At Beth Israel, Galynker decided to formalize his family-involved approach and adopt a less-structured approach with some of the elements of family-focused therapy, which he calls "family-inclusive therapy," or FIT. Galynker created a FIT program at Beth Israel in summer 2006, and he is now doing research to evaluate its effectiveness. During a conference this summer, Galynker met with the University of Colorado's Miklowitz and sought his guidance on how best to use the elements of family-focused therapy in a community hospital setting. Psychiatry residents at Beth Israel are also being trained in this approach.
Anecdotally at least, Galynker considers his efforts a success. He speaks of a "surprising level of acceptance" and the "dramatic improvements" he's seen in some in some of his participating patients and their families. He has discussed his approach with the National Alliance on Mental Illness (NAMI) and presented at the the American Psychiatric Association's 2007 annual meeting. His goal, like that of Miklowitz and others working in this area, is to see a family-oriented approach to bipolar disorder become broadly adopted. “We don't want this to be an experimental program in a lab -- we want it to become the standard of care," Galynker explains. He adds that "it's absolutely puzzling to me that more clinicians don't get the families involved," especially given the strong genetic component which makes children of bipolar patients vulnerable to developing the disorder. While there's no hard data on how often family members participate in the treatment of their bipolar relatives, those who specialize in this area say it is the exception, not the rule. By all accounts, the most common approach is periodic medication-monitoring visits with a psychiatrist, sometimes supplemented by individual CBT or supportive counseling. When the family does participate in therapy, it is typically for one or two sessions, but not for ongoing treatment. Closing the gap between research and practice
"There's clearly a gap between the research and the practice," says Miklowitz, whose work on family therapy for bipolar disorder built upon similar work with families of schizophrenia patients. "[Bipolar patients’] families frequently complain that they want to be involved in treatment but the clinician won't talk to them. Based on our findings, we feel strongly that families ought to be actively involved in treatment." Though Miklowitz once encountered considerable skepticism and resistance to the concept among clinicians, he's now seeing increased interest from them. That's evident in the number of requests he's received from hospitals and clinics to do training in family-focused therapy; the enthusiastic response to panels on the topic at professional meetings; and the various projects underway to refine and expand the treatment approach. John S. McIntyre, MD -- past president of the American Psychiatric Association and chair of its steering committee for practice guidelines -- confirms that “over the last two decades, we've seen an increasing movement to involve the family in treatment for bipolar disorder and other serious mental illnesses. The APA has been very strong in encouraging that. The evidence shows that family interventions make a real difference." Clinical guidelines discuss family intervention
The APA's clinical practice guidelines for bipolar disorder, published in April 2002, advise clinicians to “involve family members in treatment whenever possible”; “help the patient and family to recognize early signs of manic or depressive episodes”; educate family members about bipolar illness; and “recognize stress or dysfunction in the family,” as this “may exacerbate the patient’s illness.” The 2002 guidelines state that “group psychoeducational interventions” -- including family-focused therapy -- “appear useful” according to available evidence, but “despite promising results … improvements have not been consistently documented.” The APA’s interim update to these guidelines, however -- a “Guideline Watch” released in November 2005 -- notes that "knowledge of the utility of psychosocial interventions [including family interventions] has recently expanded." It cites a (previously mentioned) 2-year randomized, controlled study which found that patients who participated in family-focused therapy plus medication had fewer relapses, better post-episode adjustment and better medication adherence than a group that received a crisis-management intervention. For his part, McIntyre asserts that "in many cases, the families [of bipolar patients] are, in fact, involved in treatment." While a structured, manual-based program such as family-focused therapy is beneficial for many patients and families, he says, that is just one of several viable ways to involve families. Miklowtiz agrees. "This is not a one-size fits all solution. You have to mold the therapy to fit the situation and the patient." He notes, for example, that unlike his family-focused therapy program -- in which the patient and family attend all sessions together -- a mix of individual and family sessions is more appropriate for some patients. Regardless of the treatment model used, though, Miklowitz contends that just a few family sessions aren't enough to provide real benefit. His research finds that it takes 6-9 months of family-focused therapy to see clinically meaningful benefits, such as fewer hospitalizations and relapses. Family members reap benefits
Advocates of family-focused interventions for bipolar disorder also point to the benefits that family members gain. That's important because studies led by Deborah Perlick, PhD, associate professor of psychiatry at the Mount Sinai School of Medicine, have found that family members of bipolar patients who report strain from caregiving are at greater risk of mental and physical illness. For example, a 2005 study that assessed the family caregivers of 264 bipolar patients found that 33% of the caregivers had clinically significant levels of depressive symptoms. And, a 2007 study that evaluated the primary caregivers of 500 patients enrolled in the STEP-BD trials, found that burdened family caregivers were at higher risk of insomnia and chronic conditions such as hypertension, but were less likely to see a doctor about their ailments. "This disease can be incredibly stressful for the family," observes Perlick. "They're hypervigilant, always on the alert for mood swings. They don’t sleep well. They don’t take good care of themselves.” Perlick is leading an NIMH-funded project that combines psychoeducation and CBT techniques to develop a health-promoting intervention for family caregivers of patients with bipolar disorder. The hope is that such efforts will prevent, or reduce the severity of, family members' own mental and physical illnesses. That could reduce healthcare service utilization for entire families, making the interventions cost-effective in the long term. And, having less stress at home helps patients with bipolar disorder feel more secure, leading to longer periods of recovery. "We're not helping just the patient or just the family; we're helping both. It's all intertwined," explains Martha Tompson, PhD, associate professor of psychology at Boston University, who studies the impact of family interventions for bipolar and other mental disorders.