Kevin was doing very well in law school, until he showed up at his professor’s house in the middle of the night. Normally a thoughtful, quiet, introverted young man, Kevin was hardly recognizable to his professor, who found him outside yelling loudly and demanding to speak about an underground conspiracy he believed he had uncovered. He had always been a good student, and his family was very proud of his accomplishments up until now. At the age of 24, Kevin’s first manic episode was triggered by late nights studying for his law school exams and marijuana use to cope with stress.
Police responded to noise complaints, and Kevin was hospitalized. The manic episode resolved surprisingly quickly in the absence of marijuana use and with the help of an atypical antipsychotic. The patient’s intelligence and articulate lawyer-in-training charm made his inpatient doctors hard pressed to justify an extended hospital stay, and he was discharged 3 days later with a prescription and instructions for follow-up. He promptly discarded both.
When his next manic episode arose, Kevin disappeared for 2 weeks, and after fearing the worst, Kevin’s family was relieved to receive a call from Kevin’s aunt, who lived across the country and had just found him at her doorstep. This time, without the involvement of law enforcement, there seemed to be no way for Kevin’s mother, father, older sister, and aunt to persuade Kevin to enter the hospital or to take medications. Kevin’s aunt accompanied him on a plane home, and in the face of Kevin’s unwillingness to enter treatment alone, they decided to enter treatment as a family.
Predictors of episodes
Dr. Alison M. Heru
The strongest predictors of future episodes and poor outcome in patients with bipolar disorder are a greater number of previous episodes, shorter intervals between episodes, a history of psychosis, a history of anxiety, persistence of affective symptoms and episodes, and stressful life events. Some evidence has suggested that poor job functioning, lack of social support, increased expressed emotion in the family, and introverted or obsessional personality traits all might predict poor outcome in bipolar disorder (J. Psychiatr. Pract. 2006;12:269-82).
An overwhelmingly emotional home environment can make a large contribution to relapse. Multiple studies have shown that a high level of "expressed emotion" (characterized by overinvolvement and excessive criticism) predicts patient relapse independent of medication compliance, baseline symptoms, and demographics (Arch. Gen. Psychiatry 1988;45:225-31)
Because bipolar disorder is an unpredictable, potentially destructive illness, it is important to grab any factors that we and our patients might have control over and do our best to modify them positively. With this in mind, the Family Focused Treatment (FFT) model was developed, with the philosophy that by keeping patients well informed about the facts and realities of the disorder and working on the communication and coping mechanisms operating within the family, relapse prevention and emotional stability will be better maintained. In this way, the predictive factors of stressful life events, poor social support, and family-expressed emotion can be modified. FFT is a time limited (usually 12 sessions), highly effective treatment modality.
The principles of FFT were adapted into an ongoing-treatment model that can be implemented in a community setting, termed Family Inclusive Treatment (FIT) and used by the Family Center for Bipolar in New York City, for example. FIT consists of an engagement period at the initiation of treatment, focused on psychoeducation and relapse prevention planning. FIT is unique in that every patient is required to sign a release of information giving permission for full, open communication at all times between the patient’s clinician and a treatment partner of their choosing.
After the initial engagement period, there are quarterly family visits to supplement regular individual treatment. Other modalities such as individual therapy, pharmacotherapy, and group therapy are used according to the clinician’s judgment.
This form of treatment is innovative in that it treats bipolar illness just like any other chronic illness. It promotes open communication between families of patients with bipolar disorder and the patients themselves with regard to symptoms and medications. In this way patients are not isolated from their families; they can talk openly with one another and their clinician as they would do if somebody in the family had Alzheimer’s disease or diabetes.
It has been reported that up to 46% of the caregivers of patients with bipolar disorder report depression, and up to 32.4% report use of mental health services. These symptoms tend to be dependent on the nature of the caregiving relationship, suggesting that specialized interventions addressing the psychiatric needs of bipolar families might result in improved outcomes for both patients and their family members, in addition to decreases in health care costs (J. Affect. Disord. 2010;121:10-21).