Context-Family interventions have been found to hasten episode recovery and delay recurrences among adults with bipolar disorder.Objective-To examine the benefits of family-focused therapy for adolescents (FFT-A) and pharmacotherapy in the 2-year course of adolescent bipolar disorder.Design and setting-Two-site outpatient randomized controlled trial with 2-year follow-up.Patients-A referred sample of 58 adolescents (14.5 ± 1.6 yrs) with bipolar I (n = 38), II (n = 6), or not otherwise specified disorder (n = 14) with a mood episode in the prior 3 months.Interventions-Patients were randomly assigned to FFT-A and protocol pharmacotherapy (n = 30) or enhanced care (EC) and protocol pharmacotherapy (n = 28). FFT-A consisted of 21 sessions in 9 months of psychoeducation, communication training, and problem-solving skills training. EC consisted of 3 family sessions focused on relapse prevention.Main Outcome Measures-Independent "blind" evaluators assessed patients every 3-6 months over 2 years. Outcomes included time to recovery from the index episode, time to recurrence, weeks in episode/remission, and mood symptom severity scores.Results-Analyses were by intent-to-treat. Rates of 2-year study completion did not differ across the FFT-A (60.0%) and EC conditions (64.3%). Although there were no group differences in rates of recovery from the index episode, patients in FFT-A recovered from their baseline depressive symptoms faster than patients in EC (HR = 1.85; 95% CI: 1.04 -3.29; P = .037). The groups did not

Objective Depression and brief periods of (hypo)mania are linked to an increased risk of progression to bipolar I or II disorder (BD) in children of bipolar parents. This randomized trial examined the effects of a 4-month family-focused therapy (FFT) program on the 1-year course of mood symptoms in youth at high familial risk for BD, and explored its comparative benefits among youth in families with high vs. low expressed emotion (EE). Method Participants were 40 youth (mean 12.3 ± 2.8 years, range 9–17) with BD not otherwise specified, major depressive disorder, or cyclothymic disorder who had a first-degree relative with BD I or II and active mood symptoms (Young Mania Rating Scale [YMRS] > 11 or Child Depression Rating Scale > 29). Participants were randomly allocated to FFT–High Risk version (FFT-HR; 12 sessions of psychoeducation and training in communication and problem-solving skills) or an education control (EC; 1–2 family sessions). Results Youth in FFT-HR had more rapid recovery from their initial mood symptoms (hazard ratio = 2.69, p = .047), more weeks in remission, and a more favorable trajectory of YMRS scores over 1 year than youth in EC. The magnitude of treatment effect was greater among youth in high-EE (vs. low-EE) families. Conclusions FFT-HR may hasten and help sustain recovery from mood symptoms among youth at high risk for BD. Longer follow-up will be necessary to determine if early family intervention has downstream effects that contribute to the delay or prevention of full manic episodes in vulnerable youth. Clinical trial registration information—Early Family-Focused Treatment for Youth at Risk for Bipolar Disorder; http://www.clinicaltrials.gov/; NCT00943085.

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When structured assessment of personality disorder is performed during a clinical remission, less than one in three bipolar patients meets full syndromal criteria for an axis II disorder. Examining rates of comorbid personality disorder in broad-based community samples of bipolar spectrum patients would further clarify the linkage between these sets of disorders.

Substance use among a random sample of mentally ill, community-based patients was examined. Current use was found to have declined substantially from a high lifetime prevalence, and a family history of substance abuse was associated with moderate to heavy use. No association was found between heavy substance use and elevated psychopathology, hospitalization, or medication noncompliance. Hospital admissions and some symptoms were less prevalent among users preferring marijuana.

Labeling theory predicts that psychotic patients who accept the label of mental illness will function less well than those who reject their diagnosis. Accepted psychotherapeutic theory suggests the reverse. Two predictive models were tested. Results supported the central hypothesis of the psychotherapeutic model but not that of the labeling model, although some elements of the latter model were affirmed. Besides acceptance of diagnosis, an internal locus of control appears important for good outcome in psychosis.

