The course of bipolar disorder is marked by relapses and remissions, even when patients are maintained on appropriate pharmacotherapy. This variability in illness course may occur in part because the disorder is affected by socioenvironmental stressors, particularly significant life events and high-conflict family relationships. Considering these factors, clinicians have focused more attention on psychosocial treatments as useful adjuncts to pharmacotherapy. In this article, a psychosocial treatment program known as family-focused psychoeducational treatment (FFT) is described. Delivered in combination with pharmacotherapy during the postepisode stabilization period, FFT begins with an assessment of the family or marital environment. Then, in three consecutive, modules, participants receive education about the nature, causes, and treatment of bipolar disorder, communication enhancement training, and problem-solving skills training. The overall goals of the program are to restore family equilibrium and improve the patient's clinical functioning after the acute-illness episode. A case study illustrating the approach is presented, and the future directions of FFT are reviewed.

Network meta-analysis (NMA) is a statistical technique for making direct and indirect comparisons between different treatment and control groups. Despite its many advantages, NMA may be misleading when evaluating networks that are disconnected, inconsistent or of low reliability and validity. We review how well the analysis of trials of adjunctive psychosocial treatment in bipolar disorder is served by NMA. We conclude with recommendations for future treatment trials in bipolar disorder and guidelines for NMAs.

A growing body of evidence documents the value of structured psychotherapeutic interventions for the co-management of bipolar disorder in the context of ongoing medication treatment. This article reviews the rationale, elements, and outcomes for those psychosocial treatments for bipolar disorder that have been emmined in randomized trials. The available evidence suggests that interventions delivered in individual, group, or family settings, can provide significant benefit to patients undergoing pharmaco-theraby for bibolar disorder.

This article examines how bipolar symptoms emerge during development, and the potential role of psychosocial and pharmacological interventions in the prevention of the onset of the disorder. Early signs of bipolarity can be observed among children of bipolar parents and often take the form of subsyndromal presentations (e.g., mood lability, episodic elation or irritability, depression, inattention, and psychosocial impairment). However, many of these early presentations are diagnostically nonspecific. The few studies that have followed at-risk youth into adulthood find developmental discontinuities from childhood to adulthood. Biological markers (e.g., amygdalar volume) may ultimately increase our accuracy in identifying children who later develop bipolar I disorder, but few such markers have been identified. Stress, in the form of childhood adversity or highly conflictual families, is not a diagnostically specific causal agent but does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. A preventative family-focused treatment for children with (a) at least one first-degree relative with bipolar disorder and (b) subsyndromal signs of bipolar disorder is described. This model attempts to address the multiple interactions of psychosocial and biological risk factors in the onset and course of bipolar disorder.

This study investigates the associations between perceived stigma, depressive symptoms and coping among caregivers of people with bipolar disorder. Caregivers of 500 people with DSM–IV bipolar disorder responded to measures of these constructs at study entry Patients' clinical and functional status were evaluated within 30 days of the caregiver assessment. Perceived stigma was positively associated with caregiver depressive symptoms, controlling for patient status and socio-demographic factors. Social support and avoidance coping accounted for 63% of the relationship between caregiver stigma and depression. Results suggest that caregivers' perceptions of stigma may negatively affect their mental health by reducing their coping effectiveness.

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.This research was supported by National Institute of Mental Health Grants MH43931, MH62555, and MH073871; a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression; and a grant from the Robert Sutherland Foundation.

Bipolar disorder (BD) is a chronic, recurrent disorder carrying high morbidity and mortality, leading to health costs of at least $45 billion per year (Kleinman et al., 2003). It is the sixth leading cause of disability among all illnesses (Murray & Lopez, 1996). Between 15 and 28% of bipolar adults experience illness onset before the age of 13, and between 50 and 66% of them experience it before the age of 19 (Leverich et al., 2002, 2003; Perlis et al., 2004). The exact prevalence in children is unknown, but an estimated 420,000–2,072,000 US children have the illness (Post & Kowatch, 2006). Persons with onset of BD in childhood or adolescence have a more severe, adverse, and continuously cycling course of illness than adults, often with a preponderance of mixed episodes, psychosis, suicidal ideation or behaviors, and multiple comorbidities (Geller et al., 2002). Without early intervention, early-onset BD patients can be derailed, sometimes irrevocably, in social, neurobiological, cognitive, and emotional development (Miklowitz et al., 2004).Our work on this Special Issue and editorial was partially supported by grants from the National Institute of Drug Abuse, the National Institute of Mental Health, and the Spunk Fund, Inc.

