Sara Selis

Given the burdens of living with schizophrenia and other psychotic disorders, and the increasing emphasis on improving patients' quality of life, it's no wonder that clinicians and patients are seeking additional treatment options for psychotic disorders. Clinicians who use, study and advocate for nonconventional or “complementary” therapies in psychiatry -- treatments ranging from dietary supplements to Chinese herbs to yoga -- see an opportunity to expand the acceptance and use of these therapies as adjuncts to conventional treatments for schizophrenia.

These practitioners acknowledge that the evidence supporting most nonconventional therapies for schizophrenia is still decidedly modest: The number of rigorous, well-designed studies is limited, and research findings on several of the therapies are inconsistent.

Still, dozens of studies in recent years have found evidence that when combined with antipsychotics, several nontraditional therapies -- most notably Omega-3 fatty acids, glycine, folate, Chinese herbal medicines, yoga practices and spiritually focused group therapy -- yield measurable and sometimes clinically significant benefits in some schizophrenic patients. Based on limited and mainly small or uncontrolled studies, nonconventional therapies may be effective particularly in easing negative symptoms, cognitive symptoms and/or antipsychotic side effects.

, MD, sees it, psychiatrists owe it to their patients to be open to evidence-based nonconventional approaches.   "Patients and families are desperate -- they're saying, 'There's got to be more you can do for us,' " says Brown, an associate professor in clinical psychiatry at Columbia University, who has devoted much of his work in the past 15 years to the study and practice of complementary therapies, with an emphasis on yoga practices.   Brown says he’s seen increasing demand for this approach among patients and families. In fact, he spends 3 or more hours each week responding to calls and e-mails from individuals who seek his help -- typically refractory cases of patients who’ve tried several conventional therapies with little relief. He gives workshops and talks internationally, including a presentation on complementary therapies for schizophrenia, given in May at the 

American Psychiatric Association's 2007 annual meeting

.  Brown views complementary therapies as a broader set of tools that clinicians can employ to help patients live less disrupted, more fulfilling lives.   "It's like going to a car mechanic," he explains. "Some mechanics know how to fix only Toyotas or GM cars. Some mechanics can fix any kind of car. So I say, What kind of mechanic do you want to be?" With complementary therapies, "we can give you tools so you can help any patient who walks in the door."

Among most U.S. psychiatrists, Brown admits, there has traditionally been little interest in complementary therapies, particularly for serious disorders like schizophrenia where conventional medications produce the most dramatic improvements. "Most psychiatrists are quite frightened by the idea of alternative medicine," he says.   Still, Brown has seen an upswing in interest among some psychiatrists, particularly younger physicians and those from Asian countries. "When I give talks on this, the room is stuffed and people are overflowing out into the hall." It's a sign, he says, that "clinicians aren't satisfied with the treatments we have to offer."  According to a 

, conducted in fall 2006 regarding schizophrenia treatment, 95% of respondents said new, more effective treatment options were needed for schizophrenia. And 80% said they had changed medications for their schizophrenia patients more than once in the previous 12 months, with the drugs’ lack of efficacy as the primary reason.

, MD, is a frequent presenter at major conferences on nonconventional approaches in mental health care, chairs the 

American Psychiatric Association’s Caucus on Complementary, Alternative and Integrative Care

 -- which counts 100-plus members -- and was recently appointed to an APA Task Force on Complementary and Alternative Medicine. He is on the clinical faculty at Stanford University’s Department of Psychiatry and has a full-time private practice in integrative psychiatry -- an approach that uses both conventional biomedical therapies and evidence-based complementary therapies alone or in combination, depending on the unique symptoms and preferences of each patient.   Lake attributes the growing interest in complementary therapies to concerns about the safety, effectiveness and cost-effectiveness of antipsychotic medications, in light of research findings including 

Textbooks synthesize evidence for complementary therapies

Based on his clinical experience, training in complementary medicine, interviews with clinician-researchers, and an extensive review of the scientific literature on nonconventional therapies used to treat psychiatric disorders, Lake has produced two books for clinicians: the 

Textbook of Integrative Mental Health Care

  (Thieme Medical Publishers, October 2006, by James H. Lake) and 

Complementary and Alternative Treatments in Mental Health Care

 (American Psychiatric Publishing, December 2006, co-edited with David Spiegel, MD).

 provides critical reviews of the evidence for nonconventional and integrative approaches to core symptoms including depression, anxiety and psychosis. The key goal of the book is to evaluate nonconventional approaches used to assess and treat common mental health problems, and to present evidence-based guidelines for their appropriate use.  Lake hopes to transform the APA’s Caucus on Complementary, Alternative and Integrative Care into a full-fledged committee that will eventually recommend specific clinical practice guidelines to governing bodies within the association. (Most APA guidelines currently do not discuss complementary approaches.)

