Elsevier

Clinical Psychology Review

Volume 43, February 2016, Pages 47-57
Clinical Psychology Review

The role of family interventions in bipolar disorder: A systematic review

https://doi.org/10.1016/j.cpr.2015.11.010Get rights and content

Highlights

  • There is a mutually influential relationship between the illness and the family system.

  • Adjunctive family interventions seem to improve the illness outcomes and caregivers' wellbeing.

  • Family interventions should be tailored based on patient characteristics and family needs.

  • Relatives' involvement should form part of the therapeutic approach in BD.

Abstract

The reciprocal relationship between bipolar disorder (BD) and the family system highlights the importance of adjunctive family intervention. However, its implementation in clinical practice is not widespread. To update the knowledge in this field and identify areas of uncertainty this manuscript present a comprehensive overview of the bidirectional relationship between BD and family variables, and a systematic review of the evidence-based studies published up to March 2015 on the efficacy of adjunctive family intervention in BD. Findings show that not only specific family's attitudes/interactions affect the course of BD but that equally the illness itself has a strong impact on family functioning, caregivers' burden and health. Regarding family intervention, there are methodological differences between studies and variability in the sample characteristics and the intervention used. Most evidence-based studies support the efficacy of adjunctive family treatment in the illness outcomes, both in youth and adult population, as well as benefits for caregivers. The results emphasize the need to involve caregivers in the therapeutic management of BD through tailored interventions based on patients' characteristics and family needs.

Introduction

Bipolar disorder (BD) is characterized by a substantial rate of recurrences (Gignac, McGirr, Lam, & Yatham, 2015), persistent symptoms (Baldessarini et al., 2010) and functional impairment (Rosa et al., 2011, Tohen et al., 2000), contributing to locate the disease among those that constitute the main leading cause of disability (Catala-Lopez, Genova-Maleras, Vieta, & Tabares-Seisdedos, 2013). The illness not only affects the patient but also their relatives, who suffer the consequences of the episodes and usually become the main caregivers. Every new relapse is a stressful event that generates painful emotions, disrupts the patient's life and familial equilibrium leading to changes in the roles of each member, and requires the development and adjustment of coping strategies. It is common for caregivers to neglect theirs and other family members' needs by taking care of the patient; and, even when the patient is in remission, the fear of future episodes is present. The role of caregivers can be very demanding and distressing especially when, as happens frequently, they have not received enough information, support and training in coping strategies (Reinares, Colom, Martinez-Aran, Benabarre, & Vieta, 2002). The high level of distress experienced by caregivers can negatively affect their own mental and physical health (Steele, Maruyama, & Galynker, 2010), their quality of life (Zendjidjian et al., 2012) and the illness outcomes (Perlick, Rosenheck, Clarkin, Raue, & Sirey, 2001). Moreover, social environment in the form of adversities and life events (Gilman et al., 2014) as well as family attitudes such as high expressed emotion (Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz, 1988) and negative affective style (O'Connell, Mayo, Flatow, Cuthbertson, & O'Brien, 1991), plays a crucial negative role in the course of BD. It seems clear therefore that there is a bidirectional relationship between the illness and the family that should be taken into account when planning the therapeutic approach.

In 2007, a meta-analysis of family intervention elaborated by Justo, Soares, and Calil (2007) concluded that there was only a small and heterogeneous body of evidence on the effectiveness of family oriented approaches as an adjunctive treatment for BD. Research in this field has increased substantially in the last 10 years. However, its implementation remains a potential goal that has not yet been translated into extended use in clinical practice in the field of BDs. Adjunctive psychological interventions, and family intervention in particular, might reduce both the personal and financial burden derived from BD to the patient, the relatives and society as a whole (Reinares, Sanchez-Moreno, & Fountoulakis, 2014). To analyze the outcomes obtained using family intervention in randomized-controlled trials and to have a better understanding of the relationship between all the variables involved would lead to design more effective and efficient approaches based on individual needs.

In order to draw a more comprehensive picture of the complex relationship between the illness and the family, the aims of this review were focused on 1) the impact of BD on the family, 2) the impact of the family on the illness outcome, 3) family functioning when a member suffers from BD, and 4) systematic review of the evidence-based studies on the efficacy of family intervention in BD. The role of potential treatment moderators — for whom and under what conditions the treatment works (including variables related to the patient, the family and the illness) — and mediators — the mechanisms through which the treatment achieves its effects —, the limitations of current studies and the main areas of uncertainty will also be discussed in order to guide future research.

Section snippets

Methods

The methods were divided into two phases. Firstly, an overview was conducted on the relationship between BD and family variables (expressed emotion, affective style, family environment, family functioning, family burden and caregivers' burden). Secondly, a systematic review was performed to identify studies on family intervention in BD published until March 2015, using PubMed, Scopus and Web of Science databases, and the terms family intervention, family therapy, family psychoeducation, family

Results

Different areas of research were identified and the results were structured into the four following sections: impact of BD on the family; impact of the family on the course of BD; family functioning when a member suffers from BD; and systematic review of family intervention in BD.

Discussion

This review highlights the complex, bidirectional and dynamic relationships between BD and the family. Despite the differences between studies in terms of intervention format, duration, settings, comparison group and clinical state of the patients at implementation, most studies support the benefits of adjunctive family intervention on both the illness outcomes and caregivers wellbeing. The main findings will be summarized in order to identify limitations of current research and areas of

Acknowledgments

This research has been partially supported by the postdoctoral fellowship Beatriu de Pinós granted by the Agency for Management of University and Research Grants (AGAUR), expedient number 2013 BP_B 00195, agency of the Secretariat of Universities and Research under the Department of Economy and Knowledge of the Catalan Government, and the Marie Curie-COFUND actions of the Seventh Framework Programme of Research and Technological Development of the European Union; as well as the Biomedical

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