Evidence-Based Family Interventions for Adolescents and Young Adults With Bipolar Disorder

Evidence-Based Family Interventions for Adolescents and Young Adults With Bipolar Disorder

David J. Miklowitz, PhD

An individual can develop bipolar disorder at any age, but emergence during adolescence and young adulthood can lead to a number of problematic behaviors and outcomes. Several drugs are available as first-line treatments, but even optimal pharmacotherapy rarely leads to complete remission and recovery. When added to pharmacologic treatment, certain targeted psychosocial treatments can improve outcomes for young patients with bipolar disorder. Because bipolar disorder affects family members as well as patients, and because adolescents and young adults often live with and are dependent on their parents, the patient’s family should usually be included in treatment. Family-focused treatment and dialectical behavior therapy are promising methods of conducting family intervention. With effective treatment and the support of their families, young patients with bipolar disorder can learn to manage their disorder and become independent and healthy adults.

(J Clin Psychiatry 2016;77[suppl E1]:e05)

From the Division of Child and Adolescent Psychiatry, UCLA Semel Institute, Los Angeles, California, and Department of Psychiatry, University of Oxford, England, United Kingdom.

This article is derived from the planning teleconference series “Recognition and Treatment of Pediatric Bipolar Disorder,” which was held in August and September 2015 and supported by an educational grant from Forest Laboratories, Inc.

Dr Miklowitz has received research support from the National Institute of Mental Health, American Foundation of Suicide Prevention, Carl and Roberta Deutsch Foundation, Kayne Family Foundation, Knapp Family Foundation, Attias Family Foundation, and Danny Alberts Foundation and has received royalties from John Wiley and Sons and Guilford Press.

Corresponding author: David J. Miklowitz, MD, UCLA Semel Institute, 760 Westwood Plaza, Boulder, CO 80304 (dmiklowitz@mednet.ucla.edu).

dx.doi.org/10.4088/JCP.15017su1c.05

© Copyright 2016 Physicians Postgraduate Press, Inc.

Bipolar disorder can emerge at any age, and the diagnosis and treatment of this disorder must be tailored to the age of each particular patient.1 Adolescents (aged 12 to 17 years) and young adults (aged 18 to 25 years) with bipolar disorder require special consideration because these periods of life can be tumultuous. A certain amount of mood instability, risky behavior, and familial discord is normal in the teenage years, but, in individuals with bipolar disorder, these characteristics become extreme and can impair functioning (AV 1).2 Pediatric onset of bipolar disorder is associated with long delays to diagnosis and treatment and, compared with adult onset, less time well, greater comorbidity of anxiety and substance use disorders, and higher risk of violence and suicide attempts.3,4 Furthermore, individuals with pediatric bipolar disorder experience impaired academic and social functioning.5

New challenges are likely to emerge as adolescents with bipolar disorder transition to adulthood. Teenagers and young adults have a strong desire for autonomy and independence,2 yet the disorder may cause functional impairments that make independent living difficult. They may try to get a job and live independently but find that they are unable to handle this autonomy. They may have difficulty going to bed and waking up on time, completing their work, and keeping up with mundane tasks such as doing laundry, shopping for groceries, and managing their money. Their work performance may be inconsistent due to shifting moods or cognitive dysfunction, and they may be irritable and difficult to get along with. Medication adherence is also problematic in young adults with bipolar disorder. They may simply forget to fill prescriptions or take their medications, or they may choose to not take medications either as a means of asserting their independence or because they cannot accept the presence and severity of their disorder. All of these issues may lead to not only serious and potentially long-lasting problems for the individuals with bipolar disorder but also considerable conflict between the individuals and their family members.6

• Although pharmacotherapy is first-line treatment for adolescents and young adults with bipolar disorder, remember that adjunctive family intervention and other forms of psychotherapy may be necessary to achieve optimal outcomes.
• Educate patients and family members about the symptoms of bipolar disorder and provide information about differentiating symptoms of the disorder from age-appropriate behavior.
• Teach all patients and families crucial self- and family-management strategies such as maintaining a regular sleep schedule, adhering to medication regimens, and practicing communication and problem-solving strategies for maintaining balance within the home environment.
• Encourage patients to keep a mood chart to help recognize early warning signs of relapse and identify stressors or changes in sleep patterns that may be associated with mood fluctuations.

