Family and bipolar disorder: where are we now?

Bipolar disorder is a mental illness characterized by severe high (mania or hypomania) and low (depression) moods that alternate with periods of relative stability (euthymia). Although the frequency and severity of the episodes vary from one individual to another, without an early and appropriate treatment, the number of relapses increase and the consequences of the episodes may lead to serious disability and suffering. Pharmacological treatment is essential in bipolar disorder but the advantages of combining it with psychological interventions may contribute to improving the prognosis of the illness and decreasing the personal, familial, social and economic burden.

The impact of bipolar disorder on the family
Bipolar disorder not only affects the patient but also their relatives, who suffer the consequences of the episodes and usually become the main caregivers. Every new episode is a stressful event that generates painful emotions, disrupts the patient’s life and family equilibrium. This leads to changes in the roles of each member and requires the development and adjustment of coping strategies. The role of caregivers can be very demanding and distressing especially when, as when it happens frequently, they have not received enough information, support and training to cope with the illness. The high level of burden experienced by caregivers can negatively affect their own mental and physical health, their quality of life and the course of the illness. It has been described a poorer family functioning when a member suffers from bipolar disorder. The impact of the illness on family functioning, caregivers’ burden and health highlights the importance of preventing relapses and introducing interventions that empower the family, replacing denial, fears and helplessness with acceptance, awareness and proactive care.

The impact of the family on the course of bipolar disorder
Some of the attitude and behavior of the relatives towards the person with the illness can act either as protective or as a risk factor for relapses. A high expressed emotion, defined as the the presence of relatives’ critical comments, hostility and/or emotional over-involvement, can contribute to a stressful atmosphere that may trigger relapses. Similarly, a demanding or intrusive style of communication has also been related to a worse course of the illness. Some studies have suggested that problems that are perceived by the relatives as within the patient’s control -even if they are not- tend to lead to criticism. Many reactions are the result of misunderstanding and lack of information about the condition, and are potentially modifiable through the use of pychoeducational interventions that help the family understand the illness and its treatment, correct false attributions, learn strategies to cope with the illness, and reduce stress and negative patterns of interaction.

Family intervention in bipolar disorder
The bidirectional relationship between bipolar disorder and the family system highlights the importance of adjunctive family intervention. Many evidence-based studies with follow-ups of 1-2 years, have shown positive effects of family intervention in the course of the illness, both in youth and adult population, and the benefits on caregiver burden and wellbeing. Family intervention not only reduces patients’ risk of relapses and functional impairment, but also improves the wellbeing of family members. There are methodological differences between studies and a high variability in the intervention used. However, the common components of most programs include psychoeducation, communication skills training, problem solving training, and promoting support and self-care for caregivers. In most studies family intervention is introduced after discharge or when the patient is stable, findings are more discrepant in the acute phase. The involvement of the relatives as a habitual part of the therapeutic management of bipolar disorder should be introduced as soon as possible and tailored to each patient and family characteristics and needs.

María Reinares
Bipolar Disorders Program, Institute of Neurosciences, Hospital Clínic, University of Barcelona, Spain



The role of family interventions in bipolar disorder: A systematic review.
Reinares M, Bonnín CM, Hidalgo-Mazzei D, Sánchez-Moreno J, Colom F, Vieta E
Clin Psychol Rev. 2016 Feb


Leave a Reply