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Sharma A, Glod M, Forster T, McGovern R, McGurk K, Barron Millar E, Meyer TD, Miklowitz D, Ryan V, Vale L, Le Couteur A. FAB: First UK feasibility trial of a future randomised controlled trial of Family focused treatment for Adolescents with Bipolar disorder. Int J Bipolar Disord 2020; 8:24. [PMID: 32743735 PMCID: PMC7396411 DOI: 10.1186/s40345-020-00189-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/24/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This first mixed-methods UK trial examined the feasibility and acceptability of a future definitive randomised controlled trial (RCT) to evaluate whether Family Focussed Treatment for Adolescents with Bipolar Disorder (FFT-A) UK version can improve family functioning and well-being as part of the management of Paediatric Bipolar Disorder (PBD). METHOD The trial used a randomised, parallel group, non-blinded design where participants received FFT-A UK (16 sessions over 6 months) immediately or after 12 months (delayed arm). Measures of family functioning, well-being and quality of life of the young person and the main carer (most commonly a parent) were completed at baseline, 6 and 12-months in both arms. Primary outcome measures included rates of eligibility, consent and retention along with estimates of variability in the measures and assessment of the intervention delivery. Qualitative interviews allowed assessment of participants' views about FFT-A and the trial processes. RESULTS Twenty-seven of 36 young persons with PBD and their families consented; of these, 14 families were randomised to the immediate and 13 to the delayed arm. Two families from the immediate arm withdrew consent and discontinued participation. Quantitative measures were completed by 22 families (88%) at 6-months and 21 families (84%) at 12-months. Qualitative interviews were conducted with 30 participants (9 young people, 15 parents and 6 other family members). Nine families attended 3 post-trial focus groups. CONCLUSION It was feasible to recruit and retain to this trial. The results highlighted that trial design and measures were acceptable to participants. A benefit in family relationships was reported by participants which they attributed to the intervention in qualitative interviews. Families recommended that future modifications include definitive trial(s) recruiting participants in the age range 15-25 years as it felt this was the age range with maximum need. Trial registration ISRCTN, ISRCTN59769322. Registered 20 January 2014, http://www.isrctn.com/ISRCTN59769322.
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Affiliation(s)
- A Sharma
- Newcastle University, Newcastle upon Tyne, UK.
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - M Glod
- Newcastle University, Newcastle upon Tyne, UK
| | - T Forster
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - R McGovern
- Newcastle University, Newcastle upon Tyne, UK
| | - K McGurk
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - T D Meyer
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - D Miklowitz
- Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - V Ryan
- Newcastle University, Newcastle upon Tyne, UK
| | - L Vale
- Newcastle University, Newcastle upon Tyne, UK
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Miklowitz DJ, Schneck CD, Walshaw PD, Garrett AS, Singh MK, Sugar CA, Chang KD. Early intervention for youth at high risk for bipolar disorder: A multisite randomized trial of family-focused treatment. Early Interv Psychiatry 2019; 13:208-216. [PMID: 28776930 PMCID: PMC5797511 DOI: 10.1111/eip.12463] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/24/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022]
Abstract
AIMS Despite the considerable public health impact of bipolar disorder (BD), no psychosocial interventions have been systematically evaluated in its early prodromal stages. We describe the rationale, design and analytic methods for a 3-site randomized trial of family-focused treatment for youth at high risk (FFT-HR) for BD. METHODS Participants (ages 9-17 years) have a diagnosis of unspecified BD or major depressive disorder, current mood symptoms and at least one first- or second-degree relative with a lifetime history of BD I or II. Participants are randomly assigned to FFT-HR (12 sessions in 4 months of family psychoeducation and skills training) or enhanced care (EC; 6 individual and family sessions over 4 months), with pharmacotherapy provided as needed. A subset of participants undergo pre- and post-treatment functional MRI (fMRI) scans while performing face-rating and family problem-solving tasks designed to activate corticolimbic circuitry. Independent evaluators assess participants' status every 4 to 6 months for up to 4 years. RESULTS We hypothesize that FFT-HR will be more effective than EC in reducing the severity of mood symptoms (primary outcome) and the hazard of a first manic episode (secondary) over 4 years. Secondarily, we will explore whether FFT-HR is associated with greater decreases in amygdala activation and increases in dorsolateral, ventrolateral or anterior medial prefrontal cortex activation from pre- to post-treatment. Clinical characteristics of 133 subjects enrolled at baseline are described. CONCLUSIONS This study will test a novel intervention to reduce the early symptoms of BD, and identify neural and behavioural mechanisms that may help refine future treatments.
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Affiliation(s)
- David J Miklowitz
- Los Angeles (UCLA) Semel Institute, University of California, Los Angeles, California
| | - Christopher D Schneck
- Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Patricia D Walshaw
- Los Angeles (UCLA) Semel Institute, University of California, Los Angeles, California
| | - Amy S Garrett
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California.,Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas
| | - Manpreet K Singh
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Catherine A Sugar
- Los Angeles (UCLA) Semel Institute, University of California, Los Angeles, California.,Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
| | - Kiki D Chang
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
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Perlick DA, Jackson C, Grier S, Huntington B, Aronson A, Luo X, Miklowitz DJ. Randomized trial comparing caregiver-only family-focused treatment to standard health education on the 6-month outcome of bipolar disorder. Bipolar Disord 2018. [PMID: 29528180 DOI: 10.1111/bdi.12621] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Caregivers of people with bipolar disorder often have depression and health problems. This study aimed to evaluate the sustained effects of a 12-15 week psychoeducational intervention on the health and mental health of caregivers of persons with bipolar disorder. We also evaluated the effects of the intervention on patients' mood symptoms over 6 months post-treatment. METHODS Caregivers of 46 persons with bipolar disorder were randomized to 12-15 weeks of a caregiver-only adaptation of family-focused treatment (FFT), in which caregivers were instructed on self-care strategies and ways to assist the patient in managing the illness, or to 8-12 sessions of standard health education. Independent evaluators assessed caregivers' depression and physical health and patients' mood symptoms before treatment, immediately after the treatment, and at 6 months post-treatment. RESULTS Randomization to FFT was associated with greater decreases in depression for both caregivers and patients over a 6-month follow-up period post-treatment. Reductions in patients' depression scores over 6 months post-treatment were mediated by reductions in caregivers' depression scores (z = -2.74, P < .01). CONCLUSIONS Interventions that are effective in reducing mood symptoms and improving health behavior in caregivers may have important health and mental health benefits for patients with bipolar disorder. Specifically, a treatment focused on caregiver education about bipolar disorder and the need for the caregiver to attend to his/her own health and mental health can benefit patients, even without their direct participation.
