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Section 11
Family-Focused Treatment of the Suicidal Bipolar Patient: Part One

Question 11 | Test | Table of Contents

Suicide is the third ranking cause of death among young persons in the US. Rates of suicide in the general population are highest in the 15–24 year old age group and are four times more likely to occur among males than females. Persons with bipolar disorder are at a 15-times greater risk for committing suicide than persons in the general population. Mortality ratios due to suicide may be as high as 15–20% among patients with bipolar or unipolar affective disorders. Up to 50% of bipolar patients attempt suicide at some point in their lives. The risk of suicide is particularly acute among pediatric-onset bipolar and unipolar patients. Suicidal thoughts and behaviors are closely linked with episodes of bipolar depression or mixed disorder. By extension, suicide risk can be chronic and persistent among bipolar patients whose depression symptoms are highly recurrent and/or do not easily remit with medication. Judd et al. found in a 12.8-year follow-up that bipolar adults spent 32% of their time in states of depression, in contrast to 9% in mania. Comparable results were found in a 9-month follow-up of children and adolescents with bipolar disorders.  These younger patients had a preponderance of depressive recurrences (55%) over manic (16%) or mixed recurrences (6.1%), and 15% made at least one suicide attempt or gesture during the follow-up.

Mood stabilizers are reasonably effective in controlling episodes of mania, but their effects on bipolar depressions are less impressive. Furthermore, clinicians are reluctant to prescribe antidepressant medications to depressed bipolar patients because of the risks of manic switching or rapid cycling and, among youth, suicidal thoughts or behaviors. Thus, pharmacological strategies to manage suicidal impulses are limited. Current clinical guidelines recommend that effective treatments for bipolar depression and suicidality should in most cases involve a combination of pharmacotherapy and psychosocial treatment. Disorder-specific psychosocial interventions have the potential to enhance pharmacotherapy in decreasing time to recovery from depressive or mixed episodes, reducing suicidal thoughts or behaviors and preventing recurrences. They may also reduce the need for complex poly pharmacy. This article describes the adaptation of family focused treatment (FFT) to the treatment of suicidality among adolescents and adults with bipolar disorder (for a general review of psychosocial interventions for children and adolescents with suicidal behaviors, see 14). Although FFT was not developed specifically for suicidal patients, it has been found to be highly effective in treating depression in  relapse-prone samples. In conducting studies of FFT, we have developed a number of clinical strategies for preventing suicidal behaviors. These strategies, while not yet empirically validated in clinical trials, form the core of this article.

The empirical basis of the treatment is reviewed, followed by a discussion of how the core components of FFT – psycho education, communication training and problem solving – are adapted to the needs of bipolar patients with suicidal ideation or behaviors, along with their families. In the final sections, we offer a case study, discuss issues relevant to bipolar patients from ethnic minority cultures and offer directions for future research.

The impact of family relationships on the course of bipolar disorder. 
Adjunctive family interventions are based on the empirical observation that disturbances in family environments are strong predictors of the course of bipolar disorder. Adult bipolar patients who come from family or marital environments  characterized by _high expressed emotion_ (high levels of criticism, hostility or emotional over involvement) have higher rates of relapse and poorer symptomatic outcomes during 9- to 12-month periods of follow-up than patients who come from family environments rated low on these attributes. One study found that the prognostic effects of family expressed emotion were specific to recurrences of bipolar depression.  In a 5-year follow-up of adult bipolar I patients, Gitlin et al. found that low levels of clinician rated family functioning were associated with a greater number of depressive episodes among bipolar I patients, although there was no association between family functioning and manic episodes.

Among pre pubertal and early adolescent bipolar youth, Geller et al. found that low levels of maternal warmth predicted faster relapse after recovery from mania. Data on depressive recurrences were not presented. These findings do not directly address the impact of family functioning on the likelihood of suicidal thoughts or behaviors among bipolar patients. However, high family stress and conflict, poor parent–child communication and low perceptions of family support have been found to be associated with completed suicides and attempts among non bipolar adolescents and adults in community and clinical settings. Adolescents who have been exposed to the suicide attempts of family members – a common experience among adolescents whose first-degree relatives have bipolar disorder – are more likely to think about or attempt suicide themselves.

