Episodes of bipolar disorder are strongly associated with family discord, criticism, and conflict. There is increasing evidence that family psychoeducational treatments are effective in relapse prevention and symptom control when combined with standard drug treatment.
Much remains to be learned about the subpopulations of patients most likely to benefit from family interventions. It is not clear, for example, whether only patients with high-EE families should be given FFT, and whether patients who do not report significant family conflicts or who are disengaged from their families would be better suited to individual or group approaches. The mediating mechanisms by which family interventions achieve their effects—which may include enhancing medication adherence, family communication and problem-solving, or the family’s ability to recognize and intervene with early warning signs of recurrence—deserve further examination in randomized trials that measure mediators at systematically controlled intervals.
Longitudinal high-risk studies should clarify which family risk or protective processes operate among children who are genetically at risk for bipolar disorder. Specifically, investigators should identify early childhood temperamental or symptom attributes that bear a resemblance to manic or depressive symptoms (e.g., extreme moodiness or impulsiveness), clarify the circumstances under which these attributes evoke criticism or overprotectiveness among parents, and determine which of these children actually develop bipolar disorder in adulthood. It will be important in such studies to measure the psychiatric background of parents, as well as protective factors (e.g., a supportive secondary parent) that may reduce the likelihood that the child develops the disorder under conditions of high genetic risk.
Two uncontrolled treatment trials found that FFT alone or the combination of FFT and cognitive-behavioral therapy helped stabilize the course of bipolar disorder in adolescent and school-aged children, respectively (Miklowitz, Biuckians, & Richards, 2006
; Pavuluri et al., 2004
). Early preventative interventions involving the family are currently being developed (Miklowitz et al., 2006
). Notably, teaching communication, problem-solving, and emotional self-regulation skills to at-risk children and their parents may help ameliorate stress within the family and contribute to delaying the onset of full manic episodes. Early-intervention studies involving high-risk populations should be a central focus for the next generation of research on bipolar disorder.