Lake emphasizes that as properly practiced, "integrative psychiatry" is based on compelling evidence from randomized controlled trials, and is meant to supplement, not supplant, conventional medications. "By no means am I trying to replace antipsychotic medications with herbs," he says. "I prescribe conventional antipsychotics all the time -- they are very important."  Lake notes that several schizophrenic patients have come to him seeking to discontinue conventional medications. In most cases, he advises against it but often recommends augmentation strategies. In limited cases, he will agree to work with a patient toward the goal of reducing doses or even discontinuing antipsychotics, but the patient must be stable, have a history of good compliance, follow an appropriate regimen of complementary therapies, and must be committed to a holistic program including healthy diet, exercise, and preferably a mind-body practice such as yoga or tai-chi.

For each of the core symptoms for which Lake has reviewed the evidence for nonconventional treatment approaches, he has classified potentially beneficial therapies into 1 of 3 categories:

 are those for which there is "compelling research evidence" -- by Lake's criteria, based on positive findings of a meta-analysis or systematic review of at least 3 well-designed, randomized, placebo-controlled trials with significant statistical power.

 are those for which there is "significant positive evidence" -- meaning 1 or 2 well-designed, randomized controlled trials, and if a meta-analysis of studies has been performed, the findings are promising but not compelling.

 are those often supported by anecdotal evidence or for which the evidence from research studies is limited or inconsistent.

 concludes that "there are no substantiated nonconventional treatment approaches at the time of writing" (October 2006). In interviews, however, Lake explains that this reflects the paucity of large, well-designed studies on the subject, rather than the limited effectiveness of nonconventional treatments for schizophrenia per se.

Indeed, Lake writes, "It is important to remark that many conventional approaches in current use are also provisional or possibly effective when the same rigorous criteria are applied." In this context, "the effectiveness of many provisional nonconventional approaches is probably comparable to that of many treatments used in conventional mental health care."

Lake expects that future studies will produce compelling evidence for some complementary therapies for schizophrenia and other psychotic disorders. Meanwhile, he is encouraged by the steady pace of research on nonconventional treatments. The amount of funding that the National Institute of Mental Health has devoted to studying complementary therapies has ranged from $6.7 million in 2001 to $3.9 million in 2002, with an estimated $4.3 million in funding for 2007, according to 

data from the NIH’s National Center for Complementary and Alternative Medicine

"Provisional" and "possibly effective" therapies for schizophrenia

Lake's synthesis of published research evidence has identified these nonconventional therapies as "provisional treatments for psychosis" 

•EPA (eicosapentaenoic acid), an Omega-3 fatty acid

In addition, Lake’s work has identified the following therapies as "possibly effective for psychosis”:

•dietary changes (decreased intake of saturated fats and gluten; increased intake of Omega-3 fatty acids; improved glucose control)

•mineral supplements (manganese, selenium, zinc)

Based on some clinical studies, Chinese herbal medicine has also been identified as a promising complementary therapy for schizophrenia (though it is not mentioned in Lake’s work).

Guidance for using complementary therapies

Leaders in complementary psychiatry have the following guidance for clinicians who are considering or starting to use the approach:


    -the patient's overall health history
    -previous mental-health problems
    -family history of psychiatric disorders
    -when symptoms of psychosis started
    -frequency and severity of psychotic episodes
    -which therapies the patient has tried (conventional and   complementary); how well they worked (or didn't); side effects they  produced
    -patient's daily activities, sleep/wake patterns, and sources of stress
    -patient's family situation, living situation and significant relationships
    -diet and exercise habits
    -spiritual/religious beliefs and activities

Determine whether the patient poses a danger

 to himself or others. If so, make sure he gets immediate treatment in an emergency or inpatient setting, and emphasize to the patient the importance of staying on his prescribed medications.