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Affiliation(s)
- Deborah A Perlick
- JJ Peters, Department of Veterans Affairs Medical Center and VISN 2, South Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlos Jackson
- JJ Peters, Department of Veterans Affairs Medical Center and VISN 2, South Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Savannah Grier
- JJ Peters, Department of Veterans Affairs Medical Center and VISN 2, South Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brittney Huntington
- JJ Peters, Department of Veterans Affairs Medical Center and VISN 2, South Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew Aronson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiaodong Luo
- JJ Peters, Department of Veterans Affairs Medical Center and VISN 2, South Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J Miklowitz
- Division of Child & Adolescent Psychiatry, UCLA Semel Institute, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Bilderbeck AC, Atkinson LZ, McMahon HC, Voysey M, Simon J, Price J, Rendell J, Hinds C, Geddes JR, Holmes E, Miklowitz DJ, Goodwin GM. Psychoeducation and online mood tracking for patients with bipolar disorder: A randomised controlled trial. J Affect Disord 2016; 205:245-251. [PMID: 27454410 DOI: 10.1016/j.jad.2016.06.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Psychoeducation is an effective adjunct to medications in bipolar disorder (BD). Brief psychoeducational approaches have been shown to improve early identification of relapse. However, the optimal method of delivery of psychoeducation remains uncertain. Here, our objective was to compare a short therapist-facilitated vs. self-directed psychoeducational intervention for BD. METHODS BD outpatients who were receiving medication-based treatment were randomly assigned to 5 psychoeducation sessions administered by a therapist (Facilitated Integrated Mood Management; FIMM; n=60), or self-administered psychoeducation (Manualized Integrated Mood Management; MIMM; n=61). Follow-up was based on patients' weekly responses to an electronic mood monitoring programme over 12 months. RESULTS Over follow-up, there were no group differences in weekly self-rated depression symptoms or relapse/readmission rates. However, knowledge of BD (assessed with the Oxford Bipolar Knowledge questionnaire (OBQ)) was greater in the FIMM than the MIMM group at 3 months. Greater illness knowledge at 3 months was related to a higher proportion of weeks well over 12 months. LIMITATIONS Features of the trial may have reduced the sensitivity to our psychoeducation approach, including that BD participants had been previously engaged in self-monitoring. CONCLUSIONS Improved OBQ score, while accelerated by a short course of therapist-administered psychoeducation (FIMM), was seen after both treatments. It was associated with better outcome assessed as weeks well. When developing and testing a new psychosocial intervention, studies should consider proximal outcomes (e.g., acquired knowledge) and their short-term impact on illness course in bipolar disorder.
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Affiliation(s)
- Amy C Bilderbeck
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Lauren Z Atkinson
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Hannah C McMahon
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Merryn Voysey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Judit Simon
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Jonathan Price
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jennifer Rendell
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Chris Hinds
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - John R Geddes
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Emily Holmes
- University Department of Psychiatry, University of Oxford, Oxford, UK; MRC Cognition and Brain Sciences Unit, Cambridge, UK
| | - David J Miklowitz
- University Department of Psychiatry, University of Oxford, Oxford, UK; Semel Institute, UCLA, Los Angeles, CA, USA
| | - Guy M Goodwin
- University Department of Psychiatry, University of Oxford, Oxford, UK.
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Miklowitz DJ, Chung B. Family-Focused Therapy for Bipolar Disorder: Reflections on 30 Years of Research. FAMILY PROCESS 2016; 55:483-99. [PMID: 27471058 PMCID: PMC5922774 DOI: 10.1111/famp.12237] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.
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Affiliation(s)
- David J Miklowitz
- Department of Psychiatry and Behavioral Sciences, UCLA School of Medicine, Los Angeles, CA.
| | - Bowen Chung
- Department of Psychiatry and Behavioral Sciences, UCLA School of Medicine, Los Angeles, CA
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de Mamani AW, Suro G. The effect of a culturally informed therapy on self-conscious emotions and burden in caregivers of patients with schizophrenia: A randomized clinical trial. Psychotherapy (Chic) 2016; 53:57-67. [PMID: 26654115 PMCID: PMC4775443 DOI: 10.1037/pst0000038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Caring for a family member with schizophrenia often results in high degrees of self-conscious emotions (shame and guilt/self-blame), burden, and other serious mental health consequences. Research suggests that ethnic and cultural factors strongly influence the manner in which family members respond to mental illness. Research further indicates that certain cultural practices and values (spirituality, collectivism) may assist family members in coping with the self-conscious emotions and burden associated with caregiving. With this in mind, the authors have developed a family-focused, culturally informed treatment for schizophrenia (CIT-S). METHOD Using a sample of 113 caregivers of patients with schizophrenia (60% Hispanic, 28.2% Caucasian, 8% African American, and 3.8% other), the authors assessed the ability of CIT-S to reduce self-conscious emotions and caregiver burden above and beyond a 3-session psychoeducation (PSY-ED) control condition. They further examined whether self-conscious emotions mediated the relationship between treatment type and caregiver burden. RESULTS In line with expectations, CIT-S was found to outperform PSY-ED in reducing guilt/self-blame and caregiver burden. Furthermore, consistent with hypotheses, reductions in guilt/self-blame were found to mediate the changes observed between treatment type and caregiver burden. Although caregivers in both treatment groups demonstrated significant posttreatment reductions in shame, CIT-S was not found to outperform PSY-ED in reducing levels of this construct. CONCLUSIONS Results suggest that caregivers of patients with schizophrenia may respond well to a treatment that specifically taps in to their cultural beliefs, values, and behaviors in helping them cope with schizophrenia in a loved one. Study implications and future directions are discussed.