Pharmacotherapy is the first-line treatment for adolescents and young adults with bipolar disorder,7 but pharmacotherapy is less than ideal in achieving recovery and preventing new mood episodes. DelBello and colleagues8 studied a group of 71 adolescents who had been hospitalized for a first manic or mixed episode. After a year of pharmacotherapy, only 39% achieved functional recovery, and 52% experienced a recurrence. In this sample, 65% did not fully adhere to their medication regimens. Because of the limitations of pharmacotherapy, psychotherapies will likely be necessary components of treatment plans for this age group.7

THE ROLE OF THE FAMILY IN TREATMENT

When an individual experiences an episode of bipolar disorder, that individual’s family is also affected. Just as the patient must overcome his or her mood episode, the family must overcome the stress and disruption caused by the mood episode.6 Because adolescent and young adult patients usually live with their families, a mood episode will affect not only the patient but also the patient’s parents and any siblings. Parental involvement and encouragement is usually necessary to ensure medication compliance. Therefore, involving the family in the treatment of the patient is a critical component of care. Furthermore, more than one family member may have bipolar disorder. Bipolar disorder is highly heritable, and family studies have found higher rates of bipolar disorder among the relatives of individuals with pediatric and early-onset bipolar disorder than those with later onset.9 By involving the family in the treatment of the child or adolescent, a family member’s previously unrecognized bipolar disorder may become diagnosed.

One of the most important reasons to involve the family in treatment is that family interactions have a pronounced effect on patients’ mood symptoms. The affective climate in the home of a patient with bipolar disorder can have either a protective or harmful effect on the patient’s mood status. My colleagues and I10 conducted a 9-month study of young adult patients recently hospitalized for a manic episode. We assessed the level of expressed emotion in their homes. Homes with high expressed emotion were those in which parents had high levels of criticism, emotional overinvolvement, and/or hostility. The patients who were discharged from the hospital to homes in which parents were highly critical or overprotective were more likely to relapse in the 9-month follow-up than those who were discharged to parents with low expressed emotion (AV 2).10 The findings of this study underscore the importance of involving the family in treatment to create a more supportive and less stressful home environment and reduce the individual’s risk of relapse.

Young adults may not live with their families. Even when this is the case, however, involving the family in treatment is useful to help the patient negotiate a healthy separation from family members. Two types of family interventions are family-focused treatment and dialectical behavior therapy for adolescents.

FAMILY-FOCUSED TREATMENT

My colleague Michael J. Goldstein, PhD, and I developed family-focused treatment (FFT) in the 1980s as a psychosocial treatment to be used in conjunction with pharmacologic treatment for young adult bipolar patients.6 Family-focused treatment, which is similar to and evolved from psychoeducational programs that are effective for patients with schizophrenia, was designed to increase acceptance of the disorder and medication treatment, enhance family functioning, and help the patient avoid relapses.6

Structure of FFT

Family-focused treatment is delivered in 12 to 21 sessions over 4 to 9 months. The length varies depending on the demands of the community (ie, availability of providers) and the severity of the patient’s disorder. This method of therapy begins with an engagement phase, in which the clinician and family become acquainted, and the clinician briefly explains the program and addresses any initial resistances to it. The clinician must assess the patient’s diagnosis, inquire about the family’s history with the disorder, and evaluate the home environment, particularly the level of conflict or expressed emotion. Once the engagement phase is completed, FFT consists of 3 consecutive phases: psychoeducation, communication enhancement training, and problem-solving skills training.6

Psychoeducation. The goal of the psychoeducation phase is to teach patients and their families about the symptoms, causes, treatment, and self-management of bipolar disorder.6 This phase of treatment lasts up to 7 sessions but can vary depending on the patient’s and family’s openness to discussing the disorder and their existing knowledge of it.6 One of the most important components of the psychoeducation phase is to teach the patient and family about the symptoms of bipolar disorder. This helps them not only to understand which behaviors are part of the disorder and therefore difficult for the patient to control but also to recognize early warning signs of recurrence (ie, 2 or more manic or depressive symptoms co-occurring). The clinician may find it helpful to provide the family with handouts to help them better understand the symptoms of bipolar disorder (handouts are available here).