Family systems theory has been highly influential in the study of recurrent psychiatric disorders. This review examines two interrelated domains: research on expressed emotion (EE) attitudes among relatives (criticism, hostility, or emotionally overinvolvement) and relapses of schizophrenia or bipolar disorder, and randomized trials of family intervention in these populations. The literature is discussed in terms of contemporary systems theory and concepts from developmental psychopathology research. Several conclusions are drawn: (a) levels of EE are correlated with caregivers' attributions regarding the controllability of patients' behaviors; (b) EE attitudes are associated with bidirectional, mutually influential cycles of interaction between relatives and patients; and (c) family psychoeducational therapy, when combined with pharmacotherapy, is associated with lower rates of relapse in schizophrenia and bipolar illness. Underlying disturbances in family systems may emerge in response to illness symptoms in a family member, but also have recursive effects on the developmental course of the illness once manifest. The nature and stability of these recursive effects will depend on dynamic processes in the patient, the relative, and their relationship. Future research should elucidate mediating and moderating variables in the pathways from EE to patients' outcomes, and the conditions under which family treatments bring about favorable outcomes of psychiatric disorder.Preparation of this article was supported by Grant MH62555 from the National Institute of Mental Health and a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression. The author thanks Martha Tompson for her conceptual input.

Research in the field of interpersonal behaviour is widely recognised as an important key to understanding the nature of mental illness. In schizophrenic patients especially, deviant social interaction has been proved to be associated with pathological behaviour (see Bellack et al, 1989). Numerous studies have revealed that affective attitudes expressed towards the patient by a relative during hospital admission for an episode of schizophrenia (high expressed emotion (EE)) are predictive of the short-term course of the disorder (Leff & Vaughn, 1985; Jenkins et al, 1986; Nuechterlein et al, 1986; Mintz et al, 1987).

A number of recent studies (Leff & Vaughn, 1985; Nuechterlein et al, 1986; Jenkins et al, 1986; Mintz et al, 1987) have indicated that attitudes of family members towards a relative with schizophrenia (termed High Epressed Emotion (EE)), are predictive of the short-term course of the patient's disorder. The measure used to define EE status of a relative is a semi-structured interview, the Camberwell Family Interview (CFI) (Vaughn & Leff, 1976), which is usually administered shortly after the patient is admitted to hospital for an index episode of the disorder.

Measures of parental affective style were compared for families of schizophrenics participating in a controlled treatment study which contrasted individual and family-based therapeutic programmes. The total number of critical statements and non-critical, intrusive remarks was significantly lower after three months for parents of schizophrenics participating in family therapy, compared to those whose offspring received only individual therapy. An increased risk for relapse was associated with an increase in the number of critical and/or intrusive remarks for patients in individual treatment. A significant increase in non-emotional, problem-solving statements was observed in parents who received family therapy, compared with those who did not. The results suggest that a behaviourally-oriented, problem-solving family approach may have reduced the risk of relapse in the first nine months after discharge from hospital by teaching families concrete ways of solving problems and concomitantly reducing the amount of negative emotional relating between family members.

Measures of intrafamilial expressed emotion (EE) predict relapse in schizophrenic patients, but previous research has not investigated whether EE scores are representative of ongoing family transactions. Parents of 42 hospitalized schizophrenic patients were rated for level and type of EE. Following the patient's discharge, families participated in two 10-minute direct interaction tasks. Transcripts from these interactions were coded on dimensions of affective communication.

High-EE parents exhibited more negatively charged emotional verbal behaviour in direct transaction with their schizophrenic offspring than did low-EE parents. Some parents rated high-EE were distinguished by their frequent usage of critical comments during the interactions, whereas high-EE overinvolved parents used more intrusive, invasive statements. These findings support the construct validity of expressed emotion.