Introduction

Bipolar disorder, a complex and chronic psychiatric condition, leads to more disability-adjusted life years (DALYs) than any type of cancer or serious neurological disorders such as epilepsy and Alzheimer’s disease. This mental health disorder, characterized by alternating periods of depression and mania, has a profound impact on individuals’ quality of life and overall functioning, making it a major contributor to the global disease burden.¹ Around 2% of people worldwide suffer from bipolar illness.² Mental illness called bipolar disorder produces abrupt changes in mood, energy, level of activity, concentration, and the ability to carry out day-to-day tasks.³ Bipolar Disorder is classified as bipolar I, bipolar II, and cyclothymic. In adults with bipolar disorder (BD), between 50% and 66% say that the illness started before age 18, while 15% to 28% say it started before age 13.⁴ Bipolar Disorders I and II are found to impact approximately 2% of individuals under 18 years of age, but this prevalence can vary among different cultures. BD I involves recurring episodes of mania and major depression, while BD II is characterized by milder hypomania and depressive episodes. Both conditions significantly affect the emotional, cognitive, and social functioning of affected youths, necessitating proper clinical attention and support.⁵ Early signs of bipolar disorder, known as subthreshold or “high-risk” forms of the disorder, impact around 3%–9% of clinically referred young individuals and can be identified up to 10 years before the onset of full-blown Bipolar Disorder.⁶ Young individuals with subthreshold mood symptoms often transition to developing bipolar I disorder (BD-I) or bipolar II disorder (BD-II) in their late adolescence or early adulthood.⁷ The early occurrence of mental illness is associated with an ongoing and severe course of the condition, frequent shifts in mood, experiencing mixed episodes, psychosis, a heightened risk of suicide, reduced functioning and quality of life. Detecting and addressing these issues promptly is crucial to improving the long-term outcomes and well-being of those who are affected. Mental health professionals should prioritize early intervention and comprehensive support to offer affected individuals a more optimistic and fulfilling future.⁸ The consensus on the most effective ways to halt symptom progression in high-risk children’s cases is not universally accepted. There are different proposed approaches, but professionals have not reached a definitive agreement. The lack of consensus might be due to the complexities of paediatric cases, the diverse range of high-risk conditions, and limited extensive studies comparing various intervention strategies.^9,10  Psychosocial interventions are beneficial in helping at-risk young people develop coping skills for stress, establish supportive social networks, and attain independence. These evidence-based interventions use a person-centred approach, emphasizing individual strengths to foster personal growth and positive outcomes. Ultimately, these interventions significantly contribute to the overall well-being and success of vulnerable youths.¹¹ Psychosocial treatments, including Family-focused therapy(FFT), have been shown to be effective in improving symptoms among patients with bipolar disorder when family members exhibit high levels of expressed emotion (EE).¹² As of our current understanding, there are several research investigating the combined impact of Family-focused therapy and pharmacotherapy on the Expressed Emotions of caregivers. The primary objective is to assess the potential effectiveness of the combination of FFT and pharmacotherapy in reducing Expressed Emotions and alleviating stress among these caregivers. Overall, this study also aims to present a comprehensive and evidence-based overview of Family-focused therapy as a promising approach for the treatment of bipolar disorder, highlighting its benefits and implications for patients, families, and mental health professionals.

Effective Treatment Approaches

Treatment of bipolar disorder includes medications and some psychotherapy along with medications based on specific symptoms. The management of bipolar disorder with medications is divided into three groups: the manic phase, the depressive phase, and the maintenance phase. However, there is conflicting advice because different international bodies and FDA-approved drugs have varying recommendations. Furthermore, the official guideline from the American Psychiatric Association for Bipolar Illness has not been updated since 2002, leading to inconsistencies in treatment approaches.^13,14 Treatment for manic and hypomanic episodes usually involves the same medications. The FDA has approved drugs for managing acute mania, including lithium, valproic acid, carbamazepine, and various second-generation antipsychotics (SGAs). These medications specific have demonstrated their effectiveness in easing manic symptoms and are commonly prescribed for this purpose.¹⁵ APA guidelines recommend relegating carbamazepine to a secondary treatment option. New evidence suggests that SGAs like quetiapine and olanzapine may act more rapidly than lithium and valproic acid. Combining a mood stabilizer with an SGA is potentially more effective than using a single therapy, but further research is needed to fully understand the advantages.¹⁶

