Family interventions for bipolar disorder: a review of the literature

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1 Review Family itervetios for bipolar disorder: a review of the literature Abigail K Masfield*, Jeifer A Dealy & Gabor I Keiter Practice poits Pharmacotherapy is the maistay of treatmet for bipolar disorder, but fails to remit symptoms i some patiets. Adjuctive itervetios are therefore eeded to help patiets ad their family cope with this disorder. Both patiets ad family members beefit from itervetios aimed at helpig the family adjust to this chroic disease. Bipolar disorder ad other mood disorders are associated with lower satisfactio with family fuctioig. Family-based itervetios have ot bee effective i alleviatig acute symptoms. Family-based itervetios show promise i delayig relapse or recurrece of symptoms of bipolar disorder. Family-based psychoeducatio has show promise i reducig recurrece of maic symptoms. Family-focused psychotherapy has show promise i reducig recurrece of depressive symptoms. Summary Pharmacotherapy is the frot-lie treatmet for bipolar disorder, but for may patiets, pharmacotherapy aloe fails to fully remit symptoms. The preset review surveyed existig treatmet-outcome radomized cotrolled trials of adjuctive familybased itervetios for bipolar disorder. A review of PubMed databases performed o 1 September 2011 revealed te uique radomized cotrolled trials of family-based itervetios for bipolar disorder. Approaches to itervetio varied, but results idicated that family-based psychoeducatio is effective i reducig relapse of maic symptoms, while family-based psychotherapeutic itervetios are more effective i reducig relapse of depressive symptoms. More studies are eeded to determie which types of itervetio are most effective. Rhode Islad Hospital, Departmet of Psychiatry, 593 Eddy Street, Providece, RI 02903, USA *Author for correspodece: Tel.: ; Fax: ; amasfieldmarcaccio@lifespa.org /NPY Future Medicie Ltd Neuropsychiatry (2012) 2(3), 1 8 part of ISSN

2 Review Masfield, Dealy & Keiter Bipolar disorder is a debilitatig coditio, associated with a high degree of disease burde ad impaired fuctioig. At preset, psychopharmacology is the primary treatmet, but for may patiets, pharmacotherapy does ot result i full remissio of symptoms [1]. As a result, adjuctive idividual ad family-based itervetios are commo. Idividual psychotherapies that have demostrated empirical support iclude: psychoeducatio, cogitive behavioral therapy (CBT), ad iterpersoal ad social rhythm therapy. Family-based itervetios have icluded psychoeducatio as well as family therapy. Bipolar disorder exerts a heavy toll o family fuctioig, as both patiets ad caregivers lives are affected by the disorder. The role of the family i bipolar disorder has bee discussed sice the 1960s whe family therapy proliferated. However, util the 1980s, o research o family itervetios for bipolar disorder had bee carried out. Istead, scholarship focused o characteristics of families of patiets with bipolar disorder, ad o milieu itervetios. I the 1980s, family-based therapies for bipolar disorder were developed, but oe were tested util the 1990s whe Simoeau et al. piloted a family-based itervetio for bipolar disorder desiged to reduce expressed emotio [2]. Sice the 1990s a umber of studies have explored the effect of various forms of familybased itervetios o bipolar disorder. Despite the chroicity ad debilitatig ature of the disorder, relatively little research has systematically examied the efficacy of familybased itervetios. The purpose of the curret paper is to review radomized cotrolled trials (RCTs) of family-based itervetios for bipolar disorder. Family-based itervetios refer to psychosocial itervetios that iclude family members of the bipolar patiet with or without participatio of the patiet with bipolar disorder. Method We reviewed the literature available for RCTs of family itervetios for bipolar disorder. A review of PubMed databases performed o 1 September 2011 produced 953 citatios usig the search terms bipolar disorder ad family therapy. The citatios raged from the year 1964 to 1 September Each of these was reviewed by title