Family-focused therapy (FFT) is an evidence-based intervention for adults and children with bipolar disorder (BD) and their caregivers, usually given in conjunction with pharmacotherapy after an illness episode. The treatment consists of conjoint sessions of psychoeducation regarding bipolar illness, communication enhancement training, and problem-solving skills training. This paper summarizes over 30 years of research on FFT and family processes in BD. Across eight randomized controlled trials with adults and adolescents with BD, FFT and mood-stabilizing medications have been found to hasten recovery from mood episodes, reduce recurrences, and reduce levels of symptom severity compared to briefer forms of psychoeducation and medications over 1-2 years. Several studies indicate that the effects of FFT on symptom improvement are greater among patients with high-expressed emotion relatives. New research focuses on FFT as an early intervention for youth at risk for BD, neuroimaging as a means of evaluating treatment mechanisms, and progress in implementing FFT in community mental health settings.

Severe irritability and temper outbursts are risk factors for the onset of serious and lifelong mood disorders. In treating children and adolescents with severe irritability, clinicians should evaluate and address safety issues before acute stabilization of symptoms. Then, clinicians can initiate interventions to prevent the onset or relapses of the undesired behavior and its functional consequences. This review summarizes primary, secondary, and tertiary relapse prevention strategies, with an emphasis on strategies that build resilience in youth that mitigate the onset, recurrence, and progression of emotion dysregulation.

Psychotherapy is an important part of managing bipolar depression and its associated impairments. There is considerable evidence that psychotherapies are effective adjuncts to pharmacotherapy in delaying or preventing episodes of bipolar depression. Individuals with bipolar depression may be reticent to consider these treatments. This paper surveys the utility, evidence base, effective treatment components, and controversies surrounding adjunctive psychosocial interventions.

Background

Most longitudinal or treatment studies in bipolar disorder have used symptomatic or syndromal status as the primary outcome variable. More recently, psychosocial functioning has been highlighted as a key domain of outcome. Patients with bipolar disorder appear to be impaired in all functional domains, although the factors that cause impairment have not been clearly specified.

Methods

This paper reviews cross-sectional and longitudinal studies on functional impairment and its relationship to symptomatic, neurocognitive, personality, and stress variables in bipolar disorder; and the implications of these relationships for defining treatment targets. 93 articles were located through comprehensive MEDLINE, SCOPUS and Web of Science searches.

Results and discussion

Functional recovery following a mood episode consistently lags behind symptomatic and syndromal recovery. Longer term functional impairment is only partly explained by the number of manic/hypomanic episodes. Depression (including subsyndromal states) and persistent neurocognitive impairment are the strongest correlates of functional impairment in bipolar disorder, with personality and psychosocial stressors playing secondary roles. Possible treatment options include: more aggressive treatment of subthreshold depressive states, pharmacotherapies that target cognition (e.g., stimulants), and adjunctive psychotherapies including cognitive remediation.

Perceived criticism (PC) is a construct that plays a key role in family relationships of persons with psychiatric disorders. It can be assessed in a brief and simple way using the Perceived Criticism Measure. PC ratings made by patients about their caregivers predict adverse clinical outcomes including increases in symptoms and relapse across a broad range of psychiatric diagnoses. Although research supports the concurrent and predictive validity of PC, the measure is not widely used in clinical practice. Here, we describe the construct of PC and review evidence supporting its clinical utility. We then illustrate how criticism and perceptions of criticism can be addressed in a clinical context, describing a family focused treatment approach used with a depressed adolescent at high risk for bipolar disorder.

Levels of parental expressed emotion (EE) are prospectively associated with the symptomatic course of a range of childhood psychiatric disorders. This article reviews the literature linking parental EE to youth psychopathology and proposes a novel framework for understanding its mechanisms of action. We find that, despite noteworthy methodological limitations, parental EE is linked consistently to a more deleterious course of mood, anxiety, and psychotic disorders in youth. Its mechanism of action is unknown. Models of "toxic family stress" (referring to frequent, sustained, and uncontrollable stress without protective influences) provide one framework for understanding how high EE environments interact with individual biological vulnerabilities to promote illness onset and recurrence. Research aimed at understanding biological responses (e.g., stress reactivity, arousal) to familial EE is needed. Such work may inform efforts to understand how EE affects the course of psychiatric disorders and may guide the development of novel interventions emphasizing emotion regulation strategies.