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Affiliation(s)
| | - Giulia Suro
- Department of Psychology, University of Miami
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Neely J, Miklowitz D, Le Couteur A, Ryan V, Vale L, McGovern R, Sharma A. A feasibility study of a Family Focused Treatment for Adolescents with Bipolar Disorder-the FAB study. Pilot Feasibility Stud 2015; 1:43. [PMID: 27965821 PMCID: PMC5153680 DOI: 10.1186/s40814-015-0038-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/17/2015] [Indexed: 12/25/2022] Open
Abstract
Background The aim of this study is to examine the feasibility of a future definitive randomised controlled trial of Family Focused Treatment for Adolescents UK (FFT-A UK) in the management of early-onset bipolar disorder (EOBD) (under 18 years). The FFT-A has been evaluated in the USA to augment the pharmacological treatment of adolescents with bipolar disorder (BD). The FFT-A UK has been condensed to 16 sessions over approximately 6 months to be utilised within the UK National Health Service. Research from the USA suggests that families experience high levels of distress, stress, burden and family disharmony when living with a young person who has BD. The FFT-A UK is a family-based approach designed to increase understanding of BD (psycho-education), improve communication and increase ability to problem-solve. Methods/Design The trial will examine the feasibility of a randomised, parallel group, non-blinded design and the procedures of a subsequent definitive trial. Thirty-three young people with BD and their families will be recruited. Participants will complete measures at baseline, on completion of the 6-month treatment and again after a further 6 months. The self-report measures include the Warwick Edinburgh Mental Well-being Scale, The McMaster Family Assessment Device (FAD), Conflict Behaviour Questionnaire aka ‘Interaction Behaviour Questionnaire’, EuroQuol EQ-5D-3L and EQ-5D-Y. Primary outcomes will be rates of eligibility, recruitment and retention, estimates of the variability in the self-report measures and assessment of the intervention delivery in the study population. Participants’ qualitative views on the measures and intervention will be sought to confirm the acceptability of intervention and study design. The health economics component will establish how cost-effectiveness will be assessed in a future definitive trial. Discussion The study will produce a full trial protocol and amendments to the FFT-A UK to inform a well-designed multi-centre randomised controlled trial (RCT) as an adjunct to pharmacotherapy in the management of EOBD. Trial registration Current Controlled Trials ISRCTN59769322
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Affiliation(s)
- Joanne Neely
- Institute of Neuroscience, Newcastle University, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle Upon Tyne, NE2 4HH UK
| | - David Miklowitz
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute, David Geffen School of Medicine at UCLA, 760 Westwood Plaza Room 58-217, Los Angeles, CA 90024-1759 USA
| | - Ann Le Couteur
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Vicky Ryan
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Ruth McGovern
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Aditya Sharma
- Institute of Neuroscience, Newcastle University, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle Upon Tyne, NE2 4HH UK ; Complex Neurodevelopmental Disorders, Adolescent Bipolar Service, Walkergate Park Hospital, Benfield, Newcastle Upon Tyne, NE6 4QD UK
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Weisman de Mamani A, Weintraub MJ, Gurak K, Maura J. A randomized clinical trial to test the efficacy of a family-focused, culturally informed therapy for schizophrenia. JOURNAL OF FAMILY PSYCHOLOGY : JFP : JOURNAL OF THE DIVISION OF FAMILY PSYCHOLOGY OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION (DIVISION 43) 2014; 28:800-10. [PMID: 25286175 PMCID: PMC6816742 DOI: 10.1037/fam0000021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Research strongly suggests that family interventions can benefit patients with schizophrenia, yet current interventions often fail to consider the cultural context and spiritual practices that may make them more effective and relevant to ethnic minority populations. We have developed a family focused, culturally informed treatment for schizophrenia (CIT-S) patients and their caregivers to address this gap. Sixty-nine families were randomized to either 15 sessions of CIT-S or to a 3-session psychoeducation (PSY-ED) control condition. Forty-six families (66.7%) completed the study. The primary aim was to test whether CIT-S would outperform PSY-ED in reducing posttreatment symptom severity (controlling for baseline symptoms) on the Brief Psychiatric Rating Scale. Secondary analyses were conducted to test whether treatment efficacy would be moderated by ethnicity and whether patient-therapist ethnic match would relate to efficacy and patient satisfaction with treatment. Patients included 40 Hispanic/Latinos, 14 Whites, 11 Blacks, and 4 patients who identified as "other." In line with expectations, results from an ANCOVA indicated that patients assigned to the CIT-S condition had significantly less severe psychiatric symptoms at treatment termination than did patients assigned to the PSY-ED condition. Patient ethnicity and patient-therapist ethnic match (vs. mismatch) did not relate to treatment efficacy or satisfaction with the intervention. Results suggest that schizophrenia may respond to culturally informed psychosocial interventions. The treatment appears to work equally well for Whites and minorities alike. Follow-up research with a matched length control condition is needed. Further investigation is also needed to pinpoint specific mechanisms of change.