ad abstract, ad we geerated a list of 19 articles evaluatig te uique RCTs that evaluated the efficacy of family therapy for bipolar disorder. Three uique RCTs were 2 Neuropsychiatry (2012) 2(3) excluded because they icluded participats with ay major mood or affective disorder ad the specific impact o participats with bipolar disorder was ot reported [3 5]. Aother article [6] was excluded because the results were preseted more fully i a subsequet article [7] that is icluded i our aa lysis. Similarly, aother article [8] was excluded because it reported o the subset of patiets that achieved remissio status i a RCT that is more fully reported i aother article [9], which is icluded i our aalysis. The radomized trials examied the efficacy of three types of family-based itervetio: family-focused therapy (FFT), problem-cetered systems therapy of the family (PCSTF) ad family-based psychoeducatio. Each of the family itervetios will be described i tur, ad evidece from the RCTs for each modality will be reviewed. Study characteristics ad results of the uique RCTs ad secodary aalyses of the data are summarized ad reported. Family-focused therapy FFT is a structured approach to family therapy that begis with psychoeducatio about bipolar disorder. FFT cosists of 21 1-h sessios, the first 12 of which are delivered weekly, the ext six biweekly ad the ext three mothly. Treatmet is desiged for the patiet ad family members [10], typically spouses or parets. Therapy cosists of three modules: psychoeducatio (seve sessios), commuicatio ehacemet ad problem-solvig traiig. Psychoeducatio focuses o symptoms ad etiology of bipolar disorder, ad uses a vulerability stress model [10]. Emphasis is placed o relapse prevetio. Commuicatio ehacemet (seve to te sessios) focuses o acquirig active listeig skills, skills for deliverig feedback ad skills for requestig chages i a sigificat other s behavior. Problem-solvig skills (four to five sessios) etail idetifyig family problems, braistormig solutios, choosig the best solutio ad evaluatig the solutio oce it has bee implemeted. Problem-cetered systems therapy of the family PCSTF [11] was used i two studies ad cosists of a comprehesive assessmet of the family, icludig a assessmet of how the family fuctios i six domais: roles (how resposibilities are allocated, ad how the health ad welfare of family members are beig addressed);

3 Family itervetios for bipolar disorder: a review of the literature commuicatio (the extet to which family members ca commuicate clearly ad directly with each other); problem solvig (the family s ability to idetify ad respod to problems that arise), affective resposiveess (the capacity of each family member to experiece ad respod to emotios i a way that is appropriate to the situatio); affective ivolvemet (the ability of family members to be ivolved with each other, ad support each other); ad behavior cotrol (the family s ability to set expectatios ad rules for behavior, ad to eforce stadards of behavior). Followig the assessmet, the family egages i cotractig to choose a problem or set of problems to be addressed ad, with the therapist, sets goals ad idetifies tasks ecessary to achieve these goals. Treatmet ivolves workig o the goals laid out durig the cotractig phase, ad termiatio follows whe the family ad therapist decide together that the goals of treatmet have bee attaied or have bee addressed as fully as possible uder curret coditios. Legth of treatmet varies at the discretio of the family therapist, but most families receive family therapy sessios [12]. Family-based psychoeducatio Multigroup family psychoeducatio has bee used i a variety of studies, ad is ofte executed differetly depedig o the research group employig it. Oe approach [9] used a sixsessio format i which the followig topics were covered: sigs ad symptoms of depressio ad maia; experieces, cocers ad copig strategies for livig with a family member who has a mood disorder; questios ad aswers about pharmacotherapy; ad differeces i perspectives o the disorder betwee patiets ad family members. Multiple families, icludig family members ad patiets, participated i this group. I aother study [13 16], six 2-h sessios