Ask about patients’ use of complementary therapies

 -- and don’t be judgmental of their response. A 

2006 research review of complementary therapies in psychiatry

 found that, depending on the criteria used, between 8 and 57% of psychiatric patients use nonconventional therapies. A 

 from the Scott & White Memorial Hospital and Clinic found that among 82 psychiatric inpatients, 63% had used a complementary modality in the previous year, but most respondents had not discussed it with their psychiatrist. This may have dangerous repercussions, since some herbs and supplements can cause adverse reactions when taken with conventional medications.    

Many patients avoid mentioning complementary therapies  because they fear their doctor’s disapproval, notes William M. Greenberg, MD, clinical associate professor of psychiatry at New York University, whose private practice incorporates complementary therapies including dietary supplements, meditation and spirituality.

    "I approach patients individually and broadly," Greenberg says. If a patient seeks to use natural remedies in place of medications, he usually advises against it. Still, he says, "I don't reject that attitude outright. I find that the clinician being open to it really strengthens the therapeutic alliance."    

Until recently, Greenberg was director of outpatient research at the 

Nathan Kline Institute for Psychiatric Research

, where he led a randomized, placebo-controlled trial on the 

Effect of High-Dose B-Complex Vitamins on the Symptoms of Schizophrenia

Determine whether psychosis is the patient's only primary symptom 

, or whether there are comorbid symptoms, such as anxiety or depression. Lake's 

 includes tables and an algorithm that provide guidance on assessing and treating patients with comorbid symptoms in addition to psychosis, vs. psychosis alone.

Try all substantiated conventional therapies before starting complementary therapies

. "If the patient has tried all the antipsychotics except one, I'd try that one before going to [nonconventional] treatments," Lake says.

. When introducing or changing therapies (conventional or nonconventional) for a patient, avoid making quick or drastic changes. Start with the lowest recommended dose, then increase it incrementally if it's not having the desired effect. Always aim for the lowest possible effective dose of any treatment, to minimize the risk of adverse effects while increasing compliance.

. Nonconventional treatments are rarely covered by insurance, and many schizophrenia patients have limited financial resources, making it difficult for them to pay for treatments out-of-pocket. While common dietary supplements typically cost $20 to $50 per month, other treatments -- such as Chinese herbal medicines or less-common supplements -- can cost several hundred dollars a month.

Carefully explain to patients the rationale

 for the complementary therapies you’re recommending; the risks involved -- including potential herb-drug interactions -- and the importance of staying on the patient’s prescribed medication regimen. 

Document these discussions, and get the patient's written consent

Refer patients to high-quality brands and suppliers

 of complementary remedies. Since the FDA does not regulate herbs or dietary supplements, there are no guarantees about the products’ contents or quality. One helpful guideline is to look for a certified 

 certification (the GMP stamp will appear on the label), as well as products that have a 

 stamp. Independent evaluations of the safety and efficacy of dozens of dietary supplements are available (for a modest fee) at 

 brand and Web site for herbs and supplements (he has no ties to the foundation).

. "Doctors can seem more interested in technology than in the patient's feelings. Patients miss having that emotional connection," Brown explains. "Just listening is very important." Effective listening, he notes, requires quieting the mind, eliminating distractions and focusing on the patient.

Resources to learn more about complementary therapies in psychiatry

 The following resources can help educate mental-health clinicians about the use of complementary therapies in psychiatry:

 (Thieme Medical Publishers, October 2006, by James H. Lake) and 

 (American Psychiatric Publishing, December 2006, co-edited by Drs. James H. Lake and David Spiegel) -- identify what Lake and Spiegel regard as safe, effective complementary treatments for psychiatric disorders, and present evidence-based guidelines for their use.

 offers an e-mail newsletter, information on meetings and events in complementary psychiatry, and an e-mail discussion group for clinicians. The group is building an online database of research evidence on complementary therapies in psychiatry.

American Psychiatric Association’s annual research meeting

 includes presentations and workshops on nonconventional treatments in psychiatry.

National Center for Complementary and Alternative Medicine

, although these resources are not focused specifically on psychiatry.

