Making Treatment for Bipolar Disorder a Family Affair

One afternoon last spring, Igor Galynker, MD -- associate chairman of psychiatry at Beth Israel Medical Center in New York and director of the Zirinsky Mood Disorders Center there -- had a meeting with a bipolar man's wife that brought home to him the enormous stresses on family members of patients with bipolar disorder, and the need for mental-health clinicians to involve the family more actively in their treatment. The encounter, in fact, led Galynker -- whose work had focused on medication adherence and other aspects of mood disorders -- to change the focus of his career.

His meeting was with Susan (not her real name), a well-educated, middle-aged mother of four, who had recently gone through a divorce from her husband of more than 20 years -- a smart, successful financier who suffered from severe bipolar disorder. Susan had seen her marriage and her family fall apart due to the increasing severity of her husband's illness: his irritability and depression, his inability to function normally, and his abrupt swings into mania. Susan's husband (whom Galynker did not know) had received ECT and been hospitalized several times in the previous 5 years, and throughout these episodes she had tried to talk with his psychiatrists and become involved in his treatment. But the doctors had declined to discuss his case with her, because he had told them he didn't want his family involved. Susan felt shut out and desperate. She didn't even know what medications her husband was taking. When Susan began talking with other family members of bipolar patients, she learned that her experience wasn't unusual: Many told her they, too, felt left out of -- even pushed away from -- the treatment of their bipolar spouse, parent, sibling or child. Hoping to spur change So Susan came to Galynker's office -- not for therapy, but to share her concerns in hopes that it might spur action to help other family members. Galynker recalls being "stunned" by Susan's story, and he resolved to pursue the issue. In his many years of treating bipolar patients -- including 15 years working on an inpatient psychiatric unit at Beth Israel -- he had quietly and informally developed an approach of working with patients' families. Under this approach, Galynker had family members attend therapy sessions with the patient on a regular basis, at least quarterly. At these sessions, he would educate the patient and family about bipolar disorder; discuss the patient's symptoms and the family's reactions to them; reach a consensus on the patient's medication regimen; and work with the family on coping skills, problem-solving and a "relapse response plan." Working with patients' families made intuitive sense to Galynker: "When someone in the family is bipolar, the whole family is ill, so the whole family needs to be in treatment." Until his meeting with Susan, however, he hadn’t realized that a family-focused approach to the illness was relatively uncommon, and sorely needed. Studies show benefits of family involvement Eager to learn more, Galynker searched the literature and found a small number of studies on the stresses experienced by family members of bipolar patients; how the family's reactions affect the patient's recovery; and the pioneering work of University of Colorado psychology professor David Miklowitz, PhD, who since the early 1980s has developed and studied a structured program of family-focused therapy for bipolar disorder. Among the findings:

• Family members’ emotional responses to a patient's bipolar episodes have a significant impact on how well (or not) the patient recovers from the episodes, according to 4 independent studies in 3 countries. Specifically, if the family is highly critical, hostile and overprotective, the patient will have more severe symptoms and more frequent relapses, compared with patients whose families are supportive and understanding.
• A 2-year randomized controlled trial of 101 bipolar patients, published by Miklowitz and colleagues in 2003, found that those who completed up to 21 sessions of family-focused therapy, in addition to medication, had fewer relapses, less severe symptoms and better medication adherence than a control group who received medication, two sessions of family education, and crisis intervention as needed.
• An April 2007 study by Miklowitz and colleagues from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) found that patients who received intensive psychotherapy (weekly sessions) in addition to medication recovered faster from bipolar depression, and stayed clinically well longer, than a group that received a brief psychoeducational intervention (3 sessions). The 3 types of psychotherapy studied -- family-focused therapy, cognitive behavioral therapy and social rhythm therapy -- were all found to be beneficial, although the rates of recovery from depression were highest among those in the family-focused therapy group.

Key elements, goals of family-focused therapy

In family-focused therapy, the patient and family members attend all sessions together, in addition to the patient's (individual) medication-monitoring visits with a psychiatrist. The program has 3 key components:

• Family psychoeducation helps the family understand bipolar disorder and how it affects the patient.

   

• Skills building teaches families to improve their communication skills, deal with stresses, and solve problems collaboratively.

   

• Relapse planning entails working with the family to identify warning signs of a relapse and create an action plan that includes when to call the doctor, when to increase the patient's medications, and how to help the patient stabilize such as by regulating his sleep-wake cycle.

The main goals of family-focused therapy, and other family interventions for bipolar disorder, are to:

• help the patient to stabilize and recover from episodes
• increase the time between relapses
• prevent hospitalization
• improve the patient's functioning, such as staying in school, getting a job, or taking care of household duties
• improve medication adherence by enlisting the family's help
• ease family members' stress, and prevent them from developing -- or lessen the severity of -- their own mental-health problems
• improve family relationships and keep families together