were delivered biweekly to idividual families. The first three sessios provided disorder-specific educatio, ad the followig three sessios addressed effective copig strategies. The purpose of this multigroup psychoeducatio itervetio was to reduce expressed emotio i families. Expressed emotio refers to critical, hostile, or emotioally itrusive attitudes. Research has demostrated that psychoeducatio reduces the relapse rate i schizophreia [17,18]. The purpose of the study by Hoig et al. [15] was to examie whether a similar model would reduce relapse rates for bipolar disorder. Review Three studies delieverd psychoeducatio to a family member of the patiet, rather tha icludig the patiet i the itervetio [13,14,16]. I these studies, the family member participated i a group i which the symptoms ad etiology of bipolar disorder were reviewed, as well as the importace of adherece to pharmacotherapy ad sigs of relapse. Fidigs from FFT studies I the earliest study of FFT [19], 101 patiets with bipolar I were erolled with a family member. Four articles were published o this sample [2,19 21]. The mea age of participats was 35.6 years, 63% of participats were female ad 84.2% were Caucasia. The mea umber of prior mood episodes was 4.7. All participats had a DSM III-R diagosis of bipolar I disorder, were betwee 18 ad 60 years of age, had at least oe relative willig to participate i a study, screeed egative for alcohol ad drug disorders i the 6 moths prior to the study, ad were a i acute depressive episode at the time of erollmet. Participats also had to be willig to maitai a pharmacotherapy regime icludig mood stabilizers ad/or atipsychotics. Participats were radomized ito either FFT or case maagemet. Case maagemet icluded mothly supportive phoe calls, cotiued treatmet as usual, ad two 1-h psychoeducatio sessios o relapse prevetio ad family coflict. Participats were followed for 1 year after treatmet eded. Outcomes of iterest icluded family-level expressed emotio; family problem solvig; adherece to medicatio; maia, depressio, ad psychosis severity; ad time to relapse. Results idicated that both treatmet arms evideced symptom improvemet durig the follow-up period. However, patiets i the FFT group experieced fewer relapses, had a loger time to relapse, ad had greater improvemets i depressio symptoms over time [2,19 21]. Families with higher baselie levels of emotioal expressio experieced greater reductios i depressio severity i the FFT group tha the case maagemet group [21]. There was o differetial treatmet effect o maia symptoms [19,21]. Adherece to pharmacotherapy was associated with less severe maia scores i both treatmet arms [19,21]. Aother study explorig the efficacy of FFT drew o a sample of 53 recetly hospitalized ipatiets beig treated for a recet maic episode [7]. Patiets were icluded if they had 3

4 Review Masfield, Dealy & Keiter a diagosis of bipolar disorder, maic type as determied by a Preset State Examiatio ad supplemetary maia items from the DSM III-R SCID (Structured Cliical Iterview for Axis I DSM-IV Disorders) [7]. Medical records ad family member reports were used to aid i diagosis. Participats were aged 18 45, were takig mood stabilizig medicatios at the time of erollmet, ad had at least oe family member willig to participate i a research study. I additio, participats could ot meet criteria for a chroic orgaic ervous system disorder, or chroic alcohol or substace abuse or depedece. Participats were radomized ito oe of two treatmet arms: medicatio maagemet ad FFT or medicatio maagemet ad idividually focused treatmet, which cosisted of supportive, educatioal ad problem-solvig strategies. The idividually focused treatmet cosisted of mi sessios delivered over the course of 9 moths. The study follow-up period was 1 year. The objective of the study was to evaluate treatmet effect o maia ad depressio-symptom severity, symptom relapse, time to relapse, medicatio adherece ad rehospitalizatio rates. Results idicated that patiets i both treatmet arms did ot differ i the umber of relapses or hospitalizatios durig the active treatmet period. However, durig the follow-up year ad for the treatmet ad follow-up years combied, the