Program

Sep 15, 2016

OVERVIEW

The goals of Family Focused Therapy – High Risk (FFT-HR) are to assist children and adolescents ages 9 to 17 with high familial risk for mood disorders (bipolar, major depressive, or cyclothymic), and their family members, to recognize and intervene early with symptoms of mood episodes, and enhance familial communication and problem solving, which in turn are intended to reduce recovery times and lengthen remission periods.  An experimental evaluation of FFT-HR found that participating in the treatment resulted in statistically significant positive impacts on weeks in full remission, recovery from initial mood symptoms, time to recovery, and in a more favorable trajectory of Young Mania Rating Scale (YMRS) scores over one year, compared with those who did not receive the treatment.  Regardless of treatment assignment, patients in households with high levels of expressed emotion took significantly longer to recover from their initial symptoms than patients in households with low levels of expressed emotion, and were more likely to remain symptomatic.

DESCRIPTION OF PROGRAM

Target population:  Children and adolescents ages 9 to 17 with mood disorders, and who have first-degree relatives with bipolar disorder.

Family-Focused Therapy – High Risk (FFT-HR) is an early psychosocial intervention for early-onset mood disorders that aims to reduce familial stress, conflict, and affective arousal by enhancing communication and problem-solving among children and their caregivers. FFT-HR consists of 12 sessions (eight weekly, four biweekly, over four months) of psychoeducational therapy in the areas of individualized mood management plans (four sessions), communication enhancement (four sessions), and problem solving (four sessions).

The session-by-session manual is available from the web site referenced below.

EVALUATION OF PROGRAM

Miklowitz, D. J., Schneck, C. D., Singh, M. K., Taylor, D. O., George, E. L., Cosgrove, V. E. Howe, M. E., Dickinson, L. M., Garber, J., & Chang, K. D. (2013). Early intervention for symptomatic youth at risk for bipolar disorder: A randomized trial of family-focused therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 121-131.

Evaluated Population: A total of 40 children and adolescents with bipolar disorder, major depressive disorders, or cyclothymic disorders who had a first-degree relative with bipolar disorder and active mood symptoms participated in the study over one year.

Participants were recruited by referrals from community practitioners, parent support groups, e-mail advertisements, and inpatient settings at the University of Colorado and Stanford School of Medicine.  Eligibility requirements included speaking English; having a lifetime diagnosis of bipolar, major depressive, or cyclothymic disorder; having significant current affective symptoms; and having at least one first-degree relative with bipolar disorder.  Participants were not required to take medications to participate.

The mean age of the participants was 12.3 years, 42.5 percent were female, 50 percent were diagnosed with bipolar disorder, 42.5 percent with major depressive disorder, and 7.5% with cyclothymic disorder, and 60 percent were taking medications at entry.

Approach: Trained diagnosticians administered the Washington University Schedule for Affective Disorders and Schizophrenia for Children (K-SADS) separately to the participants and their parents. All available first-degree relatives were administered the Mini-International Neuropsychiatric Interview (MINI) diagnostic. To gauge expressed emotion, five-minute speech samples were obtained from the primary caregivers as they talked about their children and their relationships with them.

An independent data analyst not otherwise associated with the study randomly assigned the participants (N=40) to receive the treatment (n=21) or to the control group (n=19). At baseline, participants in the two groups were equivalent on demographic, clinical, and illness history variables.

Participants assigned to the control group received one or two family sessions in which clinicians summarized the results of the diagnostic assessment, introduced daily mood monitoring, and offered recommendations and instructional handouts on managing mood swings.  Families in both groups could request additional crisis sessions after the end of the therapy period, as well as referrals for additional psychosocial services. Outcomes measured included rapidity of symptom recovery, time in remission, and changes in depressive and hypomanic symptoms over one year.

Independent evaluators interviewed participants and at least one parent at baseline and again at 4, 8, and 12 months post-randomization.  The evaluators administered the Young Mania Rating Scale (YMRS) and Children’s Depressed Rating Scale Revised (CDRS-R) at each evaluation, and rated the prior one or two weeks based on a consensus of parent and child reports.  The evaluator then rated each week of the four-month interval using the Adolescent Interval Follow-up Evaluation (A-LIFE) Psychiatric Status Ratings (PSRs).

Results: At post-test, participants in the treatment group were found to have more weeks in full remission than those in the control group, on average.  The average score for those in the treatment group was 26.8 weeks, compared with 19.5 weeks for those in the control group. Members of the treatment group in households with high levels of expressed emotion were found to have significantly more weeks in remission than those in the control group who were also in high-expressed-emotion households; 26.6 weeks for those in the treatment group, compared with 12.0weeks for those in the control group. Members of the treatment group in high-expressed-emotion households were found to have significantly fewer weeks in subthreshold states than those in the control group who were also in high-expressed-emotion households; 14.9 weeks on average for participants in the treatment group compared with 26.3 weeks on average for those in the control group. Members of the treatment group were also significantly more likely to recover from initial mood symptoms; one of the patients in the treatment group did not recover, compared with five in the control group. Members of the treatment group were also significantly more likely to have a decreased time to recovery; 13.0 weeks for participants in the treatment group compared with 21.3 weeks for those in the control group. In the subgroup of patients with subthreshold or syndromal depressive symptoms at baseline, participants in the treatment group were found to have fewer weeks to recovery from depressed mood than those in the control group: 9.2 weeks for participants in the control group, compared with 21.4 weeks for those in the control group.  Although the treatment-by-time (study visit) interaction on follow-up CDRS-R scores was non-significant, members of the treatment group were significantly more likely to have a more favorable trajectory of YMRS scores over one year: the mean change in the slope for YMRS scores for those in the treatment group was -8.7 +/-10.9, compared with -4.4 +/-6.1 for those in the control group (d=0.49).

Regardless of treatment assignment, patients in high-expressed-emotion households took significantly longer to recover from their initial symptoms than patients in low-expressed-emotion households; 21.2 weeks for participants in high-expressed-emotion households, compared with 11.4 for participants in low-expressed-emotion households.  Patients in high-expressed-emotion households were also more likely to remain symptomatic: 35.7 percent for participants in high-expressed-emotion households, compared with 6.3 percent in low-expressed-emotion households.

Comorbid disorders had no significant relationship with time to full recovery or YMRS scores over time.

SOURCES FOR MORE INFORMATION

www.semel.ucla.edu/champ/resources

References

Miklowitz, D. J., Schneck, C. D., Singh, M. K., Taylor, D. O., George, E. L., Cosgrove, V. E. Howe, M. E., Dickinson, L. M., Garber, J., & Chang, K. D. (2013). Early intervention fro symptomatic youth at risk for bipolar disorder: A randomized trial of family-focused therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 121-131.

KEYWORDS: Children (3-11), Adolescents (12-17), Youth (16+), Males and Females (Co-ed), High-Risk, Clinic/Provider-based, Manual, Counseling/Therapy, Parent or Family Component, Depression/Mood Disorder, Social Skills/Life Skills, Parent-Child Relationship

Program information last updated on 9/15/2016.