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Miklowitz DJ, O’Brien MP, Schlosser DA, Addington J, Candan KA, Marshall C, Domingues I, Walsh BC, Zinberg JL, De Silva SD, Friedman-Yakoobian M, Cannon TD. Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. J Am Acad Child Adolesc Psychiatry 2014; 53:848-58. [PMID: 25062592 PMCID: PMC4112074 DOI: 10.1016/j.jaac.2014.04.020] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 04/11/2014] [Accepted: 05/13/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Longitudinal studies have begun to clarify the phenotypic characteristics of adolescents and young adults at clinical high risk for psychosis. This 8-site randomized trial examined whether a 6-month program of family psychoeducation was effective in reducing the severity of attenuated positive and negative psychotic symptoms and enhancing functioning among individuals at high risk. METHOD Adolescents and young adults (mean age 17.4 ± 4.1 years) with attenuated positive psychotic symptoms, brief and intermittent psychosis, or genetic risk with functional deterioration were randomly assigned to 18 sessions of family-focused therapy for individuals at clinical high risk (FFT-CHR) in 6 months or 3 sessions of family psychoeducation (enhanced care [EC]). FFT-CHR included psychoeducation about early signs of psychosis, stress management, communication training, and problem-solving skills training, whereas EC focused on symptom prevention. Independent evaluators assessed participants at baseline and 6 months on positive and negative symptoms and social-role functioning. RESULTS Of 129 participants, 102 (79.1%) were followed up at 6 months. Participants in FFT-CHR showed greater improvements in attenuated positive symptoms over 6 months than participants in EC (F1,97 = 5.49, p = .02). Negative symptoms improved independently of psychosocial treatments. Changes in psychosocial functioning depended on age: participants more than 19 years of age showed more role improvement in FFT-CHR, whereas participants between 16 and 19 years of age showed more role improvement in EC. The results were independent of concurrent pharmacotherapy. CONCLUSION Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis. Future studies should examine the specificity of effects of family intervention compared to individual therapy of the same duration and frequency. Clinical trial registration information-Prevention Trial of Family Focused Treatment in Youth at Risk for Psychosis; http://clinicaltrials.gov/; NCT01907282.
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Affiliation(s)
- David J. Miklowitz
- University of California, Los Angles (UCLA) School of Medicine, Los Angeles, CA
| | | | | | - Jean Addington
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta
| | | | | | | | | | - Jamie L. Zinberg
- University of California, Los Angles (UCLA) School of Medicine, Los Angeles, CA
| | - Sandra D. De Silva
- University of California, Los Angles (UCLA) School of Medicine, Los Angeles, CA
| | - Michelle Friedman-Yakoobian
- Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
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Miklowitz DJ, Schneck CD, George EL, Taylor DO, Sugar CA, Birmaher B, Kowatch RA, DelBello MP, Axelson DA. Pharmacotherapy and family-focused treatment for adolescents with bipolar I and II disorders: a 2-year randomized trial. Am J Psychiatry 2014; 171:658-67. [PMID: 24626789 PMCID: PMC4083000 DOI: 10.1176/appi.ajp.2014.13081130] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Previous studies have found that family-focused treatment is an effective adjunct to pharmacotherapy in stabilizing symptoms in adult bipolar disorder. The authors examined whether pharmacotherapy and family-focused treatment for adolescents with bipolar disorder was more effective than pharmacotherapy and brief psychoeducation (enhanced care) in decreasing time to recovery from a mood episode, increasing time to recurrence, and reducing symptom severity over 2 years. METHOD A total of 145 adolescents (mean age, 15.6 years) with bipolar I or II disorder and a DSM-IV-TR manic, hypomanic, depressive, or mixed episode in the previous 3 months were randomly assigned, with family members, either to pharmacotherapy and family-focused treatment, consisting of psychoeducation (i.e., recognition and early intervention with prodromal symptoms), communication enhancement training, and problem-solving skills training, delivered in 21 sessions over 9 months; or to pharmacotherapy and three weekly sessions of enhanced care (family psychoeducation). Independent evaluators assessed participants at baseline, every 3 months during year 1, and every 6 months during year 2, using weekly ratings of mood. RESULTS Twenty-two participants (15.2%) withdrew shortly after randomization. Time to recovery or recurrence and proportion of weeks ill did not differ between the two treatment groups. Secondary analyses revealed that participants in family-focused treatment had less severe manic symptoms during year 2 than did those in enhanced care. CONCLUSIONS After an illness episode, intensive psychotherapy combined with best-practice pharmacotherapy does not appear to confer advantages over brief psychotherapy and pharmacotherapy in hastening recovery or delaying recurrence among adolescents with bipolar disorder.
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Early intervention for symptomatic youth at risk for bipolar disorder: a randomized trial of family-focused therapy. J Am Acad Child Adolesc Psychiatry 2013; 52:121-31. [PMID: 23357439 PMCID: PMC3558946 DOI: 10.1016/j.jaac.2012.10.007] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 09/01/2012] [Accepted: 10/12/2012] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Depression and brief periods of (hypo)mania are linked to an increased risk of progression to bipolar I or II disorder (BD) in children of bipolar parents. This randomized trial examined the effects of a 4-month family-focused therapy (FFT) program on the 1-year course of mood symptoms in youth at high familial risk for BD, and explored its comparative benefits among youth in families with high versus low expressed emotion (EE). METHOD Participants were 40 youth (mean 12.3±2.8 years, range 9-17) with BD not otherwise specified, major depressive disorder, or cyclothymic disorder who had a first-degree relative with BD I or II and active mood symptoms (Young Mania Rating Scale [YMRS]>11 or Child Depression Rating Scale>29). Participants were randomly allocated to FFT-High Risk version (FFT-HR; 12 sessions of psychoeducation and training in communication and problem-solving skills) or an education control (EC; 1-2 family sessions). RESULTS Youth in FFT-HR had more rapid recovery from their initial mood symptoms (hazard ratio = 2.69, p = .047), more weeks in remission, and a more favorable trajectory of YMRS scores over 1 year than youth in EC. The magnitude of treatment effect was greater among youth in high-EE (versus low-EE) families. CONCLUSIONS FFT-HR may hasten and help sustain recovery from mood symptoms among youth at high risk for BD. Longer follow-up will be necessary to determine whether early family intervention has downstream effects that contribute to the delay or prevention of full manic episodes in vulnerable youth.