FFT group experieced fewer hospitalizatios ad relapses. Patiets with poorer premorbid fuctioig were less likely to relapse durig the active treatmet year i the FFT group relative to the idividually focused treatmet arm. Medicatio adherece was high i both treatmet arms. Better premorbid fuctioig was associated with lower rates of rehospitalizatio durig the follow-up period. Two studies addressed fidigs from two arms of the STEP-BD trials [22,23]. STEP-BD (NIMH-f uded Systematic Treatmet Ehacemet Program for Bipolar Disorder) was desiged to evaluate all existig treatmet modalities for bipolar disorder to fid out which treatmets or combiatios of treatmets are most effective for treatig depressio ad maia, ad for prevetig future episodes [24]. The two studies reported here aalyzed data from 293 participats who agreed to be radomized ito a psychosocial treatmet trial [22,23]. Aalyses examied data from participats who received oe of four psychosocial treatmets, of 4 Neuropsychiatry (2012) 2(3) which FFT was oe. FFT was compared with Iterpersoal Social Rhythm Therapy (IPSRT), CBT ad collaborative care, all of which are defied i detail elsewhere [23]. FFT, IPSRT ad CBT treatmet cosisted of 30 sessios over 9 moths. Collaborative care cosisted of three brief psychoeducatioal sessios delivered over 3 weeks, i additio to treatmet as usual. Participats were assessed at seve time poits, icludig 3 moths pretreatmet, every 3 moths for the first year of the study, ad oce every 6 moths for the remaider of the study. Outcomes icluded the presece or absece of depressio ad maia, depressio ad maia severity, fuctioal impairmet, ad time to recovery. Results idicated that patiets i ay of the itesive therapeutic arms, icludig FFT, IPSRT ad CBT, experieced shorter time to recovery, ad more days spet without symptoms durig follow-up tha patiets i the collaborative care coditio [23]. A additioal aalysis usig a subset of the same sample examied psychosocial, recreatioal ad vocatioal fuctioig at baselie ad follow-up [22]. This sample icluded the 152 participats that had completed a fuctioal impairmet assessmet at baselie ad at least oe follow-up. Results idicated that participats i the itesive treatmet arms edorsed better fuctioig overall tha patiets i the collaborative care coditio. Specifically, patiets i itesive treatmets, icludig FFT, edorsed greater chages i relatioship fuctioig ad life satisfactio. There were o differetial treatmet effects o participats work or role fuctioig [22]. Baselie depressio severity ad fuctioal impairmet scores predicted follow-up fuctioal impairmet scores [22]. Oe study explored the efficacy of FFT with adolescets [25]. Participats were 58 adolescets who met criteria for bipolar disorder I, II or Not Otherwise Specified (NOS). Iclusio criteria were: mood episodes i the 3 moths prior to erollmet; age years; at least oe paret willig to participate; ad either 1 week of maia or 2 weeks of depressio withi the 3 moths prior to erollmet. Exclusio criteria icluded active psychosis, substace abuse, or ay eatig disorders requirig hospitalizatio i the ear future, as determied by study staff. Eligible participats were radomized to the FFT group or ehaced care ad pharmacotherapy, which cosisted of pharmacotherapy ad three sessios of psychoeducatio

5 Family itervetios for bipolar disorder: a review of the literature focused o relapse prevetio ad adherece to medicatio. The follow-up period was 2 years. Outcomes studied icluded maia, hypomaia, ad depressio severity, recovery status ad recurrece. Results idicated that there were o group differeces i rate to recovery or time to recurrece from baselie maic or depressive episodes. However, patiets i the FFT arm had a quicker recovery from baselie depressio symptoms ad spet fewer weeks i depressive episodes over the 2-year follow-up period. Fidigs from PCSTF Oe uique study explored the efficacy of PCSTF for patiets with bipolar disorder ad their families [9]. Three other articles have bee published that were coducted prelimiary aalyses of the data before the total sample was erolled or o secodary aalyses [26,27]. The sample cosisted of 92 ipatiets with curret bipolar disorder I