Collectively, these findings underscore the importance of including family members in the treatment of bipolar adults or adolescents with suicidal ideation and behaviors. If family members are educated about the nature, causes and precipitants of bipolar episodes, learn to identify and avert precipitants of suicidal impulses and incorporate skills to improve communication and manage family conflict, the incidence of suicidal episodes among bipolar patients may diminish. Family-focused treatment (FFT) Family-focused treatment is a 9-month, 21 session outpatient intervention (12 weekly, 6 biweekly, and 3 monthly sessions) that includes patients of any age and their parents or stepparents, spouse, siblings or adult children. It is initiated during the stabilization period following an acute bipolar episode of any polarity. FFT commences with an assessment period in which areas of family conflict and/or lack of communication are identified. The treatment consists of three consecutive modules lasting between 5 and 10 sessions each. In the Psycho education module, clinicians offer the family concrete, didactic information about the symptoms, differential diagnosis, comorbidity, course, treatment and self-management of bipolar illness. The clinician explains the interactive roles of genetic and biological vulnerability factors with stress and coping in the disorder’s onset, and the roles of risk factors and protective factors in the disorder’s course.

A key component of psycho education is the _relapse drill_ or the planning during periods of stability for emergency intervention (medical or behavioral) when the patient’s moods start to deteriorate or when he or she becomes suicidal. Family members and patients recall previous periods of mood instability and identify sequences consisting of triggers, early warning signs of relapse and palliative measures. A prevention plan is then developed which may include elements such as _no suicide/no harm_ contracts, notifying the physician to determine the need for medication adjustments, avoiding alcohol or illicit substances and reducing stress triggers in the home. The Communication Enhancement Training module is designed to reduce unproductive interactions among family members and improve the quality of verbal and non-verbal exchanges. It is guided by the assumption that aversive communication reflects distress in the family’s attempts to cope with bipolar disorder. It uses a role-playing format to teach patients and their family members four skills: expressing positive feelings, active listening, making positive requests for changes in each others behaviors and constructive negative feedback. Finally, in the Problem Solving module, families are taught to identify and define specific areas of disagreement, generate and evaluate solutions to these problems, choose one or a combination of best solutions and develop a solution-implementation plan. For more information on the structure and content of FFT sessions, the reader is referred to the treatment manual.
- Miklowitz DJ, Bipolar Disorders 2006 Oct; Vol.8.

Personal Reflection Exercise #4
The preceding section contained information about family-focused treatment of the suicidal bipolar patient.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Prediction of Suicidality in Bipolar Disorder
Using Variability of Intrinsic Brain
Activity and Machine Learning

Tian, S., Zhu, R., Chen, Z., Wang, H., Chattun, M. R., Zhang, S., Shao, J., Wang, X., Yao, Z., & Lu, Q. (2023). Prediction of suicidality in bipolar disorder using variability of intrinsic brain activity and machine learning. Human brain mapping, 44(7), 2767–2777. https://doi.org/10.1002/hbm.26243

Peer-Reviewed Journal Article References:
Dejonckheere, E., Mestdagh, M., Houben, M., Erbas, Y., Pe, M., Koval, P., Brose, A., Bastian, B., & Kuppens, P. (2018). The bipolarity of affect and depressive symptoms. Journal of Personality and Social Psychology, 114(2), 323–341.

Goldberg, S. G. (2019). Narratives of bipolar disorder: Tensions in definitional thresholds. The Humanistic Psychologist, 47(4), 359–380.

Urošević, S., Halverson, T., Youngstrom, E. A., & Luciana, M. (2018). Probabilistic reinforcement learning abnormalities and their correlates in adolescent bipolar disorders. Journal of Abnormal Psychology, 127(8), 807–817.

QUESTION 11
What are are four components of the "relapse drill" technique for family-focused treatment? To select and enter your answer go to Test.

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