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Miklowitz DJ, Price J, Holmes EA, Rendell J, Bell S, Budge K, Christensen J, Wallace J, Simon J, Armstrong NM, McPeake L, Goodwin GM, Geddes JR. Facilitated Integrated Mood Management for adults with bipolar disorder. Bipolar Disord 2012; 14:185-97. [PMID: 22420594 PMCID: PMC3412076 DOI: 10.1111/j.1399-5618.2012.00998.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We describe the development of a five-session psychoeducational treatment, Facilitated Integrated Mood Management (FIMM), which contains many of the core elements of longer evidence-based psychosocial treatments for bipolar disorder. FIMM incorporated a novel mood monitoring program based on mobile phone technology. METHODS Adult patients with bipolar I and II disorders (N = 19) received six sessions (Pilot I: n = 14) or five sessions (Pilot II: n = 5) of FIMM with pharmacotherapy. Treatment facilitators were novice counselors who were trained in a three-day workshop and supervised for six months. FIMM sessions focused on identifying early signs of recurrence, maintaining regular daily and nightly routines, rehearsing mood management strategies, maintaining adherence to medications, and education about substance abuse. Patients sent daily text messages or e-mails containing ratings of their mood and sleep, and weekly messages containing self-ratings on the Quick Inventory of Depressive Symptomatology (QIDS) and the Altman Self Rating Mania Scale (ASRM). Patients also completed a weekly mood management strategies questionnaire. RESULTS Of the 19 patients, 17 (89.5%) completed FIMM in an average of 9.2 ± 3.4 weeks (Pilot I) and 7.6 ± 0.9 weeks (Pilot II). Patients reported stable moods on the QIDS and ASRM over a 120-day period, and on average responded to 81% of the daily message prompts and 88% of the weekly QIDS and ASRM prompts. Facilitators maintained high levels of fidelity to the FIMM manual. Patients' knowledge of mood management strategies increased significantly between the first and last weeks of treatment. CONCLUSIONS Patients with bipolar disorder can be engaged in a short program of facilitated mood management. The effects of FIMM on the course of bipolar disorder await evaluation in randomized trials. The program may be a useful adjunct to pharmacotherapy in community centers that cannot routinely administer full courses of psychosocial treatment.
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Affiliation(s)
- David J Miklowitz
- Department of Psychiatry, University of California at Los Angeles (UCLA) Semel Institute, UCLA School of Medicine, Los Angeles, CA, USA,Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Jonathan Price
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Emily A Holmes
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Jennifer Rendell
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Sarah Bell
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Katie Budge
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Jean Christensen
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Joshua Wallace
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Judit Simon
- Department of Public Health, University of Oxford, Oxford, UK
| | - Neil M Armstrong
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Lily McPeake
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - Guy M Goodwin
- Department of Psychiatry, Warneford Hospital, University of Oxford
| | - John R Geddes
- Department of Psychiatry, Warneford Hospital, University of Oxford
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Kazantzis N. Therapist Competence in Cognitive-behavioural Therapies: Review of the Contemporary Empirical Evidence. BEHAVIOUR CHANGE 2012. [DOI: 10.1375/bech.20.1.1.24845] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractTherapist competence refers to the extent that a given treatment is conducted in accordance with the instructions or intentions of the respective treatment manual. Despite this relatively straightforward notion, existing research on cognitive-behavioural therapy (CBT) processes have been unsuccessful in defining and measuring this construct. This article reviews the contemporary empirical research on therapist competence in CBT, outlines the development and psychometric evaluation of the commonly used measures of therapist adherence, and discusses how competence has been linked to treatment outcomes. The psychometric evidence for existing measures is mixed, and in particular, there has been difficulty in the demonstration of adequate interrater reliability, even among identified experts in the field. New measures of therapist competence hold promise — most notably, in the separation of therapist adherence and competence constructs. The assessment of therapist adherence, therapist competence, and the role of supervisor ratings in the clinical context are also discussed.
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Perlick DA, Miklowitz DJ, Lopez N, Chou J, Kalvin C, Adzhiashvili V, Aronson A. Family-focused treatment for caregivers of patients with bipolar disorder. Bipolar Disord 2010; 12:627-37. [PMID: 20868461 PMCID: PMC2947337 DOI: 10.1111/j.1399-5618.2010.00852.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Family members of patients with bipolar disorder experience high rates of subjective and objective burden which place them at risk for adverse physical health and mental health outcomes. We present preliminary efficacy data from a novel variation of Family Focused Treatment [Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach (2(nd) ed.). New York: The Guilford Press, 2008] that aimed to reduce symptoms of bipolar disorder by working with caregivers to enhance illness management skills and self-care. METHODS The primary family caregivers of 46 patients with bipolar I (n = 40) or II (n = 6) disorder, diagnosed by the Structured Clinical Interview for DSM-IV Axis I Disorders, were assigned randomly to receive either: (i) a 12-15-session family-focused, cognitive-behavioral intervention designed to provide the caregiver with skills for managing the relative's illness, attaining self-care goals, and reducing strain, depression, and health risk behavior [Family-Focused Treatment-Health Promoting Intervention (FFT-HPI)]; or (ii) an 8- to 12-session health education (HE) intervention delivered via videotapes. We assessed patients pre- and post-treatment on levels of depression and mania and caregivers on levels of burden, health behavior, and coping. RESULTS Randomization to FFT-HPI was associated with significant decreases in caregiver depressive symptoms and health risk behavior. Greater reductions in depressive symptoms among patients were also observed in the FFT-HPI group. Reduction in patients' depression was partially mediated by reductions in caregivers' depression levels. Decreases in caregivers' depression were partially mediated by reductions in caregivers' levels of avoidance coping. CONCLUSIONS Families coping with bipolar disorder may benefit from family interventions as a result of changes in the caregivers' ability to manage stress and regulate their moods, even when the patient is not available for treatment.