usig SCID III-R criteria combied with a ipatiet psychiatrist s evaluatio. The patiets raged i age from 18 to 65, ad had a relative or sigificat other willig to participate i the study. Participats could ot have alcohol or drug depedece withi the 12 moths prior to erollmet. Participats were radomized to pharmacotherapy ad PCSTF, pharmacotherapy ad multifamily group psychoeducatio, or pharmacotherapy aloe. The multifamily group psychoeducatio itervetio cosisted of six weekly 90-mi sessios that focused o educatio about bipolar disorder, the importace of medicatio adherece, how to respod to the patiet s bipolar episodes ad techiques to ehace commuicatio betwee family members about the disease. The follow-up period was up to 28 moths, ad outcomes measured icluded: depressio ad maia severity; family fuctioig; social support; ad fuctioal impairmet. Results idicated o group differeces i symptom severity. However, relative to patiets who received pharmacotherapy aloe, patiets from families with high levels of baselie dysfuctio experieced fewer depressio recurreces durig the follow-up period i both of the family itervetio groups [9,26,27], ad spet less time i a depressive state [26]. Of ote, attritio was high i this study, with 34% of participats i pharmacotherapy aloe, 36% i the PCSTF, ad 33% i multifamily group psychoeducatio droppig out of the study withi the 6-moth active treatmet phase, Review ad 51% droppig out prior to the 1-year assessmet [27]. Fidigs from psychoeducatio of relatives of patiets with bipolar disorder Four studies examied the efficacy of psychoeducatio itervetios for relatives of patiets with bipolar disorder [13,14,16,28]. I oe study [28], 14 spouses of patiets with bipolar disorder, as diagosed by two idepedet psychiatrists usig DSM-III-R criteria, participated i five psychoeducatioal sessios. I the cotrol coditio, 12 spouses completed questioaires but received o treatmet. The psychoeducatio sessios focused o educatio about bipolar disorder, idetifyig early symptoms, educatio about pharmacological agets ad iformatio about ehacig life satisfactio. The study period was 12 moths. Outcomes icluded medicatio adherece, problem solvig, kowledge about bipolar disorder, kowledge about lithium pharmacology ad symptom severity. Results idicated that parters i the itervetio group edorsed more kowledge of social strategies, bipolar illess ad lithium pharmacology tha parters i the cotrol group. Results of the itervetio o bipolar symptoms were ot reported clearly. I aother study, 52 participats with bipolar I or II, as determied by diagosis of the referrig psychiatrist, diagoses oted i patiets medical records ad family member reports, participated i a study of multifamily group psychoeducatio i the Netherlads [13]. Families ( = 29) of patiets with bipolar disorder were radomized ito the psychoeducatio coditio or the wait-list cotrol coditio ( = 23). The multifamily group psychoeducatio cosisted of six 2-h sessios focused o educatio about bipolar disorder ad copig strategies. The study period was 14 weeks, icludig a baselie assessmet 1 week prior to treatmet, a 12-week treatmet period, ad a assessmet 1 week after treatmet eded. The mai outcome was family levels of expressed emotio. Results idicated that the treatmet group experieced greater reductios i expressed emotio tha the wait-list cotrol group. I additio, lower rates of expressed emotio were related to lower rates of hospitalizatio, but it was ot clear whether the itervetio group experieced fewer hospitalizatios relative to the cotrol group. The impact of the itervetio o patiets bipolar symptoms was ot reported. 5