COMPLEMENTARY TREATMENTS FOR SCHIZOPHRENIA: A summary of the evidence and indications

The information below briefly summarizes the evidence and indications for the most widely studied and most promising nonconventional treatments for schizophrenia. 


Note: This is not an exhaustive listing. For further information, consult these 

clinician-oriented resources on complementary therapies in psychiatry

. See also, a related Psychiatric Times article from 2006, 

 Treatment Resistance in Schizophrenia: The Role of Alternative Therapies 

, an amino acid that interacts with the NMDA receptor, may improve positive and negative symptoms of schizophrenia, and may improve mood and overall cognitive functioning, when used along with a conventional antipsychotic, according to clinical trials and case reports. Double-blind, placebo-controlled studies of glycine supplementation include one 

. Clinical trials have found that glycine did not help people taking clozapine, but it did help (in reducing negative symptoms) individuals taking risperidone and olanzapine. Several randomized, controlled trials conducted at China Medical University and Hospital in Taiwan -- including a 

 -- have found that treatment with sarcosine (a derivative of glycine) significantly reduced positive and negative symptoms of schizophrenia when taken with antipsychotics.   

: Glycine causes upset stomach and nausea in some patients; this can be minimized by starting at lower doses and increasing it slowly over a few weeks. There are case reports of acute psychosis in some chronically psychotic patients treated with large doses.  

, an Omega-3 fatty acid, may improve both positive and negative symptoms when used with conventional antipsychotics. Controlled studies have yielded mixed results, however. A 

 (published in 2003) found that schizophrenia patients treated with EPA had a significant reduction in scores on the PANSS and BPRS scales. In a 

 of 115 treatment-refractory schizophrenics (published in 2002), clinical improvements were observed in patients taking EPA along with clozapine.  According to a 

 on the subject, however, a review of 6 studies involving 353 people “suggests that supplementation with essential fatty acids may have a positive effect on the symptoms of schizophrenia,” but “the use of Omega-3 polyunsaturated fatty acids for schizophrenia remains experimental and this review highlights the need for large well-designed studies.” Similarly, a 2006 research review (conducted by an APA subcommittee) of Omega-3 fatty acids for the prevention and treatment of psychiatric disorders, concluded that “EPA and DHA appear to have some potential benefit in major depressive disorder and bipolar disorder, but results remain inconclusive in most areas of interest in psychiatry.”  

 taken with conventional antipsychotics may reduce symptom severity in schizophrenia, especially in patients who are folate-deficient, according to the findings of some double-blind placebo-controlled trials. In a 

, folate-deficient patients with major depression or schizophrenia who took daily folic acid (methylfolate 15mg) together with their conventional antipsychotic medication had fewer positive and negative symptoms and improved more rapidly than patients taking conventional drugs alone.   Supplementing antipsychotic medications with the natural steroid 

 may reduce the severity of negative symptoms and may improve depressed mood and anxiety in some schizophrenia patients, according to findings from clinical studies. Randomized, placebo-controlled trials conducted in Israel, published in 

, found that those taking up to 150 mg of DHEA along with an antipsychotic reported improved negative symptoms and improvements in some extrapyramidal side effects.

: Patients with a history of benign prostatic hypertrophy or prostate cancer should consult their physician before taking DHEA, as research suggests that supplemental DHEA use may pose a cancer risk in patients with nascent or occult prostate cancer.  

 may also be a beneficial adjunctive treatment. A 

 evaluated 6 trials that studied the use of Chinese herbs in a Western medicine context for the treatment of schizophrenia. Though the trials were limited by their sample size and study length, the review concludes that “if used in conjunction with Western antipsychotic drugs, [Chinese herbal medicines] may be beneficial in terms of mental state, global functioning and decrease of adverse effects.” However, it adds, “further trials are needed before the effects of TCM (traditional Chinese medicine) for people with schizophrenia can be evaluated with any real confidence.”   