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Affiliation(s)
- Deborah A Perlick
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY 10029, USA.
| | - David J Miklowitz
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Norma Lopez
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY
| | - James Chou
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY
| | - Carla Kalvin
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY
| | | | - Andrew Aronson
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY
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15
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Eisner LR, Johnson SL. An acceptance-based psychoeducation intervention to reduce expressed emotion in relatives of bipolar patients. Behav Ther 2008; 39:375-85. [PMID: 19027434 PMCID: PMC2847480 DOI: 10.1016/j.beth.2007.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 10/29/2007] [Accepted: 11/01/2007] [Indexed: 01/29/2023]
Abstract
Expressed emotion (EE) is a robust predictor of outcome in bipolar disorder. Despite decades of research, interventions to reduce EE levels have had only modest effects. This study used an expanded model of EE to develop an intervention. Research has demonstrated a strong link between attributions and EE in families of patients with psychiatric disorders. There is also substantial research to suggest that anger can drive blaming attributions. Combining these ideas, this study built on previous psychoeducation interventions through the addition of an acceptance component designed to decrease anger and blaming attributions among family members of those with bipolar disorder. Twenty-eight family members attended a 1-day or 2-evening multifamily group workshop and completed a follow-up assessment 1 week later. At follow-up, participants demonstrated more knowledge about bipolar disorder. Anger, blaming attributions, and number of criticisms remained unchanged. Results of this study are consistent with others in that it is difficult to change EE. Implications for future clinical research in this area are addressed.
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Affiliation(s)
- Lori R Eisner
- Department of Psychology, University of Miami, Coral Gables, FL 33124-2070, USA.
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16
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Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, Beresford CA, Dickinson LM, Craighead WE, Brent DA. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. ACTA ACUST UNITED AC 2008; 65:1053-61. [PMID: 18762591 DOI: 10.1001/archpsyc.65.9.1053] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Family interventions have been found to hasten episode recovery and delay recurrences among adults with bipolar disorder. OBJECTIVE To examine the benefits of family-focused treatment for adolescents (FFT-A) and pharmacotherapy in the 2-year course of adolescent bipolar disorder. DESIGN Two-site outpatient randomized controlled trial with 2-year follow-up. PATIENTS A referred sample of 58 adolescents (mean [SD] age, 14.5 [1.6] years) with bipolar I (n = 38), II (n = 6), or not otherwise specified disorder (n = 14) with a mood episode in the prior 3 months. INTERVENTIONS Patients were randomly assigned to FFT-A and protocol pharmacotherapy (n = 30) or enhanced care (EC) and protocol pharmacotherapy (n = 28). The FFT-A consisted of 21 sessions in 9 months of psychoeducation, communication training, and problem-solving skills training. The EC consisted of 3 family sessions focused on relapse prevention. MAIN OUTCOME MEASURES Independent "blind" evaluators assessed patients every 3 to 6 months for 2 years. Outcomes included time to recovery from the index episode, time to recurrence, weeks in episode or remission, and mood symptom severity scores. RESULTS Analyses were by intent to treat. Rates of 2-year study completion did not differ across the FFT-A (60.0%) and EC conditions (64.3%). Although there were no group differences in rates of recovery from the index episode, patients in FFT-A recovered from their baseline depressive symptoms faster than patients in EC (hazard ratio, 1.85; 95% confidence interval, 1.04-3.29; P = .04). The groups did not differ in time to recurrence of depression or mania, but patients in FFT-A spent fewer weeks in depressive episodes and had a more favorable trajectory of depression symptoms for 2 years. CONCLUSIONS Family-focused therapy is effective in combination with pharmacotherapy in stabilizing bipolar depressive symptoms among adolescents. To establish full recovery, FFT-A may need to be supplemented with systematic care interventions effective for mania symptoms.
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Affiliation(s)
- David J Miklowitz
- Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
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17
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Scott J, Colom F. Gaps and limitations of psychological interventions for bipolar disorders. PSYCHOTHERAPY AND PSYCHOSOMATICS 2008; 77:4-11. [PMID: 18087202 DOI: 10.1159/000110054] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To highlight gaps or limitations in applying evidence-based psychological therapies as an adjunct to medication in the management of bipolar disorders. METHOD General and specific gaps in knowledge or perceived limitations were determined by the authors and published examples were identified illustrating these potential barriers to the use or application of adjunctive therapies. RESULTS Research on the benefits of psychological therapies in bipolar disorders has progressed dramatically in the last decade. There are some uncertainties that need to be further investigated. These can be broadly classified as: for whom should therapy be provided, what therapy and when should therapy be commenced. The latter can be seen from the perspective of both current mental state as well as length of history and number of recurrences. Other issues frequently highlighted by researchers in the field relate to mediators and moderators of therapy effects. CONCLUSION Gaps in our knowledge about therapy for bipolar disorder mirror those that exist whenever new treatments, including medications, are introduced into routine clinical practice. Many of these key questions relate to differences between efficacy and effectiveness of adjunctive therapies, the long-term durability of any benefits and mechanisms by which therapies achieve their effects. These can be explored using currently existing scientific paradigms.
