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Family focused therapy is more effective than crisis management for preventing relapse after a bipolar episode
  1. Ari E Zaretsky, MD FRCP(C)
  1. Assistant Professor, Department of Psychiatry, University of Toronto,
    Toronto, Canada

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Q For outpatients with a recent bipolar episode, does family focused therapy reduce relapse and improve adherence to drug treatment compared with a less intensive crisis management intervention?


Embedded ImageDesign:

Randomised controlled trial.

Embedded ImageAllocation:


Embedded ImageBlinding:

Participants and practitioners not blinded. Blinded observers assessed results for treatment adherence.

Embedded ImageFollow up period:

Up to 24 months.

Embedded ImageSetting:

Outpatient clinic, Colorado, USA.

Embedded ImagePatients:

101 people (18–62 years; mean age 36 years; 64 women) with bipolar disorder episode (DSM IIIR and DSM IV, diagnosed by Structured Clinical Interview) within past 3 months; with family support. Exclusions: neurological or developmental comorbidity; recent substance misuse. Participants recruited from inpatient and outpatient settings.

Embedded ImageIntervention:

Family focused therapy or crisis management. Concomitant drug therapy and other aspects of usual care were permitted in both groups as needed. Family focused therapy: 20 one hour long sessions over nine months, delivered by trained therapists, consisting of psychoeducation; communication enhancement, and problem solving skills training. Crisis management: two one hour family education sessions in the home in the first two months, followed by crisis intervention sessions as needed to resolve family conflicts and prevent relapse.

Embedded ImageOutcomes:

Relapse; adherence to drug therapy (rated from 1 (poor adherence) to 3 (good adherence)) based on patient, physician, and family report.

Embedded ImagePatient follow up:

Family focused therapy: 22/31 (71%) up to 24 months; crisis management: 43/70 (61%) to 24 months.


Family focused therapy resulted in fewer relapses compared with crisis management (35% v 54%, p<0.005). Family focused therapy significantly increased time to relapse compared with crisis management (intention to treat analysis; mean time to relapse: 74 weeks with family focused therapy v 53 weeks with crisis management; hazard ratio: 0.38; 95% CI 0.20 to 0.75). Family focused therapy improved adherence with drug therapy compared with crisis management (mean adherence score: 2.77 with family focused therapy v 2.56 with crisis management; p = 0.04).


Family focused therapy reduces relapse and improves drug adherence compared with crisis management in people with a recent bipolar episode.


The authors of this study have added to a recently burgeoning literature that attests to the feasibility and efficacy of manualised, psychosocial interventions as adjuncts to pharmacotherapy in the treatment of bipolar disorder.1–,4 The authors are to be commended for conducting a randomised controlled trial with a credible control intervention and for following bipolar patients for 15 months after the protocol ended. Family focused therapy conferred a clinically significant protection against relapse and time to relapse compared with basic psychoeducation and crisis management.

What still remains to be established is the mechanism of family focused therapy and other empirically supported psychosocial interventions such as cognitive behavioural therapy and psychoeducation. All of these interventions share an emphasis on psychoeducation and self monitoring in order to increase medication adherence and identify the prodromal symptoms of relapse. It remains to be seen whether more treatment specific interventions, such as cognitive restructuring techniques in cognitive behavioural therapy or communication training techniques in family focused therapy, are actually active ingredients. In addition, none of the recent studies to date has rigorously controlled for treatment intensity as well as medication intensity (which might have changed in those patients who were monitored more closely).



  • For correspondence: Professor D J Miklowitz, Deprtment of Psychology, Dvaie Hall, Campus Box 3270, University of North Carolina at Chapel Hill, Chapel Hill NC 27599-3270;

  • Sources of funding: National Institute of Mental Health, USA; National Alliance for Research on Schizophrenia and Depression, Chicago, USA; John D and Catherine T MacArthur Foundationm Network on the Psychology of Depression, Chicago, USA.

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