Family Participation Improves Outcomes

Bipolar disorder (BD) is a mental health condition characterized by alternating cycles of mania/hypomania and depression/depressive mood that have a significant impact on typical daily function and impair overall emotional and psychological wellbeing.

Bipolar disorder can be debilitating. It can prevent adolescents from participating in family life, school life, social life, and the extracurricular activities popular among adolescents. The most common evidence-based treatment for bipolar disorder is a combination of medication and psychotherapy. While most people with bipolar disorder need therapy and medication for their entire lives, it’s important for parent of teens with bipolar disorder to understand that bipolar disorder is a manageable condition.

This article is about a new development in research on the treatment of bipolar disorder that shows the importance of family participation in therapy and treatment. Previous research indicates a combination of therapy and medication as the standard of care for BD. This new research discusses which types of psychotherapy are most effective for BD. It emphasizes the success of treatment plans that include direct family involvement in all phases of treatment.

We’ll share the results of this new research in a moment.

First, we’ll define the terms we used above to define BD: mania/hypomania and depression/depressive.

Understanding Bipolar Disorder: Mania and Depression

In the 20^th century, bipolar disorder was often called manic depression. The phrase was popularized by a rock song by artist Jimi Hendrix, who describes the frustrations and challenges many people – including children and adolescents – experience during bipolar disorder. While he never received a diagnosis of BD himself, his story is a cautionary tale. It’s well-known that he self-medicated with drugs and alcohol, which eventually led to death by accidental overdose.

Many people with undiagnosed bipolar disorder self-medicate, which increases risk of accidental death, exacerbation of symptoms, and risk of suicide.

That’s why it’s important for parents of teens who show the signs and symptoms of mental health issues to know the key characteristics of bipolar disorder: untreated, it can cause lifelong problems. Appropriate treatment, however, can be both life-changing and life-saving.

With that said, we’ll define those terms: manic and depression.

In the context of bipolar disorder (BD), mental health professionals define those terms as follows:

Mania/Hypomania

Manic episodes or moods may appear as states of elation and euphoria. They may also appear as anger or extreme irritability. In the adolescent and child population, irritability is more common than elation, while in young adults and adults, elation and euphoria are more common. In addition to these extreme behavioral states, a characteristic of mania/hypomania in BD is a limited need for sleep, which may last days, and in some cases, as long as a week.

Depression/Depressive Mood

Depression or depressive episodes/moods may manifest – especially in the adolescent or child population – as irritability, negativity, or pessimism. Depressed mood in BD may also manifest in a manner more typical to depression, such as persistent sadness, low mood, recurring physical ailments such as headaches or stomachaches. Low energy and fatigue are also common, as is self-isolation/withdrawal from family and friends.

Those are the primary characteristics of bipolar disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies three distinct types of bipolar disorder, all three of which include some variation of those primary characteristics:

Bipolar I Disorder (BD-I)

BD-I is characterized by periods of mania, major depression, or mixed episodes that last for at least a week, impair sleep and typical daily functioning, and directly precede or follow a depressive episode of two weeks or more.

Bipolar II Disorder (BD-II)

BD-II is characterized by mania, hypomania, depression, or mixed episodes that are less intense and less severe than those observed in BD-I.

Cyclothymic Disorder

Cyclothymic disorder is characterized by alternating depressive and hypomanic symptoms, like BD-I and BD-II. However, teen with this variation of BD do not experience the full extremes of mania and depression that define BD-I and BD-II.

That’s what BD is and how it appears in adolescents. One last thing before we discuss the results of the new research: the prevalence of bipolar disorder among adolescents in the U.S. Here’s what the latest data says:

• 2.9% of teens age 13-18 meet the criteria for bipolar disorder each year
  • 3.3% of females
  • 2.6% of males
• Estimates indicate that around 33% of teens diagnosed with a depressive disorder may actually have early onset bipolar disorder

Those numbers tell us that close to a million adolescents have bipolar disorder in any given year – and the number may be higher. What this means for parents of teens with BD – and the teens themselves – is that they are not alone. Another thing we want to stress is what we mention above: teens who receive appropriate treatment for BD can and do learn to manage their disorder and live full and productive lives.

We’ll talk about the most appropriate – i.e. effective – treatments for BD in adolescents now.

The New Research: Family Matters

Mental health professionals have known for years that an integrated treatment approach can lead to positive outcomes for teens with bipolar depression. Integrated means the treatment plan addresses the whole person, leverages all available interventions that evidence shows help teens manage the symptoms of the disorder, and accounts for any additional mental health or behavioral disorders that may be present.

For bipolar depression, the best available interventions include:

• Psychotherapy:
  • Individual therapy
  • Group therapy
  • Family therapy
• Medication:
  • Mood stabilizers
  • Antipsychotics
  • Antidepressants
• Complementary supports:
• Mindfulness-based stress reduction
• Experiential therapies
• Expressive therapies
• Community support groups

The new research development we’re looking at in this article was published in October 2020 in a paper called Adjunctive Psychotherapy for Bipolar Disorder. This paper focuses on one specific element of treatment for bipolar in teens: the psychotherapeutic component.

