Jeffrey A. Richards

Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy

BACKGROUND Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder. This study used a randomized, controlled design to examine a 9-month, manual-based program of family-focused psychoeducational treatment (FFT). METHODS Bipolar patients (N = 101) were recruited shortly after an illness episode and randomly assigned to 21 sessions of FFT (n = 31) or to a comparison treatment involving two family education sessions and follow-up crisis management (CM; n = 70). Both treatments were delivered over 9 months; patients were simultaneously maintained on mood stabilizing medications. Patients were evaluated every 3 months for 1 year as to relapse status, symptom severity, and medication compliance. RESULTS Patients assigned to FFT had fewer relapses and longer delays before relapses during the study year than did patients in CM. Patients in FFT also showed greater improvements in depressive (but not manic) symptoms. The most dramatic improvements were among FFT patients whose families were high in expressed emotion. The efficacy of FFT could not be explained by differences among patients in medication regimes or compliance. CONCLUSIONS Family-focused psychoeducational treatment appears to be an efficacious adjunct to pharmacotherapy for bipolar disorder. Future studies should evaluate family treatment against other forms of psychotherapy matched in amount of therapist-patient contact.

Stressor and resilience factors for lesbians, gay men, and bisexuals confronting antigay politics.

When lesbian, gay, and bisexual (LGB) people encounter antigay campaigns and elections, they face explicit and implicit homophobic attacks. In order to understand the points of stress and the bases for resilience in the face of these attacks, we developed a 130-item quantitative survey on the basis of results of an earlier qualitative study. Three hundred, sixteen Colorado LGB people endorsed items representing sources of stress and sources of resilience associated with the campaign for and passage of an antigay referendum. Factor analyses of the results suggested 5 sources of stressors and 5 sources of resilience for LGB persons and their communities.

Early-onset bipolar disorder: a family treatment perspective.

Mood disorder symptoms and their associated functional impairments are hypothesized to come about as the result of the conjoint, interactive influences of genetic, biological, and psychological vulnerabilities, family distress, and life stress at different points of development. We discuss a developmental psychopathology model that delineates pathways to high family conflict and mood exacerbation among early-onset bipolar patients. New data from a treatment development study indicate that adolescent bipolar patients in high expressed emotion families have more symptomatic courses of illness over 2 years than adolescents in low expressed emotion families. Chronic and episodic stressors are also correlated with lack of mood improvement while adolescents are in treatment. Family-focused treatment (FFT) given in conjunction with pharmacotherapy appears to ameliorate the course of bipolar disorder in adults. This treatment has recently been modified to address the developmental presentation of bipolar disorder among adolescents. We present data from an open trial of FFT and pharmacotherapy (N = 20) indicating that bipolar adolescents stabilize in mania, depression, and parent-rated problem behaviors over 2 years. Future research should focus on clarifying the developmental pathways to early-onset bipolar disorder and the role of protective factors and preventative psychosocial interventions in delaying the first onset of the disorder.

Magnetic resonance imaging in schizophrenia: relationship with clinical measures

Relationships were examined between clinical features of schizophrenia and cerebrospinal fluid (CSF) volume in brain obtained by magnetic resonance imaging (MRI) in a sample of 59 patients. The volumes of the cerebral hemispheres and CSF were measured with a computer program designed to separate reliably neural tissue from CSF. The CSF to cranial volume ratios were related to history, symptom profile and outcome functioning. Earlier age of onset was associated with higher sulcal CSF ratio, r = -0.40. The anatomic measures were unrelated to symptom severity. However, patient subtypes differed in the laterality of measures. Higher left hemispheric ratios were seen in patients with severe negative symptoms, and left predominance of ventricular relative to sulcal ratios was associated with the presence of hallucinations and delusions. The results suggest that while higher CSF is related to earlier age of onset, the clinical symptoms are more related to its lateralization. This is consistent with the hypothesis that schizophrenia is a lateralized brain disease.

A method for classifying the course of bipolar I disorder

Our objective was to determine whether the long-term course of bipolar disorder could be classified into distinct categories based on specifiable course characteristics. We used retrospective data on the severity, duration, and polarity of episodes, and on interepisode functioning, to describe the life trajectories of 56 bipolar patients. Using pictorial representations from a Life Chart software program, we identified seven distinct course types. Interrater reliability for classification of patients into these course types was high. Post-hoc analyses revealed significant relationships between the broader dimensions underlying the proposed course types (i.e., primarily manic vs. mixed symptom profiles) and traditional course of illness variables (e.g., the number of lifetime hospitalizations). This course classification method may provide a means for documenting progress in behavior therapy outcome studies.

Bipolar Disorder and Family Psychoeducational Treatment: A Comparison of One-Year Effects Using Repeated Measures Analysis of Variance and Random Regression Models

Bipolar disorder manifests over time in a recurrent or episodic manner. Symptoms progress and recede in fluctuating patterns of frequency, severity and duration, as well as shifts in mood valence (Goldberg et al., 1995). Investigators interested in describing bipolar disorder longitudinally, particularly those assessing outcome in treatment efficacy research, must determine how best to capture these fluctuations (Coryell and Winokur, 1992). One may conceptualize the course of the disorder in various ways, each of which carries strengths and weaknesses. One common approach is to address symptom severity, which is assessed at select time points, and measure change from baseline to a specific time (e.g., percentage decrease at 12 months) or across select time points. Others have focused on understanding the bipolar symptom course in terms of events. For example, Frank et al. (1991) proposed operational criteria for the course event descriptors remission, recovery, relapse, and recurrence based on symptomatic variation in severity and duration. Thus, treatment efficacy may be shown by establishing a longer time to relapse or shorter time to remission, by comparing duration of time spent in a symptomatic state, or simply by counting the number of episodes occurring during a follow-up period.