TCPR: Why should we as psychiatrists focus on the psychosocial aspects of bipolar disorder?
Dr. Miklowitz: There is evidence that life events, family distress, and antecedent adversity variables in childhood are related to the course of bipolar disorder. So as with any other psychiatric disorder, you have to consider the psychosocial triggers of episodes and to what extent those are related to how people respond to medications, whether they are compliant with medications, and their psychosocial functioning between episodes.
As good as they are, the medications that we use are not always effective, particularly for depressive as compared with manic episodes. Paradoxically, some psychosocial treatments have more of an effect on depression than mania symptoms. So I think of the two as complementary; they are not substitutes for each other, but a good treatment program ought to be a combination of targeted psychosocial treatments and medication.
TCPR: So psychosocial treatment addresses the “big picture”?
Dr. Miklowitz: Right. The typical psychosocial treatment should be psychoeducational. We should focus on the factors that contributed to the most recent episode—be that manic, depressive, or mixed. We ask what the family or the patient can do to anticipate and hopefully minimize stressors that might trigger symptoms of the disorder. In addition, we should focus on whether a patient has accepted the diagnosis and the necessary pharmacological treatments.
TCPR: I think it is fair to say that ideally most doctors, when doing medication management, offer some psychoeducation about the disorder. But are you talking about something that is more in depth?
Dr. Miklowitz: I would make the distinction between education and psychoeducation. I think most doctors provide education: “You have a disorder; here are the signs and symptoms; the medication I am going to give you will do this or that; here are the side effects that you can expect; and this is the trajectory of improvement.”
But addressing the patients’ affective reactions to that information requires a different level of understanding. We also want to know whether they believe what they’re being told, whether they think it applies to them, and whether they believe that medications provide a route to better health and functioning.
TCPR: Beyond just laying the groundwork, is it important to have this sort of dialogue with the patient at every visit?
Dr. Miklowitz: Yes, as well as making the family a central part of psychoeducation. Family members are often the first to recognize a new manic episode or that the person is getting more depressed. They may also know if a patient is not taking his or her medications regularly. If family members are empowered with information about bipolar illness, they are in a better position to help during crises.
TCPR: Could you tell us more about the importance of involving family members in treatment?
Dr. Miklowitz: There are some major reasons to involve the family. Most patients live with family members. Parents or spouses are often major contributors to whether patients stay on regular daily or nightly routines, fill prescriptions, take medications, or get to their treatment appointments. They may play a key role in whether the patient abuses alcohol or other substances. We have some evidence that highly conflictual families can be a stress factor that contributes to recurrences (Miklowitz DJ, Cur Direct Psychol Sci 2007;16(4):192–196). Research on “expressed emotion” has shown in multiple disorders that if you have a family that is very critical, hostile, and overprotective, you are going to have a tougher time staying out of the hospital and staying relapse-free.
TCPR: Can you define “expressed emotion”?
Dr. Miklowitz: In research, you interview a parent, sibling, or spouse of a patient who has just had an illness episode. In one hour you count how many times they criticize the patient. Do they express hostility about the patient? Do they show any evidence of what we call emotional over-involvement? Along with expressing many criticisms of the patient, it is also common for high expressed emotion family members to be locked into back and forth verbal “negative escalation cycles” with the patient. They have a tough time walking away or calling for a time-out.
TCPR: What are the types of psychosocial treatments that psychiatrists can offer?
Dr. Miklowitz: Ours is called family focused treatment (FFT) and is a nine-month program that involves the family. It involves psychoeducation for the patient and family and communication/problem-solving skills training to reduce conflict and enhance the protective effects of family relationships. There is a program of CBT (cognitive behavioral therapy) for people with bipolar disorder as well. Like the CBT for depression, therapists encourage patients to identify and challenge negative cognitions. There is also “pleasant life event scheduling” for trying to get people reactivated during depression. Another type of psychosocial treatment is interpersonal and social rhythm therapy (IPSRT). The premise of that treatment is that triggers of recurrences often come in the form of changes in routines that lead to changes in sleep cycles. Patients can empower themselves first by regulating their daily routines and keeping a fairly regimented lifestyle and anticipating when certain events are going to throw their system off kilter: a change in the seasons, for example.
TCPR: Can you outline what happens in the nine months of treatment in FFT?