After presenting this information, the clinician opens a dialogue in which the patient is called the “expert.”6 Throughout treatment, patients are asked about their experience of symptoms, their feelings and thoughts during mood episodes, any indications they might have had that mood episodes were starting, and the things their family members have done that were helpful or unhelpful. Family members are also asked to share their memories and impressions of the patient’s symptoms during mood episodes.

Clinicians ask the patient to keep a mood chart to track their symptoms and how these change over time (AV 3).2 Ideally, this chart includes a log of sleep-wake cycles (see example in the patient handouts) because the relationship between changes in sleep patterns and mood fluctuations may become apparent. This log may also reveal how events in daily life, such as sports matches or tests, can affect mood symptoms. Preferably, the patient should keep this log for multiple weeks until patterns are evident.

Self-management strategies for bipolar disorder are also discussed during the psychoeducation phase. The patient and family learn important steps they can take to reduce the risk and/or severity of mood episodes. One of these strategies is establishing good sleep hygiene.2,6 Adolescents and young adults with bipolar disorder benefit greatly from maintaining a regular sleep schedule with consistent times for going to sleep and waking up, as sleep-wake cycle abnormalities may contribute to symptoms.11 Parents are coached on establishing a predictable family routine. Patients need to avoid caffeine or other stimulating substances or activities close to bedtime. They may need some time to wind down before sleeping at night. Similarly, they may need some quiet time in the mornings to collect themselves for the day ahead.

Adhering to medication regimens is another crucial component of the self-management of bipolar disorder. Adolescents and young adults with bipolar disorder may have very conflicted feelings about medication. They are encouraged to talk about these feelings during treatment. They may feel that the medications deprive them of creativity or strong emotions. Young people may experiment with not taking their medications. The parents’ opinions about bipolar medications must also be explored because these can affect the patient’s willingness to adhere to treatment. If the parents are in favor of the medications, the patient may feel pressured to take them, but if the parents do not agree with each other about the necessity of drug treatment, the patient may not believe the drugs are necessary either and may side with one parent against the other. The clinician educates the parents about the importance of supporting the treatment plan.6 The clinician and parents also let the patient know that his or her feelings about the medication are understandable, and that in the future the medications might not be necessary, but that in the present, the medication is crucial for the patient to recover.2 Once the need for medication has been accepted, the clinician and family can establish strategies to make sure the patient remembers to take his or her medications, such as pill organizers or smartphone notifications.

As the psychoeducation phase of FFT draws to a close, the patient and family will have gained knowledge about the symptoms of bipolar disorder, begun to accept the need for medication, and become aware of some of the warning signs and potential triggers of mood episodes. Families should be aware that episodes may be triggered by seemingly innocuous events such as the start of school, a family vacation, or the achievement of a cherished goal.

At this point, the clinician works with the family to develop a relapse prevention plan. This plan includes 3 parts: monitoring early warning signs, recognizing stressful events that might be related to the warning signs, and implementing coping or preventative strategies. These problem-solving strategies will be explored in more depth during the third phase of FFT.2,6

Communication enhancement training. The communication enhancement training (CET) phase of FFT, which usually lasts 4 to 7 sessions, is intended to reestablish functional family relationships after an episode of bipolar disorder.6 One important component of CET is to reduce expressed emotion in the patient’s household by teaching appropriate speaking, negotiating, and listening strategies. Patients and their families are taught 5 basic communication skills: to express positive feelings, to listen actively, to make positive requests for change, to communicate clearly, and to express negative feelings about specific behaviors.6 They practice these new communication skills during treatment sessions through modeling and rehearsal and are then encouraged to practice the skills at home as homework.