Psychotherapy

Interpersonal therapy (IPT)

Interpersonal therapy (IPT) is a successful and time-limited intervention designed to target specific diagnoses. With its structured format, it has proven effective in treating various psychiatric disorders. Assigning patients a “sick role,” viewing their problems as treatable medical conditions, and connecting their emotional distress to interpersonal situations, fosters a collaborative effort to address their challenges. This therapy focuses on the current issues in patients’ lives, resolving interpersonal problem areas, rather than dwelling on the past. Ultimately, Interpersonal therapy offers a versatile and efficient approach to improving well-being through interpersonal understanding and resolution.¹⁷

Numerous studies have highlighted the limitations of solely relying on medication to treat bipolar I disorder, emphasizing the need for additional psychotherapeutic approaches. In a randomized trial comparing interpersonal and social rhythm therapy (IPSRT) to intensive clinical management (ICM), involving 175 individuals, various treatment strategies were explored across a two-year preventive maintenance phase. While no significant differences were observed in stabilization times among treatments, those receiving IPSRT during the acute phase experienced prolonged periods without new affective episodes, independent of maintenance treatment. Post-acute treatment, IPSRT recipients demonstrated increased regularity in social rhythms, which correlated with a reduced likelihood of recurrence during the maintenance phase.

This suggests that IPSRT may offer supplementary benefits in managing bipolar I disorder, particularly in preventing new episodes, enriching the therapeutic options available for this condition.¹⁸

Cognitive behavioural therapy

Cognitive Behavior Therapy (CBT) is a well-structured and goal-oriented form of psychotherapy used to address a wide range of psychological issues.¹⁹ It emphasizes practicality and collaboration between the therapist and patient, to modify negative thought and behavior patterns to bring about positive changes in emotions and daily life.²⁰ Cognitive Behavior therapy employs evidence-based techniques tailored to the patient’s specific diagnosis and challenges. Through active participation and practice, individuals can develop healthier coping mechanisms and experience improvements in their mental well-being.²¹ Cognitive Behavior therapy is widely recognized and valued in the field of psychology for its effectiveness in promoting lasting positive transformations in patients’ emotional and functional capacities.²²

In a study with 103 bipolar 1 disorder patients prone to frequent relapses despite medication, those receiving cognitive therapy (CT) in addition to mood stabilizers displayed remarkable progress over 12 months. Compared to the control group, the CT recipients experienced significantly fewer bipolar episodes, spent less time within these episodes, and had fewer hospital admissions related to their condition. Their social functioning notably improved, accompanied by reduced monthly mood symptoms and better management of manic indicators. These results underline the effectiveness of integrating CT alongside mood stabilizers in preventing relapses and enhancing social functioning among individuals with bipolar affective disorder.²³

Psycho-education

Psycho-education is a therapeutic approach that focuses on educating patients and/or their relatives about the disorder.²⁴ it aims to enhance their comprehension of the condition, identify warning signs and mood changes at an early stage, and improve treatment adherence.^25,26 Implementing psycho-educational methods for individuals with BD can lead to a higher frequency of recognizing new mood episodes and better compliance with medication.²⁷

Family-focused therapy

Family-focused therapy is a proven intervention for adults and children with bipolar disorder and their caregivers. It is typically administered alongside pharmacotherapy after an illness episode. The treatment involves joint sessions where the family receives Psycho-education about bipolar illness, communication enhancement training, and problem-solving skills training. The primary goal of Family-focused therapy is to help families better understand bipolar disorder, allowing all members to actively participate in the treatment process. Through comprehensive psycho-education, individuals with bipolar disorder and their caregivers gain valuable insights into the condition, its potential triggers, and effective coping strategies.²⁸

Family-Focused Therapy Techniques and Interventions

Family therapy is an organized type of psychotherapy that aims to improve the systems of communication within families to lessen conflict and pain. It is the best counselling approach for assisting family members in adjusting to a member of their immediate family who is coping with an addiction, a health condition, or a mental health diagnosis. Relational therapists, in particular, are family therapists.²⁹