6 Review Masfield, Dealy & Keiter A study coducted i Spai explored the impact of psychoeducatio for family members of patiets with bipolar disorder [16]. I this study, 113 medicated, euthymic, bipolar outpatiets who met criteria for bipolar I or II usig SCID-IV criteria were radomized to oe of two treatmet arms. Participats raged i age from 18 to 60, had to be euthymic for at least 3 moths prior to radomizatio, ad had to have at least oe family member or sigificat other livig with the patiet for at least a year who was willig to participate i a research study. No ratioale was provided for havig patiets meet criteria for euthymia for 3 moths prior to radomizatio. Exclusio criteria icluded ay comorbid axis I disorders, as assessed by SCID-IV criteria, as well as metal retardatio or ay ustable opsychiatric illess. Relatives were excluded if they had bipolar disorder I or II, were illiterate, were metally retarded, or had ay severe metal disorder. Study duratio was 15 moths, which icluded 3 moths of the itervetio period ad 12 moths of follow-up. The psychoeducatioal itervetio cosisted of mi weekly sessios focused o educatio about bipolar illess, symptom maagemet, copig with emergecies, the role of family members i maagig bipolar illess ad the effect of bipolar illess o families. Outcomes icluded maic ad depressive symptoms, ad time to relapse. There were o differeces betwee groups i rates of attritio. The itervetio group had lower rates of total relapses, ad maic ad hypomaic relapses, relative to the cotrol group. There were o betwee-group differeces i depressio relapse or mixed episode relapse. There were also o differeces betwee groups o adherece to medicatio. Fially, i 2010, a US group published a study which icluded 46 patiets with bipolar disorder I or II, ad caregivers of these patiets who edorsed either physical or metal health problems as assessed by the Health Risk Behavior Scale, the Ceter for Epidemiological Depressio Scale, ad the Social Behavior Assessmet Schedule [14]. Bipolar diagosis was established usig the SCID for the DSM-IV. The caregivers received FFT adapted for caregivers ( = 24), while the cotrol group ( = 19) received eight to 12 sessios of educatio about health-related topics, provided via videotapes. FFT was admiistered to caregivers ad cosisted of sessios focused o educatio about bipolar disorder, while the secod phase 6 Neuropsychiatry (2012) 2(3) cosisted of educatio about how to optimize caregivig behaviors, icludig self-care for the caregiver. To complete participatio i the study, participats i the FFT group had to complete a miimum of 12 sessios, while participats i the health educatio group had to complete eight sessios. The study tracked outcomes at baselie ad immediately followig treatmet. Outcomes for bipolar patiets icluded depressio ad maia severity. Outcomes for sigificat others icluded depressio symptoms of caregivers, self-care behaviors ad caregiver objective ad subjective burde. Results idicated that relative to the health educatio group, patiets i the FFT group evideced decreased depressio ad maia scores. I additio, relative to the health educatio group, caregivers i the FFT group evideced greater decreases i depressio symptoms ad health-risk behaviors. Improvemets i caregiver depressio were associated with patiet improvemets i depressio. Decreases i patiets avoidat copig appeared to be related to decreases i depressio amog caregivers. Coclusio & future perspective As of Jauary 2012, te uique studies have explored the impact of adjuctive family itervetios o patiets bipolar disorder symptomology. I all studies, family itervetios were added to pharmacotherapy for bipolar disorder. The family itervetios employed have varied sigificatly, as has the size ad quality of the studies coducted. Fidigs from this review suggest that adjuctive family therapy has little effect o acute treatmet respose or remissio; most results emerged after treatmet had eded, suggestig a delayed treatmet effect. I additio, fidigs suggest that family itervetios have a greater impact o relapse ad recurrece of symptoms ad mood episodes. Thus, the beefit of family itervetios for bipolar disorder may derive largely from the effect of family itervetios o recurrece of symptoms. Literature suggests that the impact of family itervetios o family levels of expressed emotio may cotribute to their effect o reoccurrece of patiet symptoms [29]. Fially, it is ot possible at this time to commet o which family itervetios are best because, to date, there has bee o direct comparisos of the various itervetios, apart from oe study which employed both PCSTF ad multifamily group psychoeducatio [9,26] ad foud both to be equally effective i reducig recurrece of symptoms.