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Affiliation(s)
- Jan Scott
- University Department of Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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18
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Abstract
BACKGROUND Pharmacological treatments are the principal intervention for bipolar disorder. Alone, however, they are not sufficient to control symptoms and maintain psychosocial functioning. Adjunctive psychosocial interventions may help to improve the patient's condition and the course of the illness. Family interventions are deserving of special attention, since they may help to relieve the burden of care borne by relatives and caregivers, which in turn may facilitate the task of supporting the patient. OBJECTIVES The objective of this review was to investigate the effectiveness of family interventions in the treatment of bipolar disorder compared with no intervention and other forms of intervention. SEARCH STRATEGY We searched the electronic databases CCDANRCT-Studies and CCDANCTR-References on 1/8/2007, CENTRAL (2006-3), MEDLINE (2006), EMBASE (2006) and LILACS (2006), and searched the reference lists of included studies. We also made personal contact with authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised trials. Participants were people with bipolar disorder and their relatives or caregivers; family psychosocial interventions of any type were considered; primary outcomes were changes in the status of symptoms and relapse rates. DATA COLLECTION AND ANALYSIS Data were independently extracted by two review authors. Quality assessment of included studies was carried out. The findings were presented descriptively. Where there were sufficient studies, dichotomous data were combined using relative risk, and continuous data were combined using weighted mean difference, with their 95% CIs. MAIN RESULTS Seven RCTs were included in the review, involving a total of 393 participants. All of the included studies assessed psychoeducational methods, and one study also assessed a type of systems psychotherapy. In all trials, participants continued to receive pharmacotherapy treatment. Due to the diversity of interventions, outcome measures and endpoints used across studies, it was not possible to perform meta-analyses for primary outcomes. Five studies compared a variety of family interventions, involving carers, families or spouses, against no intervention, with individual findings indicating no significant added effect for family interventions. Three studies compared one type or modality of family intervention against another family intervention, with inconsistent findings. AUTHORS' CONCLUSIONS To date there is only a small and heterogeneous body of evidence on the effectiveness of family oriented approaches for bipolar disorder, and it is not yet possible to draw any definite conclusions to support their use as an adjunctive treatment for bipolar disorder. Further well designed RCTs should be a research priority.
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Affiliation(s)
- L P Justo
- Universidade Federal de Sao Paulo, Departmento de Psicobiologia, Rua Napoleao de Barros 925, Vila Clementino, Sao Paulo, Brazil, CEP 04024002.
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19
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Clinician Integrity in Multiple Family Groups: Psychometric Properties and Relationship with Schizophrenia Client and Caregiver Outcomes. COGNITIVE THERAPY AND RESEARCH 2007. [DOI: 10.1007/s10608-006-9098-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Miklowitz DJ, George EL, Axelson DA, Kim EY, Birmaher B, Schneck C, Beresford C, Craighead WE, Brent DA. Family-focused treatment for adolescents with bipolar disorder. J Affect Disord 2004; 82 Suppl 1:S113-28. [PMID: 15571785 PMCID: PMC2754177 DOI: 10.1016/j.jad.2004.05.020] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2004] [Accepted: 05/17/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Research has begun to elucidate the optimal pharmacological treatments for pediatric-onset bipolar patients, but few studies have examined the role of psychosocial interventions as adjuncts to pharmacotherapy in maintenance treatment. This article describes an adjunctive family-focused psychoeducational treatment for bipolar adolescents (FFT-A). The adult version of FFT has been shown to be effective in forestalling relapses in two randomized clinical trials involving bipolar adults. METHODS FFT-A is administered to adolescents who have had an exacerbation of manic, depressed, or mixed symptoms within the last 3 months. It is given in 21 outpatient sessions of psychoeducation, communication enhancement training, and problem solving skills training. We describe modifications to the adult FFT model to address the developmental issues and unique clinical presentations of pediatric-onset patients. RESULTS An open treatment trial involving 20 bipolar adolescents (11 boys, 9 girls; mean age 14.8+/-1.6) found that the combination of FFT-A and mood stabilizing medications was associated with improvements in depression symptoms, mania symptoms, and behavior problems over 1 year. LIMITATIONS These early results are based on a small-scale open trial. CONCLUSIONS Results from an ongoing randomized controlled trial will clarify whether combining FFT-A with pharmacotherapy improves the 2-year course of adolescent bipolar disorder. If the results are positive, then a structured manual-based psychosocial approach will be available for clinicians who treat adolescent bipolar patients in the community.
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Affiliation(s)
- David J Miklowitz
- Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
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21
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Chan EKH, O'Neill I, McKenzie M, Love A, Kissane DW. What works for therapists conducting family meetings: treatment integrity in family-focused grief therapy during palliative care and bereavement. J Pain Symptom Manage 2004; 27:502-12. [PMID: 15165648 DOI: 10.1016/j.jpainsymman.2003.10.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2003] [Indexed: 11/19/2022]
Abstract
The purpose of this study was to evaluate the treatment integrity of Family-Focused Grief Therapy (FFGT), a preventive intervention designed for families at high risk of poor functioning during palliative care and bereavement. From the 81 families participating in a randomized controlled trial (53 assigned to therapy), 28 were randomly selected for this study of treatment fidelity using the FFGT integrity measure. A total of 109 family sessions were appraised. This represented a review of 62% of treated families, 38% of total therapy sessions, and 87% of the 15 participating therapists. Weighted mean percentage occurrences of therapist behaviors permitted trends in therapy application to be observed. Inter-rater reliability using the FFGT integrity measure was satisfactory, with 88% overall agreement. Eighty-six percent of therapists adhered faithfully to core elements of the model. Therapist competence was evidenced by a strong therapeutic alliance (94%), affirmation of family strengths in over 90%, and focus on agreed themes in 76% of sessions. Therapists averaged 10 grief-related questions per session, 7 on communication-related issues during assessment, 7 on conflict late in therapy, and 4 on cohesiveness across the course of therapy. Consistent application of FFGT, with attention to its four key themes of family communication, cohesiveness, conflict resolution, and shared grief has been demonstrated. The model is generalizable when applied by family therapists.
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Affiliation(s)
- Eunice K H Chan
- Center for Palliative Care, Department of Medicine, St. Vincent's Hospital, and Department of Psychiatry, University of Melbourne, Victoria, Australia
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22
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Abstract
With the emergence of manualized treatments in the 1980s, research protocols have focused increasing attention on documenting the integrity of treatment delivery. Two constructs have guided the conceptualization of assessing treatment integrity. The first, adherence, concerns the extent to which therapists adhere to the interventions of a therapy being tested, and measuring which particular interventions are performed. The second, competence, concerns the quality or skill in therapists’ execution of the therapy being tested. This article reviews the development of treatment integrity research for cognitive therapy in depression, and discusses salient issues that have arisen in its assessment. Recommendations for further refining the considerations of adherence and competence in the delivery of cognitive therapy are provided.