Dr. Miklowitz: There are three stages spread out over 21 sessions. As a patient’s mood episode is resolving, you meet weekly with the patient and family members (parents, spouse, siblings) for 12 weeks. As the treatment progresses and the patient stabilizes, you meet biweekly for another 12 weeks, and then monthly for up to nine months. Stage 1 is focused on psychoeducation. The family talks about what the patient’s most recent episode and symptoms were like, and the patient describes the experiences of mania and depression from his or her perspective. Together, they examine triggers of past episodes and develop a relapse prevention plan. Stage 2 is focused on communication training, where the goal is to reduce family tension. Patients and families learn skills like active listening, conflict negotiation, and how to request changes in other people’s behaviors. This is our more direct attempt to reduce expressed emotion. Finally, stage 3 is focused on problem solving. They are taught how to break big problems down to smaller problems. By that time in treatment the patient is often more stable and able to implement some of these strategies.
TCPR: If the patient experiences an episode or is hospitalized during this process, does the treatment then restart from the beginning?
Dr. Miklowitz: Ideally when there has been a relapse, the patient and family come in as soon as possible and review what happened. Something about the relapse prevention plan didn’t work. We try to put it in context and help the family realize that this is not a failure of the treatment or their efforts. It is just that this is a recurrent disorder and people have to expect that it will recur from time to time, but over time with their efforts there may be fewer of these, or the episodes may be shorter or less severe.
TCPR: Does this approach require special training on the part of the person doing the therapy?
Dr. Miklowitz: We are doing some research now to try to make it easier for practitioners to use this treatment. The current training process starts with a weekend workshop and then practitioners are supervised on two cases. We have written a book for practitioners that they can use as a guide (Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach. Second Edition. New York, NY: Guilford Press; 2008).
TCPR: Is there is an age or a particular phenotype for which family therapy just doesn’t work, or are their clinical presentations where you actually don’t want the family involved?
Dr. Miklowitz: A good predictor of who will respond to FFT is the expressed emotion level of the family. The more conflict, hostility, or overprotectiveness, the more likely the patient is to show a big improvement in family therapy. However, I would not necessarily recommend this treatment for people if there is or has been physical or sexual abuse in the family. Also, sometimes a young person’s issues have to do with drugs, alcohol, or sexuality and they are not comfortable talking about these things with a parent present. A lot of older patients just don’t have families who are still involved in their lives. Probably 40% of adult patients in the community are disconnected from their families, but of course the proportion of young adult or adolescent patients without families is much lower. Sometimes we involve a friend, sibling or a roommate. In one case, we even involved an AA sponsor.
TCPR: Could family therapy or other psychosocial intervention take the place of medications?
Dr. Miklowitz: I don’t think we have the data to answer that question. A group of researchers headed by Holly Swartz and Ellen Frank (University of Pittsburgh) is testing a version of interpersonal therapy as a substitute for medication for bipolar II patients. They have some early findings that suggest that interpersonal therapy and quetiapine have an equivalent shortterm effect on depressive symptoms (Swartz HA et al, Bipolar Disord 2012;14(2):211–216).
TCPR: Are there specific aspects of the disease that make family therapy less promising?
Dr. Miklowitz: Someone who is acutely psychotic is not going to respond to any psychotherapy at that point. But somebody who has had psychosis and is recovering in a family environment is perfectly appropriate for this kind of approach. There are also people who are disconnected from their families because of substance abuse; their families don’t want anything more to do with them and obviously this won’t work for them. In general, bipolar patients with active substance abuse are harder to treat with psychotherapy and often need a more intensive chemical dependency program.
TCPR: Can you tell us what is new in your field and what you see in the future?
Dr. Miklowitz: The things that I am most excited about are studies of kids at risk for bipolar disorder. For example, we are conducting a randomized trial of kids, ages nine to 17, who have parents diagnosed with either bipolar I or II, and who are showing early warning signs of the condition. The participants may have already had a depressive episode or significant mood swings, but they are not yet bipolar. They are being randomized to either FFT or a comparison intervention, and the goal is to find out if we can prevent conversion to the full syndrome and reduce symptom severity. There are also studies on group mindfulness-based cognitive therapy that has been successful with recurrent depression. We are doing a trial with women who are either pregnant or in the postpartum, to teach mindfulness skills for coping with stress. In the long run, we are hoping to find that mindfulness-based treatment strategies are an alternative for women with mood disorders who are pregnant and don’t want to take psychiatric medications. But we have a ways to go before we can show this.
TCPR: Thank you, Dr. Miklowitz.