Until recently, research showed that medication and therapy led to better overall treatment outcomes than medication alone or therapy alone. This research explored whether medication and a specific type of therapy – individual, group, or family – and specific therapeutic modality – i.e. dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT), motivational interviewing, or interpersonal and social rhythm therapy (IPSRT) – led to better outcomes than medication and treatment as usual (TAU). In the context of treatment for teen bipolar disorder, TAU means individual psychotherapy.

Researchers examined records from 39 randomized control studies that included data from 3863 participants. To gauge the benefits of each type of therapy and each therapeutic modality, they use the following metrics:

1. Recurrence of manic or depressive episodes
2. Stabilization of symptoms
3. Treatment retention (whether or not an individual stays in treatment and completes their program).

Here’s what they found.

Recurrence of Manic or Depressive Episodes

• Medication + group psychoeducation yielded better outcomes than medication + TAU
  • Psychoeducation includes workshops on maintaining appropriate sleep/wake cycles, identifying symptoms, implementing coping strategies, and understanding the science of bipolar disorder
• Medication + family therapy yielded better outcomes than medication + TAU
  • Family cognitive behavioral therapy (CBT) yield better outcomes than motivational interviewing
• Medication + interpersonal and social rhythm therapy (IPSRT) yielded better outcomes than medication + TAU

Stabilization of Symptoms

• Medication + individual cognitive behavioral therapy (CBT) yielded better outcomes than medication + TAU
• Medication + family therapy yielded better outcomes than medication + TAU
  • Family cognitive behavioral therapy (CBT) yield better outcomes than motivational interviewing
• Medication + interpersonal and social rhythm therapy (IPSRT) yielded better outcomes than medication + TAU

Treatment Retention

• Medication + family therapy yielded better outcomes than medication + TAU
• Medication + group psychoeducation yielded better outcomes than medication + TAU

These results address an open question in the research on treatment for bipolar disorder. In recent years, evidence from some studies indicated there was no difference in treatment outcomes between medication only and medication + family therapy. In fact, one study indicated that when the family participated in psychoeducation classes without the individual diagnosed with BD, outcomes improved.

However, that study focused on adults, while this study included teens. In the teenage bipolar population, this study finds that outcomes improved when both the family and the teen participated in treatment. Further, it showed that when the family and teen participated in more than one type of therapy – i.e. group therapy, family therapy, and individual therapy – outcomes were better than when the family and teen participated in only on type and/or mode of therapy.

Finally, of all the mode of therapy the researchers considered, they found that cognitive behavioral therapy had the most beneficial effect on recurrence of episodes and stabilization of symptoms, while group psychoeducation and interpersonal and social rhythm therapy (IPSRT) had the most beneficial effect on treatment retention.

What This Means for Families and Teens

The main takeaway from this research mirrors the adage it takes a village to raise a child.

The data show a clear advantage for medication + family and group psychotherapy over medication + individual therapy or medication + no therapy. It also shows the importance of skill-building group psychoeducation classes. The results tell us that teens with bipolar disorder do best when they’re in a group, rather than alone. This means they learn recovery skills, coping mechanisms, and symptom management best in an interactive environment, in context, where they can receive feedback and engage in interplay with family, treatment peers, and therapists. It’s also important to have people that know how to help after the treatment program is finished.

In the words of study author Dr. David Miklowitz:

“Not everyone may agree with me, but I think the family environment is very important in terms of whether somebody stays well. There’s nothing like having a person who knows how to recognize when you’re getting ill and can say, ‘you’re starting to look depressed or you’re starting to get ramped up.’ That person can remind their loved one to take their medications. Or stay on a regular sleep-wake cycle. Or contact the psychiatrist for a medication evaluation.”

Parents and family members of teens diagnosed with bipolar disorder should take these words to heart. There are facts about bipolar disorder that are hard to face. One of them is that a person with bipolar disorder will likely be on medication and in therapy their entire lives. Families capable of accepting this fact can go all-in on helping their teen. They can participate in the family therapy. They can learn everything there is to know about bipolar disorder. And help their teen develop the habits and skills necessary for an independent and fulfilling life.

Treatment for Bipolar Disorder Works

It’s important for families to understand that their bipolar teen can learn to manage and live with bipolar disorder. What that means is that when they become adults, they can live an independent life. This means an adult with bipolar can:

• Find and keep a job
• Enter and complete college and graduate school
• Find a place to live and handle all the details, like leases, turning utilities on and off, paying bills, and everything living solo implies

The best way to ensure a bipolar teen can function as an adult is to help them as much as possible. Help in the early stages of their treatment matters most. As early as possible, teens need to know the importance of staying on their medication. They need to recognize the signs and precursors of manic and depressive phases. They also need to understand how to ask for support when they realize they’re in a manic or depressive phase that has the potential to become unmanageable.

Families can help do all that. They can help a bipolar teen establish a firm foundation that will carry them into adulthood with every chance of success. It takes work and commitment. But our experience – and now this research – tells us that when a teen with bipolar disorder has the help of a supportive community and a loving family, they can achieve sustained recovery.

In the context of BD, sustained recovery means:

“…a process through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

That is, indeed, what every parent of a teen with bipolar disorder wants for their teen. With the help of this research, parents – not to mention therapists, friends, and loved one, too – now have a clear template for helping their teen achieve that goal.