David Miklowitz on Treating Bipolar Disorder

By Lynn Mollick

            On April 29, David J. Miklowitz presented “Family-Focused Therapy (FFT) of Bipolar Disorder,” NJ-ACT’s 18^th annual Master Lecture. Dr. Miklowitz asserted that medication is not sufficient to treat bipolar disorder, and psychotherapy adds significantly to outcome because:

            a) Although medication is a potent treatment for mania, it is less effective for the depressive phase of the disorder, and antidepressants sometimes precipitate mania.

            b) Even when they receive medication, bipolar patients are symptomatic about 50% of their lives.

            c) Medicated Bipolar I adults who received Dr. Miklowitz’s Family-Focused Treatment (FFT) relapsed significantly less often than similar patients who received Crisis Management. The difference between treatments was evident at 2-year follow-up and increased over time.

            d) In the same study, FFT had a stronger influence on depression than on mania.  

            e) Three empirically-supported treatments – FFT, Cognitive Therapy and Interpersonal Therapy – are equally effective in achieving symptom remission for depressed bipolar patients. Symptom remission was reached in an average of 169 days for patients in the three treatment groups compared to 268 days for patients who received a 3-session control treatment.

            The FFT protocol prescribes 21 sessions delivered over 9 months. The entire family is present at every session. But the approach is flexible, and Dr. Miklowitz believes that it is more important to cover all concepts and information in FFT than it is to follow the protocol precisely. Components of FFT are:

            1. Psychoeducation about mood disorders. During assessment and early FFT sessions, the patient’s symptoms are used to explain the patient’s bipolar disorder diagnosis. Covered issues include:

• This patient’s signs and symptoms of mania and depression.
• How mania and depression are different from the patient’s personality and temperament.
• How the patient’s other problems are different from or overlapping with Bipolar Disorder, ADHD, substance abuse, conduct and anxiety disorders, and other co-morbidities.

 Distinguishing Bipolar disorder from ADHD:

• Bipolar Disorder is episodic, but ADHD is not.
• Bipolar patients are almost always grandiose; ADHD patients seldom are.
• 60% of bipolar patients become psychotic, but ADHD patients never do.    

Dr. Miklowitz teaches patients to use terms correctly:

• Hypomania is elevated mood, rapid speech, and increased activity that does not interfere with functioning.
• Bipolar II is Hypomania with Major Depression.
• Rapid cycling means having 4 or more manic episodes in one year.
• Mixed bipolar means meeting the criteria for both a manic episode and a depressive episode nearly every day for at least one week.

            2. Explaining risk factors and implementing prevention measures. Relapse is more likely when patients abuse alcohol and drugs, don’t get adequate sleep, and/or experience stress or interpersonal conflict, especially family conflict. Relapse is less likely when patients take medication regularly, receive family and social support, attend therapy appointments, and solicit help when needed from family and professionals. 

            3. Identifying early warning signs and implementing episode prevention plans.Especially at the beginning of treatment, keeping a daily symptom and mood diary helps the family recognize problems before they escalate into manic episodes. Chain analysis is more helpful in identifying early warning signs than didactic discussions or reading assignments. According to Dr. Miklowitz, making specific plans for handling early warning signs of manic episodes is the most important component of FFT.      

            4. Accepting the patient’s genetic and biological vulnerability and the ongoing necessity for psychotropic medication. Bipolar Disorder is highly heritable. Vulnerability is lifelong, and an early onset is associated with worse prognosis.

            Lithium, Zyprexa, Lamictal, and Abilify all prevent relapse, but often are accompanied by unwanted side effects such as weight gain, diminished creativity and lack of sex drive. Find out what side effects mean to the patient and see if the problem can be relieved. Ask patients to disclose if they want to change, reduce, or stop medication. Collaboration is the key. Dr. Miklowitz recommends, but does not insist that patients be medicated at all times. 

            5. Recognizing and coping with stressful events that may trigger recurrences. FFT teaches communication and problem-solving skills: active listening, making positive requests, and expressing negative feelings about specific behaviors. Learning these behaviors reduces expressed emotion and prevents relapse.

            6. Re-establishing functional family relationships after an episode. Once families can communicate and solve problems effectively, they can work on undoing the damage that occurs to family relationships during bipolar episodes. Parents and spouses can also learn stress management strategies.

@2012 NJ-ACT. All rights reserved.