It is a modularized, time-limited treatment that combines Psycho-education, training in improved communication, and problem-solving techniques.³

The protocol consists of three modules:

Psycho-education

Psycho-education is defined as the ” process of explaining the nature of the mental illness to clients with the condition and their family members, including its etiology, progression, consequences, prognosis, treatment, and alternatives. There are several ways to deliver psycho-education. By providing individual interventions to families and groups of professionals. To maximize the impact and retention of the information, a variety of media are used, including written, audio, video, interactive, and online delivery. Many interventions include more than one delivery medium.³¹

In a controlled study, a total of 109 outpatients participated, divided into two groups: the control group (N=52) and the experimental group (N=57). The patients in the experimental group received standard treatment, which included a monthly appointment with the treating psychiatrist, specific medication for the disorder (BD-specific medication), and additional Psycho-education. On the other hand, patients in the control group only received the standard treatment without any additional psycho-education. The treatment phase lasted for 21 weeks, and after a follow-up period of up to 4 years, the survival study revealed significant variations in the interval before the patients’ first hospitalization. Specifically, the patients who received psycho-education as part of their treatment showed greater hospital avoidance compared to those in the control group.³²

These findings indicate that the addition of psycho-education to the standard treatment regimen may have a positive impact on hospitalization rates and can potentially contribute to better patient outcomes in the long term.

Communication Enhancement Training

A variety of methods are taught to the family to help with dysfunctional communication habits.

The goal of Communication Enhancement Training (CET) is to lessen negative interactions between youth and their families while enhancing communication. Participants acquire the skills to (a) reduce impulsive negative affect expressions by pausing and putting difficult feelings into words, (b) communicate in a way that does not cause emotional dysregulation in others, and (c) shift attention from negative emotions to more conciliatory moods when participating in role-playing skill-training activities, and between-session practice. Teenagers and family members acquire four skills: expressing pleasant emotions, actively listening, positively requesting behavioural adjustments from one another, and providing constructively critical criticism. The clinician models each skill for the family and provides handouts listing the elements of each ability (e.g., for listening attentively: establishing eye contact, and interpreting each other’s words). Then, with the clinician’s guidance and coaching, the participants practice the skills with one another. Adolescents receive communication instruction less formally than adults, making use of the natural connections within the family. The participant’s efforts to employ each skill are documented in homework assignments, which improve generalization to different contexts.³³

Problem-Solving Skills

Problem-solving techniques for people with bipolar disorder take a structured, team-based approach that incorporates both patients and parents. The main goal of this program is to pinpoint particular problems that can affect the patient’s family or individual life. Participants will be encouraged to come up with and assess potential solutions throughout this process to identify the most practical ones.³⁴

Historical Context

Family-focused therapy was developed as a variation of behavioural family management (Falloon, Boyd, & McGill, 1984; Miklowitz & Goldstein, 1990), a 9-month treatment for schizophrenia patients and their families. Behavioural family management consists of sessions of psycho-education, communication skills training, and problem-solving skills training for patients with schizophrenia and their parents (s) or, in rare cases, their spouses or adult siblings. Falloon et al. (1985) found that for schizophrenia patients who had just been discharged from the hospital, the combination of 9 months of behavioural family management and neuroleptic medication was more effective in reducing rates of psychotic relapse and improving social functioning than 9 months of supportive individual therapy and neuroleptic medication. The extension of family psycho-education to other recurrent, impairing psychiatric disorders including BD seemed promising.³⁵

Empirical Evidence for Family-Focused Therapy in Bipolar Disorder Treatment

Miklowitz et al. conducted a randomized clinical trial (RCT) aimed at assessing the efficacy of Family-focused therapy in combination with medication for treating bipolar disorder in teenagers. The study involved the participation of twenty teenagers with a mean age of 15 years. The trial was an open trial and spanned over a nine-month duration, during which the participants attended 21 sessions of FFT and received medication. At the 2-year follow-up assessment, the results revealed significant improvements in the teenagers’ scores for depression, mania, and overall problem behaviour. This finding underscores the effectiveness of the combined treatment approach in ameliorating the symptoms associated with bipolar disorder in adolescents.³⁶