Problem-solving skills training. As the patient and family enter the final phase of FFT, the clinician ensures that the patient and family are continuing to monitor symptoms and warning signs of a relapse. Ideally, the patient has continued to keep a weekly mood chart and has begun implementing regular sleep/wake habits. The final phase of FFT typically lasts for about 5 sessions6 and consists of practicing strategies for solving problems.6 First, the family is encouraged to define current problems as simply and clearly as possible. Complex problems should be broken down into smaller, more easily addressed components. Next, the patient and family brainstorm as many possible solutions as they can without evaluating or passing judgments on any. The patient and family then discuss the pros and cons of each possible solution and collaboratively decide on 1 or 2 solutions that they think might work. Then, they work toward devising a plan for how to implement the proposed solution(s) and cooperatively execute the plan. Finally, they praise each other for their efforts and evaluate whether the original problem has been solved. Clinicians encourage the family to first practice these steps during a treatment session by attempting to solve a simple problem and to then continue to practice at home when problems arise.6 The clinician also reminds the family that, because the symptoms of bipolar disorder wax and wane, some problems will be more severe than others and they will need to be flexible with their problem-solving strategies. Moreover, not every problem requires an adjustment to the patient’s medications.

Evidence Base for FFT

The evidence base for FFT has been established in a number of clinical trials with adolescents and adults. Rea and colleagues12 conducted a trial of 53 young adults who had recently been hospitalized for a bipolar mood episode. After discharge, all of the patients received optimal pharmacologic treatment plus either FFT (21 sessions) or individual psychoeducation (also 21 sessions). The study consisted of 9 months of active psychosocial treatment, and the patients were followed for 2 years. At endpoint, those who had received FFT were less likely to be rehospitalized and had longer time to relapse than those receiving individual psychoeducation.12

In a later study of 58 adolescents, my colleagues and I13 compared FFT with an enhanced care program consisting of 3 family sessions focused on relapse prevention. All patients received pharmacotherapy. We found that, after 2 years of follow-up, the patients who had received FFT had shorter times to recovery from depression and greater reductions in mood severity scores over time than those who had received enhanced care. A secondary analysis14 revealed that the greater reductions in manic and depressive symptoms found with FFT than with enhanced care occurred only among patients whose families had high levels of expressed emotion; these treatment differences were not found among the patients whose families had low expressed emotion.

More recently, my colleagues and I15 conducted a similar study of 145 adolescents with a recent mood episode, recruited and treated in 3 sites. All patients received carefully controlled pharmacologic treatment and were randomly assigned to 21 sessions of adjunctive FFT or 3 sessions of enhanced care. After 2 years, we found no differences between FFT and enhanced care in terms of recovery or recurrence rates. This finding, which seems to contradict the earlier studies, may be related to the more tightly controlled pharmacologic treatment, which may have been effective in preventing recurrences. One notable finding of this study, however, is that after 12 months, the mania/hypomania scores of the patients receiving enhanced care began to increase, whereas the mania/hypomania scores of the patients receiving FFT continued to decrease.15 Thus, FFT may have a “sleeper effect” in which the benefits of the treatment become more pronounced as the patient stabilizes and families begin to practice the relapse prevention, communication, and problem-solving strategies more systematically.

Among children and adolescents at risk for bipolar disorder, FFT has been investigated as an early intervention. My colleagues and I conducted a study16,17 in which we administered FFT to 40 youths between 9 and 17 years old who were at high risk for developing bipolar disorder. They were currently experiencing mood symptoms that met diagnostic criteria for bipolar disorder not otherwise specified, major depressive disorder, or cyclothymic disorder, and they had at least 1 first-degree relative with bipolar I or II disorder. Participants received either a shortened version of FFT consisting of 12 sessions or enhanced care consisting of 1 to 2 family education sessions. Some participants also received pharmacotherapy, but 40% were medication free at study entry and 41% at the 1-year endpoint.17 The study found that the patients who received FFT recovered significantly more quickly from their index mood episode than those receiving enhanced care (P = .047) and spent more weeks in full remission (P < .0001).16 Moreover, patients from homes with high expressed emotion benefited more from FFT than those from low expressed emotion households.16 The study also found that the patients receiving FFT had more improvement in manic symptoms over 12 months than those receiving enhanced care.16 Although this study does not show that FFT can prevent the development of bipolar disorder in high-risk children or adolescents, these findings do indicate that FFT may be able to help stabilize their early mood symptoms and sustain recovery.

