Early Intervention for Youth at Risk for Bipolar Disorder
Sharon M. Kahler, MD
Clinical Instructor of Child and Adolescent Psychiatry
NYU Child Study Center
Dr. Kahler has disclosed that she has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
Bipolar I and II disorder (BD I and II) together affect an estimated 2.5% of US adolescents (Merikangas KR et al, Arch Gen Psychiatry 2012; 68(3):241-251), and there is little argument that they result in significant morbidity. Symptoms can often be seen prior to the onset of BD— as early as 10 years beforehand—and many youth who are diagnosed with BD not otherwise specified (BD NOS), Major Depressive Disorder (MDD), and cyclothymia will ultimately go on to develop BD.
Is it possible that early psychosocial interventions, targeted at high risk youth for the development of BD could stabilize mood symptoms and perhaps impede the progression to BD? Recent research suggests that it might be. Family focused therapy (FFT), which, in prior studies has been associated with more rapid and complete remission from depressive episodes in adolescents with BD I and II, may help to do just that.
In a recent randomized trial researchers looked at 40 youth ages nine to 17 at high risk for progression to BD I and II, defined as having BD-NOS, MDD, or cyclothymia with active mood symptoms and at least one first degree relative with BD I or II. Participants were randomly assigned to either FFT-High Risk Version (FFT-HR), which entailed 12 sessions of communication and problem-solving skills training and psychoeducation, or a control group that received one or two family education sessions.
The researchers hypothesized that youth assigned to the FFT-HR group would recover more quickly, spend more time in remission, and have greater improvement in symptoms over a one-year period. A secondary aim was to examine the benefits of FFT-HR for those in families of high expressed emotion (EE) compared to families of low EE. Youth included in the study were also allowed to receive pharmacotherapy, and assignments to FFT-HR vs control were balanced accordingly for medications, age, and initial diagnosis.
As predicted, researchers found that youth assigned to the FFT-HR group recovered more quickly than those in the control group, in 13 weeks compared to 21.25 weeks, a significant difference. Furthermore, those in the FFT-HR group spent a mean of 28.6 weeks in full remission compared with 19.5 weeks in the control group, also a statistically significant difference. Over the one- year period, the youth in the FFT-HR group had a more favorable trajectory of scores on the Young Mania Rating Scale, though not on the child Depression Rating Scale. Overall, youth in high-EE households did significantly worse than those in low-EE households in time to recovery from initial symptoms, and over the follow-up period were more likely to remain symptomatic. Notably, however, FFT-HR had a greater treatment effect on youth from high EE vs low EE households (Milkowitz DJ et al, JAACAP 2013;52(2):121-131).
CCPR’s Take: The small sample size was a limitation to this study. In addition, basic differences in the treatment conditions compared with the control conditions (mean number of contacts 12.43 vs 2.26 respectively) make it unclear if favorable response was due to the content of the contact or frequency and number of hours of contact. Nonetheless, FFT-HR may be a non-pharmacological intervention worth considering for youth who are at high risk for development of bipolar disorder, especially for those who come from high EE households. The favorable effects of FFT-HR found in this study suggest that it may be worthwhile to conduct further research in this area.