, used at 360 mg per day, may enhance the efficacy of conventional antipsychotics by helping to reduce positive and negative symptoms, according to placebo-controlled studies conducted in the 

: Ginkgo biloba may be associated with an increase in bleeding risk, according to a 

, so caution should be taken, particularly in patients with known bleeding risks. Ginkgo biloba should not be taken with warfarin or other drugs that affect bleeding time.  Possibly effective 

 for psychosis include increased intake of unsaturated fats (including foods rich in Omega-3 fatty acids), reduced intake of saturated fats and gluten, and improved regulation of glucose. Findings from epidemiological studies including a 

 suggest that schizophrenic patients who consume a diet high in saturated fats have more severe symptoms compared with patients who follow diets with moderate fat intake. Conversely, chronically psychotic patients who consume large amounts of unsaturated fats, including Omega-3 fatty acids, generally have milder symptoms, according to a 

. There is also evidence that some schizophrenic patients become more symptomatic when they eat foods containing gluten -- and therefore, eliminating gluten from the diet may be beneficial -- but most of these reports are anecdotal.

: Schizophrenia patients who are considering diet changes should first consult a nutritionist or other specialist.  

Regular yoga practice and yoga breathing techniques

 may reduce agitation and anxiety in chronically psychotic patients, according to anecdotal reports. And, according to a 

 from the National Institute of Mental Health and Neuro Sciences, in Bangalore, India (published in September 2007), yoga practice combined with antipsychotic medication improved positive and negative symptoms, social functioning and quality of life.

: Certain yoga breathing practices can cause agitation and can worsen symptoms in some psychotic symptoms. Patients should therefore practice yoga only under the guidance of a skilled instructor.   

 may benefit schizophrenia patients who are stable or have well-controlled residual symptoms, according to some observational studies and case reports. Spiritually oriented support groups have been established at various U.S. healthcare centers, including a group formed at the Nathan Kline Institute, discussed in an 

, and another formed at a New York Hospital, discussed in a 

. According to the literature, these efforts have yielded significant benefits for patients with schizophrenia, including a sense of encouragement, social support, improved range of affect, improved hopefulness and self-esteem, enhanced feelings of well-being, and a deeper sense of connection with peers. The groups are typically nondenominational and may include group prayer, reading and discussion of passages from various spiritual traditions.

: Mental health practitioners should use their clinical judgment when considering whether it is appropriate to invite any patient with a history of psychosis to explore spiritual issues. Involvement in religious/spiritual groups could aggravate symptoms in individuals who are experiencing religious delusions or other severe psychotic symptoms.  

 may be beneficial in some cases of chronic schizophrenia, but the results of clinical trials have been mixed. Several case reports and small double-blind placebo-controlled studies -- including a 

 (Israel), published in 2006 -- suggest that niacin taken with a conventional antipsychotic results in greater improvement in psychotic symptoms compared with conventional antipsychotics alone. However, a 1991 

 review of 53 trials of niacin and other vitamins

 for the treatment of schizophrenia and other mental illnesses identified shortcomings in the research design methods and concluded that the reported findings had only marginal statistical significance.

There is ongoing debate over the effectiveness of high doses of vitamins in the management of psychosis. The American Psychiatric Association considers the approach discredited, but Lake asserts that it still “warrants serious consideration” given the “large number of positive case reports and the growing level of professional interest.” A randomized, placebo-controlled trial of the 

 Effect of High-Dose B-Complex Vitamins on the Symptoms of Schizophrenia

 was recently completed at the Nathan Kline Institute for Psychiatric Research (lead investigator William M. Greenberg, MD), but results are not yet available. 

 Treatment Resistance in Schizophrenia: The Role of Alternative Therapies

Articles

Given the burdens of living with schizophrenia, and the increasing focus on patients' quality of life, it’s no wonder clinicians are seeking other treatment options for the disorder. Here, a discussion of the most promising nonconventional therapies and how to use them.

Complementary Therapies for Schizophrenia: Expanding the Clinician’s Toolbox

Family Therapy in the Treatment of Depression

WHIPLASHED: A Mnemonic for Recognizing Bipolar Depression

Nations Convene to Create Bipolar Consensus Statement

, MD-associate chairman of psychiatry at Beth Israel Medical Center in New York and director of the 

 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.

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 

, 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.

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.

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:

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

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

 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

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

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 

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. 

, 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 

 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 

 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. 

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.

 that assessed the family caregivers of 264 bipolar patients found that 33% of the caregivers had clinically significant levels of depressive symptoms. And, a 

 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.”

