Study: Family focused therapy may reduce relapse rate for those with bipolar disorder

CHAPEL HILL -- Individuals with bipolar disorder who are on medication experience fewer relapses and longer periods of wellness if they also participate in family focused therapy, a newly published study indicates.

A report on the study’s findings appears in the September issue of the journal Archives of General Psychiatry. Dr. David Miklowitz, professor of psychology at the University of North Carolina at Chapel Hill’s College of Arts and Sciences and formerly with the University of Colorado at Boulder (CU-Boulder), was principal investigator.

The study, conducted at CU-Boulder, compared the effectiveness of family focused therapy with less intensive crisis management in bipolar (or manic-depressive) patients who were receiving mood-stabilizing medications. Earlier research had shown that medication alone, no matter how specific the drug regimen, was less than adequate in preventing recurrences. A 1996 National Institute of Mental Health report had recommended that new research on bipolar disorder include a focus on psychotherapeutic interventions as adjuncts to medications.

"Bipolar disorder is a highly recurrent illness where people go from highs to lows, some even experiencing both extremes at the same time," said Miklowitz. "People go in and out of episodes, and some people can’t work even though they are relatively stable. This is a very complicated and tough illness for sufferers and their families.

"Medications reduce relapse rates considerably, but just taking medication is not enough."

The randomized controlled study trial, involving 101 patients diagnosed with bipolar disorder, assigned participants to family focused therapy and medication or a less intensive crisis management intervention and medication. The family focused therapy was conducted in families’ homes and consisted of 21 sessions stressing illness education, communication training and development of problem-solving skills. Crisis management consisted of two sessions of home-based family education and crisis intervention sessions as necessary.

Both treatment plans lasted nine months, with patients receiving medication for two years. Of the 70 participants in the crisis management protocol, 54 percent experienced disease relapse within two years, 17 percent did not experience relapse and 6 percent were unchanged. Twenty-three percent stopped participating in the study before its completion.

In comparison, of the 31 family focused therapy participants, only 35 percent experienced disease relapse within two years, 52 percent did not experience relapse and 3 percent were unchanged. Ten percent ended participation prematurely.

"Our findings indicated that if patients were in family focused therapy and medication, they had fewer relapses, longer periods of wellness and less severe depressive and manic symptoms," said Miklowitz.

Among the advantages of family focused therapy, he added, are that family involvement can improve the patient’s adherence to medication, and family members become able to recognize early signs of relapse and intervene before an episode is full-blown.

Generally, family communication improved during the course of treatment, Miklowitz said. Conflict gave way to more positive attitudes – family members and patients became more empathetic, and they listened better and showed more positive nonverbal behavior toward each other.

And, Miklowitz added, when patients’ interactions with their family members improved, so did their clinical conditions.

"Family members start recognizing that this is an illness, not something the patient is doing to make people angry or reflection of an ill temperament. When families start thinking of the behaviors associated with the disorder as biologically or genetically driven, they tend to be more tolerant."

More research is necessary, Miklowitz said, to further examine the effectiveness of family focused therapy. He and his research group at CU-Boulder and a collaborative group at the University of Pittsburgh Medical Center are now studying adolescents ages 13 through 17 with bipolar disorder, to determine whether intensive family therapy and medication are more effective in staving off relapses than less intensive family education and medication.

He also is part of the multi-center National Institute of Mental Health-funded Systematic Treatment Enhancement Program for Bipolar Disorder, which examines a broad variety of psychological and pharmacological interventions – including family focused therapy – for individuals with bipolar disorder who live in different regions of the country.

Bipolar disorder affects an estimated one in 70 people nationwide, and onset usually occurs between the ages of 15 and 19.

"Therapy designed specifically for bipolar disorder is a pretty new field," said Miklowitz. "One day, with enough research, we may be able to identify people who are at risk for bipolar disorder and introduce interventions to minimize the severity of its onset. We’re a long way from that day, though."

Other study investigators are Dr. Elizabeth L. George, Dr. Teresa L. Simoneau, Dr. Richard L. Suddath and Jeffrey A. Richards of CU-Boulder’s department of psychology.

Funding was provided by the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression and the John D. and Catherine T. MacArthur Foundation Network on the Psychobiology of Depression.

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Note: To view the study, click on http://archpsyc.ama-assn.org/cgi/content/full/60/9/904. Contact Miklowitz at (919) 962-3354 or miklow@email.unc.edu.

News Services contact: Deb Saine, (919) 962-8415 or deborah_saine@unc.edu