7 Family itervetios for bipolar disorder: a review of the literature I summary, although family itervetios appear to be a useful adjuctive treatmet for bipolar disorder, more studies are eeded to replicate prelimiary fidigs, to discer whether specific types of family itervetios are especially effective, ad to ascertai more about the impact of such itervetios o a variety of outcomes, especially bipolar symptoms ad family fuctioig. Papers of special ote have bee highlighted as: of iterest 1 Keck PEJ, McElroy SL, Strakowski SM et al. Twelve-moth outcome of patiets with bipolar disorder followig hospitalizatio for a maic or mixed episode. Am. J. Psychiatry 67(11), (1998). 2 Simoeau TL, Miklowitz DJ, Richards JA, Saleem R, George EL. Bipolar disorder ad family commuicatio: effects of a psychoeducatioal treatmet program. J. Aborm. Psychol. 108(4), (1999) Fristad MA, Gavazzi SM, Mackiaw-Koos B. Family psychoeducatio: a adjuctive itervetio for childre with bipolar disorder. Biol. Psychiatry 53(11), (2003). Fristad MA, Verducci JS, Walters K, Youg ME. Impact of multifamily psychoeducatioal psychotherapy i treatig childre aged 8 to 12 years with mood disorders. Arch. Ge Psychiatry 66(9), (2009). Clarki JF, Glick ID, Haas GL et al. A radomized cliical trial of ipatiet family itervetio V. Results for affective disorders. J. Affect. Disord. 18, (1990) Goldstei MJ. Psycho-educatio ad family treatmet related to the phase of a psychotic disorder. It. Cli. Psychopharmacol. 11(Suppl. 2), (1996). 7 Rea MM, Tompso MC, Miklowitz DJ, Goldstei MJ, Hwag S, Mitz J. Familyfocused treatmet versus idividual treatmet for bipolar disorder: results of a radomized cliical trial. J. Cosult. Cli. Psychol. 71(3), (2003). 8 9 Solomo DA, Keiter GI, Rya CE, Kelley J, Miller IW. Prevetig recurrece of bipolar I mood episodes ad hospitalizatios: family psychotherapy plus pharmacotherapy versus pharmacotherapy aloe. Bipolar Disord. 10(7), (2008). Miller IW, Solomo DA, Rya CE, Keiter GI. Does adjuctive family therapy ehace The authors have o relevat affiliatios or fiacial ivolvemet with ay orgaizatio or etity with a fiacial iterest i or fiacial coflict with the subject matter or materials discussed i the mauscript. This icludes employmet, cosultacies, hooraria, stock owership or optios, expert t estimoy, grats or patets received or pedig, or royalties. No writig assistace was utilized i the productio of this mauscript. fidigs. Psychiatry Res. 56(3), (1995). This 3-arm radomized cotrolled study examied whether adjuctive family therapy improved recovery from bipolar I mood episodes. The authors foud that the media time to recovery was highest for families receivig pharmacotherapy plus multifamily psychoeducatio. There were o other betwee-group differeces. Miklowitz DJ, George EL, Richards JA, Simoeau TL, Suddath RL. A radomized study of family-focused psychoeducatio ad pharmacotherapy i the outpatiet maagemet of bipolar disorder. Arch. Ge. Psychiatry 60(9), (2003). Keiter GI, Heru AM, Glick ID. Cliical Maual of Couples ad Family Therapy. America Psychiatric Publishig Ic., Washigto, DC, USA, 336 (2010). 16 Reiares M, Colom F, Sáchez-Moreo J et al. Impact of caregiver group psychoeducatio o the course ad outcome of bipolar patiets i remissio: a radomized cotrolled trial. Bipolar Disord. 10(4), (2008). 17 Aderso CM, Griffi S, Rossi A, Pagois I, Holder DP, Treiber R. A comparative study of the impact of educatio vs. process groups for families of patiets with affective disorders. Family Process 25, (1986). 18 Berkowitz R, Shavit N, Leff JP. Educatig relativdes of schizophreic patiets. Soc. Psychiatry Psychiatry Epidemiol. 5, (1990). 19 Miklowitz DJ, Simoeau TL, George EL et al. Family-focused treatmet of bipolar disorder: 1 year effects of a psychoeducatioal program i cojuctio with pharmacotherapy. Biol. Psychiatry 48(6), (2000). 