DIALECTICAL BEHAVIOR THERAPY

Dialectical behavior therapy (DBT), an alternative approach to family therapy for adolescents with bipolar disorder, was first developed as a psychotherapy for adults with borderline personality disorder. Emotional dysregulation is a core feature of both borderline personality disorder and bipolar disorder, and, because this feature is the main target of DBT, this type of treatment is well-suited for both disorders.18

Structure of DBT

Goldstein and colleagues18 developed an adapted version of DBT for use in adolescents with bipolar disorder. The therapy is delivered during 36 treatment sessions spread over a year. The treatment sessions alternate between family skills training and individual therapy.

The family skills training sessions begin with 2 sessions of psychoeducation, which are modeled on the psychoeducational phase of FFT. In addition, information about DBT and the rationale for its use in bipolar disorder is presented. The clinician emphasizes the need for balance in managing bipolar disorder, describes biological and environmental influences on the illness, and addresses emotional vulnerabilities. Triggers for mood episodes are also identified. Next, the sessions proceed through the following modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Throughout these sessions, parents receive information from an additional module called “walking the middle path,” which teaches participants to avoid thinking about behavior change in black and white terms and instead consider multiple options.

The skills covered during these sessions have been tailored for bipolar disorder. Participants not only learn a new skill set, but they also learn how to select and apply these skills depending on the adolescent’s different mood states. The family and patient practice the new skills through guided exercises and activities and are encouraged to practice them at home.18 For example, participants may learn that meditating individually or as a family can improve stress tolerance and help regulate emotions. The family sessions may then contain a guided meditation practice that is further rehearsed in the home setting.

The individual therapy sessions are devoted to problem solving. The clinician and patient identify and prioritize target behaviors and then develop problem-solving strategies. The process includes identifying the function of the behavior, devising alternative solutions, and planning ways to avoid the problematic behavior in the future.18

In addition to the family skills training and individual therapy sessions, participants are asked to keep diary cards that document mood, sleep, suicidality, medication adherence, treatment goals, and use of DBT skills. Participants are also allowed to call their therapists on the telephone for in vivo skill coaching.18

Evidence Base for DBT

Goldstein and colleagues conducted a pilot study of DBT in 10 adolescent patients with bipolar disorder.18 They found that DBT was feasible to administer and acceptable to patients. Participants experienced improvements in suicidality, emotional dysregulation, and depressive symptoms, as well as nonsuicidal self-injury. In a pilot randomized trial involving 20 adolescents who also received pharmacotherapy for bipolar disorder, Goldstein and colleagues19 compared DBT (n = 14) with a psychosocial program (n = 6) consisting of psychoeducational, supportive, and cognitive-behavioral techniques. Patients were randomly assigned in a 2:1 ratio. The patients receiving DBT experienced greater improvements in depressive symptoms than those receiving standard psychosocial treatment; they were also 3 times more likely to show improvements in suicidal ideation.19 The majority of patients in the trial (85%) had bipolar disorder not otherwise specified or bipolar II disorder, suggesting the importance of replication and extension of these effects in patients with fully syndromal manic (ie, bipolar I) episodes. Nonetheless, DBT appears to be promising in the treatment of adolescent bipolar disorder.

CONCLUSIONS

Pharmacotherapy alone is rarely sufficient to promote recovery in adolescents and young adults with bipolar disorder. When combined with pharmacologic treatment, psychotherapeutic treatments can improve outcomes in this age group. Because adolescents and young adults are still highly dependent on their parents, family psychoeducation and skills training are key components of the outpatient management of bipolar disorder in this population. Parents can play an important role in helping teens learn to self-regulate their emotions, communicate their needs more effectively, and successfully manage their disorder. Family-focused treatment and dialectical behavior therapy are two promising methods of providing psychotherapy to young patients with bipolar disorder and their families. With optimal pharmacotherapy, family education, and support, people with early-onset bipolar disorder can lead fulfilling and independent lives.

