This article described a one-year treatment development trial of an adapted version of FFT for youth who were at high risk of developing BD-I or BD-II. The results suggest that FFT-HR is feasible to administer in this population and associated with a high rate of treatment retention (85%). Clinicians at both study sites showed high levels of fidelity to the treatment manual. Moreover, youth who participated in FFT-HR showed significant reductions in depression and hypomania symptoms and improvements in global functioning over one year.
Family psychoeducation may augment individual and family coping skills and protect high-risk youth from family stress or other life stressors that would otherwise contribute to their overall vulnerability to disease onset. Youth with adverse parent-child relationships are vulnerable to more severe depressions when under chronic stress than are youth with healthier parent-child relationships (33
). The skill-training modules of FFT attempt to ameliorate the impact of high-EE attitudes and behaviors in families, including aversive communication between parent and offspring, hostility, low family cohesion and adaptability, and difficulties with conflict resolution (28
). Family psychoeducation has been shown to improve similar dimensions of family behavior among adults with mood disorders (29
Because the primary goals of this study were to determine the feasibility and acceptability of FFT-HR, it was designed as an open trial with no randomized control. Thus, it was not designed to address whether family treatment is necessary to bring about symptom reductions in high-risk youth or whether the passage of time would have accomplished the same result. Relatedly, this study could not determine whether any form of psychosocial intervention, whether or not it involved the family, would have been associated with significant reductions in mood symptoms. Longer-term follow-up (i.e., four years or more) would be necessary to determine whether the addition of FFT-HR to usual care reduces the likelihood of syndromal manic onset, and, in turn, whether improvements in family affect, communication, or problem solving mediate the likelihood or timing of this endpoint.
We also cannot rule out the explanatory effects of medications on the observed symptom outcomes. Although medication regimens were largely stable during the period of study, they were also quite variable, and the sample size precluded examining each medication in relation to symptom severity. For example, a larger sample would have enabled an examination of whether psychostimulants (3/13, or 23% of cases) were associated with the emergence of manic or mixed symptoms among high-risk youth.
Only three studies have examined whether early intervention with mood stabilizers has preventative effects on children at risk for BD. In an open trial, Chang et al. (8
) showed that children with subthreshold mood symptoms and a positive family history of BD improved with divalproex over 12 weeks. DelBello et al. (9
) reached a similar conclusion in an open trial of quetiapine. The single randomized, controlled trial (RCT) comparing divalproex and placebo found that children with BD-NOS or cyclothymia and at least one biological parent with BD-I did not differ on time to medication discontinuation due to a mood event (10
). Thus, evidence for the effectiveness of specific forms of pharmacotherapy in high-risk youth is quite limited. Nonetheless, in future RCTs involving psychosocial interventions, the impact of pharmacotherapy should be examined through implementing medication algorithms administered by psychiatrists who are blind to psychosocial treatment conditions.
We were unable to examine whether FFT-HR was equally effective with youth with different risk subtypes (e.g., MDD versus BD-NOS) or with comorbid disorders that might have affected youths’ responses to the skill-building strategies (for example, attention-deficit hyperactivity disorder). We also were unable to determine whether attributes of the parent (e.g., whether it was the mother or father who had BD, or whether he or she had BD-I or BD-II) were associated with the degree of clinical response or attrition rates.
Fortunately, randomized trials of psychotherapy in BD and MDD youth are beginning to unravel the role of moderators of response. For example, we found in an earlier RCT that adolescents with BD-I or BD-II who were in high-EE families showed a greater magnitude of response to FFT than adolescents in low-EE families (28
). In contrast, in the Treatment for Adolescent Depression Study, adolescents who described their family environments as more negative showed a poorer response to cognitive-behavioral therapy and a better response to fluoxetine (34
). Identifying moderators of response in high-risk populations will be increasingly important as the number of evidence-based treatment options grows (35
Finally, examining the impact of psychosocial interventions on the social and academic functioning and quality of life of high-risk youth—dimensions which are compromised substantially in this population (4
)—should be a key objective of future trials. Preventing or minimizing the toxic and impairing effects of early episodes before they become recurrent may help prevent the long-term functional disability caused by bipolar illness.