DisclosuresDr. Miklowitz has received research funding from the National Institute of Mental Health (NIMH), the National Association for Research on Schizophrenia and Depression (NARSAD), the Danny Alberts Foundation, the Attias Family Foundation, and the Robert L. Sutherland Foundation; and royalties from Guilford Press and John Wiley and Sons. Dr. Schneck has received funding from the Crowne Family Foundation. Dr. Cosgrove has received funding from the Lucille Packard Foundation for Children's Health, Spectrum Child Health, and the Klingenstein Third Generation Foundation. Dr. Garber has received funding from NIMH and the William T. Grant Foundation. Dr. Chang has received research funding from NIMH, NARSAD, Merck, and GlaxoSmithKline; and is a non-paid consultant for GlaxoSmithKline, Eli Lilly and Company, Bristol-Myers Squibb, and Merck. Drs. Singh, Taylor, George, Dickinson, and Ms. Howe report no biomedical financial interests or potential conflicts of interest.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptObjective-Depression and brief periods of (hypo)mania are linked to an increased risk of progression to bipolar I or II disorder (BD) in children of bipolar parents. This randomized trial examined the effects of a 4-month family-focused therapy (FFT) program on the 1-year course of mood symptoms in youth at high familial risk for BD, and explored its comparative benefits among youth in families with high vs. low expressed emotion (EE).Method-Participants were 40 youth (mean 12.3 ± 2.8 years, range 9-17) with BD not otherwise specified, major depressive disorder, or cyclothymic disorder who had a first-degree relative with BD I or II and active mood symptoms (Young Mania Rating Scale [YMRS] > 11 or Child Depression Rating Scale > 29). Participants were randomly allocated to FFT-High Risk version (FFT-HR; 12 sessions of psychoeducation and training in communication and problem-solving skills) or an education control (EC; 1-2 family sessions).Results-Youth in FFT-HR had more rapid recovery from their initial mood symptoms (hazard ratio = 2.69, p = .047), more weeks in remission, and a more favorable trajectory of YMRS scores over 1 year than youth in EC. The magnitude of treatment effect was greater among youth in high-EE (vs. low-EE) families.Conclusions-FFT-HR may hasten and help sustain recovery from mood symptoms among youth at high risk for BD. Longer follow-up will be necessary to determine if early family intervention has downstream effects that contribute to the dela...

Objectives-Previous studies have identified behavioral phenotypes that predispose genetically vulnerable youth to a later onset of bipolar I or II disorder, but few studies have examined whether early psychosocial intervention can reduce risk of syndromal conversion. In a one-year open trial, we tested a version of family-focused treatment adapted for youth at high risk for bipolar disorder (FFT-HR).Methods-A referred sample of 13 children (mean 13.4 ± 2.69 years; 4 boys, 9 girls) who had a parent with bipolar I or II disorder participated at one of two outpatient specialty clinics. Youth met DSM-IV criteria for major depressive disorder (n = 8), cyclothymic disorder (n = 1), or bipolar disorder not otherwise specified (n = 4), with active mood symptoms in the past month. Participants were offered FFT-HR (12 sessions in four months) with their parents, plus psychotropic medications as needed. Independent evaluators assessed depressive symptoms, hypomanic symptoms, and global functioning at baseline and then every four months for one year, with retrospective severity and impairment ratings made for each week of the follow-up interval.Results-Families were mostly adherent to the treatment protocol (85% retention), and therapists administered the FFT-HR manual with high levels of fidelity. Youth showed significant improvements in depression, hypomania, and psychosocial functioning scores on the Adolescent Longitudinal Interval Follow-up Evaluation. They also showed significant improvements in Young Mania Rating Scale and Children's Depression Rating Scale scores.Conclusions-FFT-HR is a promising intervention for youth at high risk for BD. Larger-scale randomized trials that follow youth into young adulthood will be necessary to determine whether early psychosocial intervention can reduce the probability of developing bipolar I or II disorder among genetically vulnerable youth. Between 50-66% of adult patients with bipolar disorder (BD) report onset of their disease prior to 18 years, and 15-28% report onset before age 13 (1). BD in childhood or adolescence exhibits a more severe, protracted, and continuously cycling course compared to adult-onset BD, often with mixed episodes, longer episode durations, psychosis, and multiple comorbidities (2). Many of these features also characterize prodromal forms of the illness, which can be identified in childhood or early adolescence (3,4).Several research groups have identified the phenotype that may be most likely to predispose youth to the later development of bipolar illness. Birmaher et al. (3) found that youth (mean age 7-17 years) who met research criteria for BD not otherwise specified (NOS)-operationalized by multiple short periods of mania that do not meet the DSM-IV episode duration thresholds or symptom count criteria-are at substantially elevated risk for 'converting' to bipolar I disorder (BD-I) or bipolar II disorder (BD-II). When stratifying by family history of BD-I or BD-II, the risk of conversion in youth presenting with the BD-NOS phenotype was 51...