For the context of this current series, Psychiatry and Mental Healthiness, please read my previous post Healthcare and the Human Experience.

What if I told you that research has demonstrated that an add-on treatment for Bipolar Disorder could make at least a 500% improvement in long term outcomes (fewer mood episodes, fewer hospitalizations)? This is absolutely true, but this “treatment” is not a medication.

In 2003, the second year of my Psychiatry residency at UCLA, one of my attendings was giving us a lecture on his specific area of expertise, Bipolar Disorder. This particular talk still stays with me to this day and was probably one of the early seeds planted regarding my present health-oriented focus. He was reviewing a recent study published out of McLean-Harvard (Tohen et al, Am J Psychiatry, 2003) regarding the long term follow up (2 to 4 years) of people with Bipolar Disorder after their first hospitalization with a manic episode. What was memorable to me about this particular study was that rather than answering a question, which is the usual expectation from published scientific research, for me the results created a new question – one that to this day has no clear answer but is still important to understand. This study showed that even though almost all patients had complete symptom resolution of their mania after hospitalization (98%), only 43% achieved functional recovery in the years that followed. In other words, more than half continued to have ongoing impairment in their everyday life. Part of this was explained because some remained symptomatic to some degree, but the curious part was that a large group, roughly a third, remained symptom-free during the follow up period, but were not able to to regain their previous level of functioning. No longer symptomatic, but somehow still chronically impaired. So this mystery, the new question that came out of these results is why? If the symptoms were gone, what would be keeping these people from getting back to their previous baseline level of functioning, years after their last mood episode? Other research has since made strong links between subsequent mood episodes (mania and depression) and its impact upon cognition as a cause of long term impairment in Bipolar Disorder. Researchers have also described the chronic impact of mild and intermittent symptoms on psychological and social impairment. However, in this study that research doesn’t apply, because this third had one and only one episode of mania and full symptom resolution. And yet they remained disabled in the years that followed.

A few years ago, I was reminded of this study while I was attending UCLA’s Psychiatry & Psychopharmacology Annual Review. The lunchtime presenter’s talk also focused on Bipolar Disorder long-term outcomes. Part of the presentation discussed the role of families and how they impact the individual’s prognosis. The part I remember most from this talk was a head to head study comparing crisis management intervention vs. what the researchers called Family-Focused Therapy (Miklowitz et al, Arch Gen Psychiatry. 2003). The results of this study had also been replicated at UCLA. Family-Focused Therapy (FFT) is a long term family therapy that focuses on skills training, healthy communication, and collaboration within the family. The results showed that for real world meaningful outcomes, FFT was superior to crisis management intervention. Fewer hospitalizations. Longer periods between mood episodes. Fewer symptoms. More likely to stay on medication. Based on the specific goals of FFT, the reasons these clinical outcomes improved were that these families had improved communication and were more collaborative in problem solving. They were less judgmental and critical, showed more warmth and positive regard. They were more able to separate problems that were unrelated to psychiatric illness, and were able to take focus away from the identified “patient.” Also, everybody – patients and family members, grew in their sense of self-efficacy and competency to handle stress and crisis. In other words, the family learned how to treat the “patient” as a person, and the family as a whole was more connected and positive towards each other.

Related to these Family-Focused Therapy studies, is the body of research studying what is called Expressed Emotion (EE), a measure of the emotional attitudes of caregivers or relatives toward a family member with a psychiatric disorder. In fact, FFT was developed to address what has been learned regarding the negative impacts found from EE research. For example, “high-EE” is associated with poorer outcomes for Schizophrenia, Bipolar Disorder, clinical depression, alcoholism, eating disorders, social anxiety, and dementia. What is high-EE? Based on a structured interview with family members in discussing their interactions with the identified “patient,” they are considered to have “high-EE” if they express a high number of critical comments, make at least one statement of hostility, or show emotional overinvolvement, such as being overprotective, exaggerating their own emotional responses, or have what is described as “inordinate self-sacrifice.”

How much can high-EE in families affect a person’s lifetime illness? A lot. It has been strongly correlated to the number of recurrences of psychosis in Schizophrenia. It has an even stronger predictive value regarding the number of manic episodes or depressions a person has with Bipolar Disorder. In regards to relapse rates or hospitalizations, studies have shown that this risk is five to nine times (not percentage points) greater compared to “low-EE” families. What is low-EE? Instead of expressing criticism, hostility, and overinvolvement, family members express positive regard and warmth. So, if there are two families, each with one member with the diagnosis of Bipolar Disorder and they were both receiving the same Psychiatric care, a critical home environment alone could make it at least five times more likely that someone would have another manic or depressive episode or get hospitalized.

Is it possible that these unhealthy home environments could explain the inability for the patients in the McLean-Harvard study to get back to where they were before they were hospitalized, even if the negative outcomes weren’t as bad as relapse or rehospitalization? This is my belief, supported by the research above and my own experience in practice. In fact, as much as is possible, I try and make family therapy an integrated part of treatment for younger patients in my practice. It makes sense that a healthy support system is extremely important not only for recovery, but also for stability, acceptance and personal growth, as you would find in low-EE homes. High-EE homes reinforce the “sick” role, cause shame, causes people to feel like a burden, and undermine stability and autonomy. These pressures likely cause a mindset of disability, even in those that are otherwise fully recovered.

I mentioned that the negative effects of high-Expressed Emotion are not limited to Bipolar Disorder, so you could see how Family Focused Therapy interventions could also improve the long term outcome for Schizophrenia, depression, eating disorders, and alcoholism as well. In relationship to mental healthiness, it makes sense that an intervention that reinforces a strong self-identity, self-efficacy, and personal growth despite illness, and one that reinforces positive relationships would also lead to health and wellbeing.

So in similar fashion to my prescription for Schizophrenia, here’s my prescription for the best treatment for Bipolar Disorder: 1) the most effective and least restrictive medication to prevent future mood episodes, 2) developing a positive, warm and supportive, non-judmental social support system, 3) reinforcing a self-identity that maintains one’s individuality and potential despite their diagnosis.

In the next entry in this series, we’ll talk about how clinical depression can be “treated” by interpersonal skill development and changing beliefs regarding self-efficacy – with outcomes equal to taking antidepressants in the short-term, and superior to medication for the long-term.

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