 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 

, PhD, associate professor of psychology at Boston University, who studies the impact of family interventions for bipolar and other mental disorders.

Despite the compelling reasons for involving family members in the treatment of bipolar disorder, several barriers can get in the way:

 In that case, try to enlist the cooperation of a friend, neighbor or someone else in regular contact with the patient.

The family doesn't want to be involved in treatment. 

 This is often due to stigma and shame surrounding mental illness-or a feeling that seeking help with caregiving is a sign of weakness. The clinician should try to dispel these notions and encourage family members to talk about their experiences with the illness. Ask if the family member will try attending one session with the patient.

If the family declines to participate in therapy, 

, a structured 12-week course for family caregivers of those with severe mental illness, 

 found that participants who completed the program felt less burdened, more empowered and more knowledgeable about their family member's mental illness. The 

 for patients and their families. While these programs aren’t a substitute for therapy, they offer helpful psychoeducation and support.

The patient doesn't want his family to participate 

 in treatment. Often this is because the patient perceives his family as a threat, or fears that they and the therapist will "gang up" on him. In this case, try reassuring the patient and explain that the goal is to help the family understand him better. Ask the patient if it's OK to speak with a family member by phone-then see if the patient will agree to bring that person to a session.

 Clinicians may fear that working with patients' families could violate standards of confidentiality or open them up to lawsuits. In reality, the legal risks are minimal, provided that the patient and family agree-ideally in writing-to participate in treatment and to discuss the patient's symptoms openly. The clinician should also make clear when and how the patient should disclose to the clinician confidential information that he doesn’t want shared with family members.

The clinician lacks experience in family-focused therapy. 

 Willing clinicians can develop the needed skills through CME courses, seminars and other resources. A helpful professional guide is Miklowitz’s 1997 book 

Bipolar Disorder: A Family-Focused Treatment Approach

. He is also developing an educational DVD for clinicians in conjunction with the American Psychological Association. Miklowitz cautions that based on his experience, a book or video is not enough to master the approach, and some consultation with an experienced clinician-trainer, in person or by phone, may be needed.

Some clinicians view family intervention as counter to the psychoanalytic tradition 

 of focusing on the patient’s personal insight and autonomy. Miklowitz asserts the opposite is true: "Say you have an adult male patient living at home with his mother. He wants to go out, get a job and live on his own. To help the patient achieve those things, you may need help from his mother."

To succeed with family-focused interventions for bipolar disorder, and to deal with the inevitable challenges, experts offer this guidance:

 It's crucial to establish a rapport with all family members from the outset. "Let them know you're on their side and you want to help them. Assure them you're not going to take sides with one person over another," Miklowitz advises.

Help families and patients see each other's point of view. 

 Through psychoeducation and open discussion, encourage the patient and family to see how the others view the illness and its symptoms.

 Make sure all of the family members in attendance contribute to discussions; make efforts to draw out those who may be hanging back. Getting the buy-in of all family members is especially important when doing problem-solving.

Make sure the family understands and supports the patient's medication regimen.

 Family members can play an important role in making sure the patient attends his appointments and takes his medication(s) as prescribed.

Strike a balance between the disorder's effects and patient responsibility. 

 "Family members often think, ‘He's acting this way because he hates me and wants to hurt me,’" Miklowitz says. "You need to help them understand it's the illness that's causing him to act this way. Still, you don't want to give the patient a blank check to do whatever he wants and blame it on the illness. The patient needs to take responsibility for his actions."

Make sure the family doesn't feel blamed. 

 Families are sensitive to any suggestion that their interactions might have caused the illness.

 Miklowitz's research has found that it takes 6-9 months of family-focused therapy to produce clinically measurable benefits. That can seem like a long time, he acknowledges. "You have to be patient, believe in what you're doing and view this as a long-term investment."

A Randomized Study of Family-Focused Psychoeducation and Pharmacotherapy in the Outpatient Management of Bipolar Disorder

, Archives of General Psychiatry, September 2003

Mounting evidence shows that patients with bipolar disorder benefit significantly when their families are involved in treatment. Despite the challenges entailed, clinicians can successfully implement a family-focused approach if they’re willing, flexible and patient.

Sara Selis

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