Family-focused treatment for caregivers of patients with bipolar disorder

Bipolar disorder affects the family members of a patient and is affected by the family environments associated with caregiving. From 89% to 91% of family members report feelings of emotional distress (i.e., ‘subjective burden’) in relation to the severity of the patient’s illness symptoms (1, 2); between 24% and 38% score above the standard cutoffs on self-report measures of depressive symptoms (2). Patient suicidal ideation and behavior in particular have been associated with increased symptoms of caregiver depression (3). For family members with their own history of mood disorders, caregiving more than doubles the risk of recurrence of an episode of major depression in the caregiver compared to the risk of recurrence among persons with a history of mood disorder but without caregiving responsibilities (4). Recent studies suggest that subjective burden and/or depression also compromise caregivers’ ability to effectively manage the demands associated with caregiving, which in turn leads to less favorable patient outcomes. Higher levels of caregiver burden are associated with more emotion-focused coping and/or lower mastery among caregivers (5–7) and with poorer patient medication adherence and clinical outcomes among patients (8, 9). Highly burdened family members are also less likely to practice adequate self-care and to suffer adverse effects on their physical health (2, 10, 11), further compromising their resilience and readiness to manage acute or subacute problems with the relative with bipolar disorder. The widespread dissemination of education and support groups for family members alone (i.e., without the patient), such as the Family to Family Program developed by the National Alliance on Mental Illness (NAMI) (12) and the Support and Family Education Program (SAFE) (13), attests to the family’s interest in psychosocial interventions for bipolar disorder and other major mental disorders. However, programs developed for family members have seldom evaluated the impact of such programs on patient as well as family outcomes, leaving unanswered the important question of whether interventions with family members alone can benefit the patient as well. We developed a Family-Focused Treatment-Health Promoting Intervention (FFT-HPI), a brief (12–15 session), manualized, psychoeducational intervention for family members of patients with bipolar disorder which aims to provide the caregiver with enhanced skills for managing the relative’s illness, defining self-care goals and resolving barriers to patient care and self-care through education, examination of core beliefs that maintain dysfunctional interaction patterns, and problem solving. FFT-HPI targets both patient symptoms and caregiver health behavior (e.g., seeking appropriate medical care and following recommendations) and mental health outcomes. The main purpose of this study was to evaluate the efficacy of FFT-HPI in an initial clinical trial where family members were randomized to receive either FFT-HPI or education about bipolar disorder and health problems that are common among caregivers. Primary outcome variables for caregivers were depressive symptoms and health behavior. Primary outcome measures for the patient were symptoms of bipolar depression and mania. First, we hypothesized that caregivers treated with FFT-HPI would demonstrate decreased depressive symptoms and subjective burden and improved health behavior from pre- to post-treatment compared to caregivers treated with a health education intervention (HE). Second, we hypothesized that the patients with bipolar disorder associated with caregivers treated with FFT-HPI would report reduced symptoms of bipolar disorder post-treatment relative to the patients of caregiver treated with HE. Recently, Miklowitz and Scott (14) identified “the lack of clarity about the mediators of outcome” as a key weakness in the psychotherapy literature on change. Therefore, a secondary aim was to identify potential mediators of patient and caregiver outcomes. We predicted that the hypothesized differential reduction in patient symptoms between treatment groups would be mediated by changes in caregivers’ levels of depression. Secondarily, based on prior studies of caregiving and depression, we predicted that clinical improvement in the caregiver would be mediated by reductions in avoidance coping, a form of emotion-focused coping characterized by denial, wishful thinking, and displays of emotion (5).