In another study involving 58 adolescents, randomly divided into two groups (FFT with pharmacotherapy and EC with pharmacotherapy), the FFT group demonstrated better recovery from baseline compared to the Enhanced Care (EC) group. This indicates that FFT may be more effective in improving symptoms when combined with medication.³⁷

Additionally, A research focused on reducing Suicidal Ideation (SI) in high-risk youth, a sample of 127 patients with active mood symptoms and a family history of bipolar disorder participated. Those who received 12 sessions of FFT and medication showed lower levels of SI. This suggests that Family-focused therapy may have a beneficial impact on reducing suicidal ideation in high-risk teenagers.³⁸

Furthermore, a randomized controlled trial with 119 adolescents and a family history of BD revealed that youth in FFT reported higher gains in family functioning than those in EC over 24 months. The improvement in depression symptoms was largely mediated by increases in family functioning. Additionally, teenagers with comorbid anxiety and externalizing disorders experienced larger impacts from FFT on family functioning compared to EC.³⁹

The research investigated the efficacy of two therapeutic interventions, Child and Family-focused Cognitive Behavioral Therapy (CFF-CBT) and standard psychotherapy, among 71 youths aged 7–13 diagnosed with pediatric bipolar disorder. Over a structured course of 12 weekly sessions and subsequent booster sessions, both interventions demonstrated significant reductions in the frequency and intensity of suicidal thoughts reported by the participants, initially prevalent in approximately 39% of the cohort. Notably, while both treatments yielded marked improvements, the study did not observe a statistically significant discrepancy between the two therapeutic modalities concerning their impact on reducing suicidal ideation. These findings suggest that early intervention, regardless of specialized or conventional therapies, holds promise in mitigating suicidal ideation in this high-risk demographic of youth diagnosed with pediatric bipolar disorder.⁴⁰

In India, caregivers supporting individuals with bipolar disorder face considerable strain, often leading to expressed emotions (EE) like hostility and over-involvement. A study involving two caregivers of bipolar adults in manic episodes revealed high EE levels. Family-focused therapy delivered over 12 sessions in 3–4 weeks on an inpatient basis showed promising results. It notably reduced EE and family stress while enhancing patients’ psychosocial functioning, sustaining these improvements over 9–10 months. FFT emerges as a valuable addition in alleviating EE and stress among bipolar caregivers, fostering better family dynamics.⁴¹

Another research examines the effectiveness of Family-focused cognitive-behavioural therapy for adolescents (aged 13–18) with Pediatric Bipolar Disorder (PBD) in Swedish psychiatric care, adapted from a US program for younger children. Assessments before, after treatment, and at a 6-month follow-up by 45 adolescents, 61 parents, and clinicians evaluated psychosocial functioning, depression, PBD knowledge, and family dynamics. Results showed improved functioning as per parents and clinicians post-treatment, with parents noting reduced mania and a better family atmosphere. Both parents and adolescents reported enhanced knowledge and skills, with moderate positive effects. While most individuals showed improvement, some experienced no change or deterioration. The study highlights the therapy’s acceptance and its positive impact on adolescents’ psychosocial function and PBD awareness in families, but variability in mood and family climate suggests the need for tailored treatment approaches. This therapy complements pharmacological PBD treatments effectively.⁴²

Conclusion

In this review, we concluded that Family-focused therapy is effective in preventing and reducing the symptoms of bipolar disorder. Family-focused therapy is the most effective therapy for stabilizing children and adults with bipolar disorder when combined with pharmacotherapy. It can also lead to improved psychosocial functioning and symptom reduction in teenagers with bipolar disorder. Family functioning appears to be a critical factor in mediating the effectiveness of Family-focused therapy in treating depression symptoms. These findings underscore the importance of involving families in the treatment process to enhance outcomes for adolescents with bipolar disorder and related mood symptoms.

Acknowledgement

We express our sincere thanks to Our guide and our college management and Dr. N. Venkateswaramurthy, M.Pharm., Ph.D., Professor and Head, Department of Pharmacy Practice and Dr.K. Srinivas, Pharm. D., Assistant Professor, Department of Pharmacy Practice for help during our review.

Conflict of Interest

The authors have no conflicts of interest regarding this investigation.

Funding Sources

The authors didn’t receive any funding sources.

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