12 Uebelacker LA, Beevers CG, Battle CL et al. Family fuctioig i bipolar I disorder. J. Fam. Psychol. 20(4), (2006). 20 Kim EY, Miklowitz DJ. Expressed emotio as a predictor of outcome amog bipolar patiets udergoig family therapy. J. Affect. Disord. 82(3), (2004). 13 Hoig A, Hofma A, Rozedaal N, Digemas P. Psycho-educatio i bipolar disorder: effect o expressed emotio. Psychiatry Res. 72(1), (1997). 6 Fiacial & competig iterests disclosure recovery from bipolar I mood episodes? J. Affect. Disord. 82(3), (2004). Refereces Review Usig a radomized cotrolled wait-list desig, the study aim was to examie the effect of psycho-educatioal itervetio o bipolar disorder o the levels of expressed emotio (EE) i key relatives of bipolar patiets. Family members i the treatmet group demostrated sigificat decreases i EE. Patiets livig with low-ee key relatives had sigificatly fewer hospital admissios compared to patiets livig with high-ee key relatives. Perlick DA, Miklowitz DJ, Lopez N et al. Family-focused treatmet for caregivers of patiets with bipolar disorder. Bipolar Disord. 12(6), (2010). Hoig A, Hofma A, Hilwig M, Noorthoor E, Pods R. Psychoeducatio ad expressed emotio i bipolar disorder: prelimiary 21 Drawig upo the extesive literature o EE i schizophreia research, this study evaluated the effect of EE. Patiets were radomized to two maualized treatmet arms ad followed for up to 2 years. Patiets with high-ee relatives reported higher frequecy of critical commets predicated by higher levels of depressio ad maia at follow-up. Miklowitz DJ, Richards JA, George EL et al. Itegrated family ad idividual therapy for bipolar disorder: results of a treatmet developmet study. J. Cli. Psychiatry 64(2), (2003). 22 Miklowitz DJ, Otto MW, Frak E et al. Itesive psychosocial itervetio ehaces fuctioig i patiets with bipolar depressio: results from a 9 moth radomized cotrolled trial. Am. J. Psychiatry 164(9), (2007). 7

8 Review Masfield, Dealy & Keiter 23 Miklowitz DJ, Otto MW, Frak E et al. Psychosocial treatmets for bipolar depressio: a 1 year radomized trial from the Systematic Treatmet Ehacemet Program. Arch. Ge Psychiatry 64(4), (2007). This study examied the impact of itesive psychotherapy o participats bipolar symptomology. Participats ( = 293) were erolled i oe of two treatmets arms of the STEP-BD trial. Participats i these aalyses were erolled i oe of the itesive psychotherapy treatmet groups (i.e., FFT, CBT ad IPSRT) or i the collaborative care group. Results idicated that participats i ay of the itesive psychotherapy groups had a shorter time to recovery tha patiets i the collaborative care group. 24 Sachs GS, Thase ME, Otto MW et al. Ratioal, desig, ad methods of the 8 systematic treatmet ehacemet program for bipolar disorder (STEP-BD). Biol. Psychiatry. 53, (2003). 25 Miklowitz DJ, Axelso DA, Birmaher B et al. Family-focused treatmet for adolescets with bipolar disorder: results of a 2-year radomized trial. Arch. Ge. Psychiatry 65(9), (2008). 26 Miller IW, Keiter GI, Rya CE, Uebelacker LA, Johso SL, Solomo DA. Family treatmet for bipolar disorder: family impairmet by treatmet iteractios. J. Cli. Psychiatry 69(5), (2008). 29 Miklowitz DJ. Adjuctive psychotherapy for bipolar disorder: state of the evidece. Am. J. Psychiatry 165(11), (2008). This study coducted a comprehesive review of the literature o the relatioship betwee family characteristics (i.e., high EE vs low EE) ad patiet s disorder trajectory. The authors formulate a recursive biopsychosocial model of the iteractios betwee symptoms, cogitios ad family trasactios that give rise to, ad perpetuate, EE, poor family outcomes ad poor patiet outcomes. 27 Weistock LM, Miller IW. Psychosocial predictors of mood symptoms 1 year after acute phase treatmet of bipolar I disorder. Compr. Psychiatry 51(5), (2010). 28 va Get EM, Zwart FM. Psychoeducatio of parters of bipolar-maic patiets. J. Affect. Disord. 21(1), (1991). Neuropsychiatry (2012) 2(3)