Disclosure of off-label usage: Dr Miklowitz has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this activity.

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

2. Miklowitz DJ, George EL. The Bipolar Teen: What You Can Do to Help Your Child and Your Family. New York, NY: Guilford; 2008.

3. Perlis RH, Miyahara S, Marangell LB, et al; STEP-BD Investigators. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2004;55(9):875-881. PubMed doi:10.1016/j.biopsych.2004.01.022

4. Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolar disorder. J Pediatr. 2007;150(5):485-490. PubMed doi:10.1016/j.jpeds.2006.10.070

5. Wolf DV, Wagner KD. Bipolar disorder in children and adolescents. CNS Spectr. 2003;8(12):954-959. PubMed

6. Miklowitz D, Goldstein M. Bipolar Disorder: A Family-Focused Treatment Approach. New York, NY: Guilford Press; 1997.

7. Kowatch RA, Fristad M, Birmaher B, et al; Child Psychiatric Workgroup on Bipolar Disorder. Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2005;44(3):213-235. PubMed doi:10.1097/00004583-200503000-00006

8. DelBello MP, Hanseman D, Adler CM, et al. Twelve-month outcome of adolescents with bipolar disorder following first hospitalization for a manic or mixed episode. Am J Psychiatry. 2007;164(4):582-590. PubMed doi:10.1176/ajp.2007.164.4.582

9. Faraone SV, Glatt SJ, Tsuang MT. The genetics of pediatric-onset bipolar disorder. Biol Psychiatry. 2003;53(11):970-977. PubMed doi:10.1016/S0006-3223(02)01893-0

10. Miklowitz DJ, Goldstein MJ, Nuechterlein KH, et al. Family factors and the course of bipolar affective disorder. Arch Gen Psychiatry. 1988;45(3):225-231. PubMed doi:10.1001/archpsyc.1988.01800270033004

11. Frank E, Swartz HA, Kupfer DJ. Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder. Biol Psychiatry. 2000;48(6):593-604. PubMed doi:10.1016/S0006-3223(00)00969-0

12. Rea MM, Tompson MC, Miklowitz DJ, et al. Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. J Consult Clin Psychol. 2003;71(3):482-492. PubMed doi:10.1037/0022-006X.71.3.482

13. Miklowitz DJ, Axelson DA, Birmaher B, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry. 2008;65(9):1053-1061. PubMed doi:10.1001/archpsyc.65.9.1053

14. Miklowitz DJ, Axelson DA, George EL, et al. Expressed emotion moderates the effects of family-focused treatment for bipolar adolescents. J Am Acad Child Adolesc Psychiatry. 2009;48(6):643-651. PubMed doi:10.1097/CHI.0b013e3181a0ab9d

15. Miklowitz DJ, Schneck CD, George EL, et al. Pharmacotherapy and family-focused treatment for adolescents with bipolar I and II disorders: a 2-year randomized trial. Am J Psychiatry. 2014;171(6):658-667. PubMed doi:10.1176/appi.ajp.2014.13081130

16. Miklowitz DJ, Schneck CD, Singh MK, et al. Early intervention for symptomatic youth at risk for bipolar disorder: a randomized trial of family-focused therapy. J Am Acad Child Adolesc Psychiatry. 2013;52(2):121-131. PubMed doi:10.1016/j.jaac.2012.10.007

17. Schneck CD, Singh MK, Chang KD, et al. A pharmacologic algorithm for youth at risk for bipolar disorder. Bipolar Disord. 2015;17(suppl 1):106-107.

18. Goldstein TR, Axelson DA, Birmaher B, et al. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry. 2007;46(7):820-830. PubMed doi:10.1097/chi.0b013e31805c1613

19. Goldstein TR, Fersch-Podrat RK, Rivera M, et al. Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. J Child Adolesc Psychopharmacol. 2015;25(2):140-149. PubMed doi:10.1089/cap.2013.0145