This study elicited provider and administrator preferences in implementing an evidence-based practice (EBP) for bipolar disorder or psychosis, family-focused therapy (FFT). Providers (n = 35) and administrators (n = 5) from three community mental health centers took part in FFT training and participated in pre- and post-training focus groups. Transcripts were examined using conventional content analysis. Providers and administrators discussed barriers to implementing EBPs. Successful EBPs were described as incorporating flexibility and close supervision to maximize provider adherence. Providers expressed preferences for structured EBPs like FFT that have both explicit implementation steps and built-in flexibility.

Objectives

Network analyses of psychopathology examine the relationships between individual symptoms in an attempt to establish the causal interactions between symptoms that may give rise to episodes of psychiatric disorders. We conducted a network analysis of mood symptoms in adolescents with or at risk for bipolar spectrum disorders.

Methods

The sample consisted of 272 treatment-seeking adolescents with or at high risk for bipolar disorder who had at least subsyndromal depressive or (hypo)manic symptoms. Based on symptom scores assessed via semi-structured interviews, we constructed the network of depressive and manic symptoms and identified the most central symptoms and symptom communities within the network. We used bootstrapping analyses to determine the reliability of network parameters.

Results

Symptoms within the depressive and manic mood poles were more related to each other than to symptoms of the opposing mood pole. Four communities were identified, including a depressive symptom community and three manic symptom communities. Fatigue and depressed mood were the strongest individual symptoms within the overall network (ie the most highly correlated with other symptoms), followed by motor hyperactivity. Mood lability and irritability were found to be "bridge" symptoms that connected the two mood poles.

Conclusions

Symptoms of activity/energy (ie fatigue and hyperactivity) and depressed mood are the most prominent mood symptoms among youth with bipolar spectrum disorders. Mood lability and irritability represent potential warning signs of emergent episodes of either polarity. Targeting these central and bridge symptoms would lead to more efficient assessments and therapeutic interventions for bipolar disorder.

BACKGROUND: Since the COVID-19 pandemic, psychosocial therapies have been provided in varying formats, including remote, in-person, and hybrid services. It is unclear whether varying formats are similarly efficacious in improving psychiatric symptoms and functioning, lead to similar rates of treatment retention, and are equally acceptable to patients. This study compared youth with mood disorders and/or psychosis-risk syndromes who participated in a group cognitive behavioral therapy (CBT) in-person prior to COVID-19, to youth in the same treatment given remotely during the pandemic. METHODS: Adolescents ages 13-17 years participated in 9 sessions of group-based CBT given in-person (2018-2019) or remotely (2020-2021). Youth participants provided self-report ratings of psychiatric symptoms, psychosocial functioning, and emotional regulation at the study baseline and post-treatment and ratings of treatment satisfaction and burden at post-treatment. RESULTS: There were no differences between in-person and remote treatment improvements in psychiatric symptoms, psychosocial functioning or emotional regulation. However, youth in remote treatment had increased retention compared to youth who received treatment in person. Youth in the remote treatment reported similar levels of satisfaction but reported lower burden compared to those who received in-person treatment. LIMITATIONS: Participants were not randomized into remote or in-person treatment. Participants prior to COVID did not have the same frame of reference for alternative treatment delivery options as those during or post-COVID. CONCLUSIONS: Remote group treatment can provide similar levels of psychiatric benefit but less burden than in-person treatment for youth with mood disorders and/or psychosis-risk syndromes.

Perceived criticism (PC) is a measure of how much criticism from 1 family member "gets through" to another. PC ratings have been found to predict the course of psychotic disorders, but questions remain regarding whether psychosocial treatment can effectively decrease PC, and whether reductions in PC predict symptom improvement. In a sample of individuals at high risk for psychosis, we examined a) whether Family Focused Therapy for Clinical High-Risk (FFT-CHR), an 18-session intervention that consists of psychoeducation and training in communication and problem solving, brought about greater reductions in perceived maternal criticism, compared to a 3-session family psychoeducational intervention; and b) whether reductions in PC from baseline to 6-month reassessment predicted decreases in subthreshold positive symptoms of psychosis at 12-month follow-up. This study was conducted within a randomized controlled trial across 8 sites. The perceived criticism scale was completed by 90 families prior to treatment and by 41 families at 6-month reassessment. Evaluators, blind to treatment condition, rated subthreshold symptoms of psychosis at baseline, 6- and 12-month assessments. Perceived maternal criticism decreased from pre- to posttreatment for both treatment groups, and this change in criticism predicted decreases in subthreshold positive symptoms at 12-month follow-up. This study offers evidence that participation in structured family treatment is associated with improvement in perceptions of the family environment. Further, a brief measure of perceived criticism may be useful in predicting the future course of attenuated symptoms of psychosis for CHR youth.