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23
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Rea MM, Tompson MC, Miklowitz DJ, Goldstein MJ, Hwang S, Mintz J. Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. J Consult Clin Psychol 2003; 71:482-92. [PMID: 12795572 DOI: 10.1037/0022-006x.71.3.482] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recently hospitalized bipolar, manic patients (N = 53) were randomly assigned to a 9-month, manual-based, family-focused psychoeducational therapy (n = 28) or to an individually focused patient treatment (n = 25). All patients received concurrent treatment with mood-stabilizing medications. Structured follow-up assessments were conducted at 3-month intervals for a 1-year period ofactive treatment and a 1-year period of posttreatment follow-up. Compared with patients in individual therapy, those in family-focused treatment were less likely to be rehospitalized during the 2-year study period. Patients in family treatment also experienced fewer mood disorder relapses over the 2 years, although they did not differ from patients in individual treatment in their likelihood of a first relapse. Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder.
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Affiliation(s)
- Margaret M Rea
- Department of Psychiatry, University of California, Los Angeles, USA
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24
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Schoenwald SK, Halliday-Boykins CA, Henggeler SW. Client-level predictors of adherence to MST in community service settings. FAMILY PROCESS 2003; 42:345-359. [PMID: 14606199 DOI: 10.1111/j.1545-5300.2003.00345.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This study examined the association of youth and family characteristics with therapist fidelity to an evidence-based treatment provided in real world practice settings. Participants were 233 families that reported on the 66 therapists organized into 16 teams in nine organizations providing multisystemic therapy (MST). Therapist adherence ratings were lower for youths referred for both criminal offenses and substance abuse than for youths referred either for substance abuse or status offenses, and was negatively associated with pretreatment arrests and school suspensions. Adherence ratings were positively associated with educational disadvantage and caregiver-therapist ethnic match and marginally positively associated with economic disadvantage. The findings suggest directions for future research on the implementation of evidence-based treatments in community settings.
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Affiliation(s)
- Sonja K Schoenwald
- Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street-Suite CPP, P.O. Box 250861, Charleston, SC 29425, USA
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Denton WH, Walsh SR, Daniel SS. Evidence-based practice in family therapy: adolescent depression as an example. JOURNAL OF MARITAL AND FAMILY THERAPY 2002; 28:39-45. [PMID: 11813364 DOI: 10.1111/j.1752-0606.2002.tb01170.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- Wayne H Denton
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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26
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Weisman A, Tompson MC, Okazaki S, Gregory J, Goldstein MJ, Rea M, Miklowitz DJ. Clinicians' fidelity to a manual-based family treatment as a predictor of the one-year course of bipolar disorder. FAMILY PROCESS 2002; 41:123-131. [PMID: 11924080 DOI: 10.1111/j.1545-5300.2002.40102000123.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This study assessed whether therapist adherence to the family focused treatment model for patients with bipolar disorder and their relatives was associated with patient outcomes at one year after treatment entry. A total of 78 videotaped sessions of FFT consisting of 26 families with a member with bipolar disorder (3 sessions/family) were rated on fidelity using the Therapist Competence/Adherence Scale (TCAS; see Endnote 1, p. 130). Patients' outcomes (relapse status) were assessed using the Brief Psychiatric Rating Scale (BPRS) and selected items from the Schedule of Affective Disorders and the Schizophrenia-Change (SADS-C) scale (measured at 3-month intervals for 12 months). Contrary to expectations, therapist fidelity was not related to overall outcome as assessed by the BPRS and the SADS-C. Among patients who did relapse, higher levels of cooperation among therapists predicted a later date for relapse than did lower levels of cooperation. Surprisingly, and in opposition to the study's hypotheses, patients who were hospitalized because of relapses had therapists who were rated as more competent in their ability to conduct the problem-solving module of FFT. Study implications are discussed.
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Affiliation(s)
- Amy Weisman
- Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124-2070, USA.
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Miklowitz DJ, Simoneau TL, George EL, Richards JA, Kalbag A, Sachs-Ericsson N, Suddath R. Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy. Biol Psychiatry 2000; 48:582-92. [PMID: 11018229 DOI: 10.1016/s0006-3223(00)00931-8] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder. This study used a randomized, controlled design to examine a 9-month, manual-based program of family-focused psychoeducational treatment (FFT). METHODS Bipolar patients (N = 101) were recruited shortly after an illness episode and randomly assigned to 21 sessions of FFT (n = 31) or to a comparison treatment involving two family education sessions and follow-up crisis management (CM; n = 70). Both treatments were delivered over 9 months; patients were simultaneously maintained on mood stabilizing medications. Patients were evaluated every 3 months for 1 year as to relapse status, symptom severity, and medication compliance. RESULTS Patients assigned to FFT had fewer relapses and longer delays before relapses during the study year than did patients in CM. Patients in FFT also showed greater improvements in depressive (but not manic) symptoms. The most dramatic improvements were among FFT patients whose families were high in expressed emotion. The efficacy of FFT could not be explained by differences among patients in medication regimes or compliance. CONCLUSIONS Family-focused psychoeducational treatment appears to be an efficacious adjunct to pharmacotherapy for bipolar disorder. Future studies should evaluate family treatment against other forms of psychotherapy matched in amount of therapist-patient contact.
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Affiliation(s)
- D J Miklowitz
- Department of Psychology, University of Colorado, Boulder 80309-0345, USA
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28
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Tompson MC, Rea MM, Goldstein MJ, Miklowitz DJ, Weisman AG. Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes. FAMILY PROCESS 2000; 39:105-120. [PMID: 10742934 DOI: 10.1111/j.1545-5300.2000.39110.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.
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Affiliation(s)
- M C Tompson
- Department of Psychology, Boston University, MA 02215-2407, USA.
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