of EE have been conducted with adolescent bipolar patients, but Geller et al. (2002) found that low maternal warmth ratings predicted shorter survival intervals prior to relapse among prepubertal and early adolescent bipolar patients.

Because adolescents are generally more dependent on their families of origin than young or middle-aged adults, negative affective relationships with parents have an even greater potential to influence the course of the disorder. Modifying the emotional reactivity of parents to their mood disordered offspring may be an efficient way of reducing the impact of these contextual risk factors on the child.

Second, various models of family intervention have been shown to be powerful adjuncts to pharmacotherapy among adult bipolar I patients (for reviews, see Miklowitz and Craighead, 2001, Craighead and Miklowitz, 2000, Huxley et al., 2000). The most well-studied of these models, FFT, is delivered in 21 outpatient sessions over 9 months and consists of three modules: education for the patient and family about bipolar disorder (e.g., identifying early warning signs of relapse, developing strategies for preventing new episodes, methods to enhance drug adherence), training for patients and family members in communication strategies (e.g., active listening, balancing positive and negative feedback), and training in problem solving skills for negotiating family conflicts. A randomized study of 101 bipolar adults who began in an acute illness episode revealed that, over a 2-year study period, patients undergoing FFT and routine pharmacotherapy had lower relapse rates, longer community survivorship, less severe depressive and manic symptoms, and better medication adherence than patients in a comparison group who received two sessions of family education, crisis intervention sessions (given as needed for 9 months), and routine pharmacotherapy (Miklowitz et al., 2003). Furthermore, laboratory assessments of family interactions conducted before and after the 9-month treatment interval revealed that communication between patients and relatives was more positively toned after FFT than after the comparison treatment, especially in the nonverbal domain (e.g., frequency of positive facial expressions or voice tones; Simoneau et al., 1999).

In a separate 2-year randomized trial of 53 bipolar adults, FFT combined with mood stabilizing medications was found to be more effective in delaying relapse and rehospitalization than an individual psychoeducational therapy of identical duration and frequency, also given with mood-stabilizing medications (Rea et al., 2003). Thus, FFT appears to be an efficacious adjunct to pharmacotherapy for adult bipolar patients.

The applicability of family psychoeducation to adolescent bipolar patients has not been examined despite various calls for this kind of research (Geller and Luby, 1997, McClellan and Werry, 1997). There is nascent literature suggesting that family psychoeducation groups may be effective in school-aged bipolar children. Fristad et al. (2002) examined 35 families of children with unipolar and bipolar mood disorders (aged 8–11) assigned to multifamily psychoeducation groups or a wait-list control condition. Over a 6-month follow-up, parents in the multifamily psychoeducation groups gained more knowledge about mood disorders and showed greater improvement in their ability to obtain health services for their child than parents in the wait-list condition. Children in the psychoeducation groups had significantly greater gains in social support from their parents. A large-scale randomized trial of this multifamily group psychoeducation is underway, as is a small-scale controlled trial of a single family variant of this treatment model (Fristad et al., 2003).

A third reason to focus on families is that lithium and the anticonvulsants can be difficult to dispense safely to an adolescent living in a chaotic family environment, where attendance at medication monitoring appointments is unpredictable (Geller and Luby, 1997). Rather than adapting the choice of medication to qualities of the family environment, it makes more sense to modify the family context in which lithium or other mood stabilizers are administered. This modification may be accomplished through educating families and patients about the necessity of medications and blood monitoring and coaching them on ways to improve the adolescent's drug adherence (e.g., altering environmental cues for nonadherence).

Thus, there are a number of compelling reasons to involve family members as allies in the outpatient management of early-onset bipolar disorder. But how is this done? How does one take a treatment developed for bipolar adults, like FFT, and adjust it to the developmental requirements of bipolar teenagers? This article addresses these questions.