Family Therapy May Delay Mood Episodes In Youth At High Risk For Bipolar Disorder

Family-focused therapy (FFT) is associated with longer times between mood episodes in young people at high risk for bipolar disorder, a randomized trial reveals.

"Bipolar disorder is associated with significant problems in day-to-day functioning, such as whether a kid finishes school or not," Dr. David Miklowitz of the University of California, Los Angeles, told Reuters Health by email. "Catching the illness early by teaching kids and families how to cope with mood swings and communicate more effectively may contribute to a better outcome for the child over time."

"What we do in FFT is train children/teens and their parents to recognize the early warning signs of an oncoming episode and intervene to prevent a full episode from occurring (e.g., getting their medication changed, adopting more regular sleep/wake cycles, using communication skills to reduce stress in family conflicts).

The multisite randomized clinical trial included young people with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least one first- or second-degree relative with bipolar disorder I or II.

Youths and parents were randomly allocated to FFT (12 sessions in four months of psychoeducation, communication training, and problem-solving skills training) or enhanced care (six sessions in 4 months of family and individual psychoeducation). Medication was permitted in both groups.

As reported in JAMA Psychiatry, 127 young people (mean age, 13.2; 64.6% female) were followed up every 4 to 6 months for a median of 98 weeks.

No between-group differences in time to recovery from pretreatment symptoms were detected. High-risk youths in the FFT group had longer intervals from recovery to the emergence of the next mood episode (hazard ratio, 0.55), and from randomization to the next mood episode (HR, 0.59) compared to those in enhanced care.

Although FFT was associated with longer intervals to depressive episodes (HR, 0.53), it did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories.

Dr. Miklowitz said, "We are conducting studies of FFT accompanied by a mobile app that reminds kids and family members to use certain skills in their day-to-day lives, such as communicating more effectively, sitting down as a family to solve a problem, or planning their day to have a good balance of rewarding vs 'must-do' activities. We are trying to determine whether people who get the treatment with the app are more likely to adopt mood management skills than those who get the therapy alone or therapy with a different kind of app."

The team is also using functional magnetic resonance imaging to see whether FFT is associated with brain activity changes, and whether the intervention is associated with reductions in suicidal thoughts and behaviors in children at high risk for bipolar disorder.

Dr. Nicki Nance, an associate professor of human services and psychology at Beacon College in Leesburg, Florida, commented in an email to Reuters Health, "Family therapy is a growing field with independent licensure and credentialing, so the number of specialized providers is on the rise in the United States."

"Family services are available, but not always accessible," said Dr. Nance, who was not involved in the study. "At an average cost of $100 per session, the recommended four months of treatment would cost between $800 and $1600. That is not affordable for many families."

"Some insurance companies do pay for family therapy, but the guidelines for treatment may be prohibitive," she said. "More notable is that prevention is not treatment, and insurance companies may exclude it for that reason."

"Because any diagnosis of family member is stressful, an astute therapist can often appeal to an insurance company to have a few sessions covered as treatment for the family adjustment," she noted. "In addition, some treatment facilities may be able to include some services to families as patient education."

"Advocacy is important," she added. "Any work-arounds to make services to the family accessible will help the family and the patient. More important to insurance carriers is that the decrease in frequency, intensity, and duration of episodes will also decrease the number of claims made. Being armed with research findings that increase profit may help make the case to pay for early family intervention."

—Marilynn Larkin

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