Nursing -- Group Therapy Peer-reviewed literature regarding effective treatments of bipolar I disorder reveals that patients are significantly helped by family-focused or "family skills" therapy, particularly when dealing with depressive symptoms. However, studies also reveal that family therapy is less effective when dealing with manic episodes than are some other adjunctive treatments. Furthermore, quite a bit is as yet unknown about the relationship between family therapy and effective treatment of bipolar I disorder. Researchers lack evidence linking mania or hypomania factors to specific burdens on caregivers. In addition, families of bipolar patients undergo considerable stress and must struggle with limited and too often inaccessible avenues for their effective involvement. Finally, considerable additional study and focus is required so the health care industry can effectively incorporate relatives' thoughts, beliefs, attitudes, cultural identities and worldviews in operational structures and policy plans for the effective treatment of bipolar I disorder.

2. Body: Scholarly Presentation

a. Beentjes, T. A., Goossens, P. J., & Poslawsky, I. E. (2012). Caregiver burden in bipolar hypomania and mania: A systematic review. Perspectives in Psychiatric Care, 48(4), 187-197.

Beentjes et al. began with the hypothesis that a bipolar patient's impairments during mania episodes should be reflected correspondingly in the burden on informal caregivers, such as family members and friends. While literature review discerned that some characteristics of bipolar mania, such as aggression, lack of insight and financial difficulties, pose substantial encumbrances on caregivers, the literature does not sufficiently link mania or hypomania factors to specific burdens on caregivers. The researchers concluded that there is a need for more study to define the links between mania or hypomania and unambiguous burdens on caregivers.

b. Britta, B., Schaub, A., Kummler, P., Dittmann, S., Severus, E., Seemuller, F., . . . Grunze, H. (2006). Impact of cognitive-psychoeducational interventions in bipolar patients and their relatives. European Psychiatry, 21(2), 81-86.

Schaub et al. followed recent studies indicating that psychoeducational interventions for bipolar patients are effective in preventing relapses. Researchers employed 14 sessions with 62 bipolar patients in which the patients were given education about bipolar disorder, information about early warning signs of depression and mania, strategies for managing stress and social rhythm. Forty-nine relatives of those bipolar patients also attended 2 sessions of 4-hour workshops in which researchers gathered data about their demographics, care burdens, high expressed emotions regarding caregiving for bipolar patients and depressive symptoms. patients and relatives were assessed, before and after sessions, as well through a 1-year follow-up; Researchers found that both groups were better informed and more confident and that caretaker burdens and high expressed emotions were both reduced at the 1-year follow-up. The team concluded that a combination of psychoeducational intervention for both patients and their relatives greatly improved both groups' wellness and coping abilities.

c. Chatzidamianos, G., Lobban, F., & Jones, S. (2015). A qualitative analysis of relatives, health professionals and service users views on the involvement in care of relatives in bipolar disorder. BMC Psychiatry, (15).

Chatzidamianos, Lobban and Jones acknowledge the efficacy of relatives' involvement in the treatment of bipolar disorder; however, relatives complain that current health services are inadequate for their needs as caregivers. Though there are some avenues for their effective involvement, those are limited and too often inaccessible. Researchers interviewed 12 relatives of bipolar patients, 11 service users and 12 health care professionals in an attempt to discern common themes that might assist the health care industry in developing more effective involvement of relatives. Three common themes were developed: avenues for relatives' involvement are limited and sometimes inaccessible due to pre-existing worldviews, the quality of relationships and communications among all those involved and operational barriers within the health care industry. The team concluded that the health care industry must hypothesize the incorporation of relatives' thoughts, beliefs, attitudes, cultural identities and worldviews in operational structures and policy plans.

d. George, E. L., Taylor, D. O., Goldstein, B. I., & Miklowitz, D. J. (2011). Family focused therapy for bipolar adolescents: Lessons from a difficult treatment case. Cognitive and Behavioral Practice, 18(3), 384-393.

Researchers applied previously successful Family Focused Therapy -- A for bipolar adults to the cases of bipolar adolescents, modifying treatment for the special needs of adolescents. Application to a particularly difficult case revealed the need for future research and ways in which treatment may be improved specifically for adolescents with bipolar disorder.

e. Heru, A. M. (2012). Family therapy: The neglected core competence. Academic Psychiatry, 36(6), 433-5.

Heru discusses the unwarranted neglect of family therapy in the treatment of bipolar patients. Efforts to involve family therapy differ, often according to the patient's age. Child psychiatrists dealing with family therapy view it as "family intervention," a structured set of practices ideally altering family interaction, environment and parental functions. A broader view of family therapy deems...

Miklowitz, D. J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the evidence. American Journal of Psychiatry, 165(11), 1408-19.
Miklowitz explored the relative effectiveness of treatments adjunctive to pharmacotherapy for bipolar disorders, including group psychoeducation, systematic care, family therapy, personal therapy, and cognitive-behavioral therapy. Through 18 trials, Miklowitz discerned that family therapy is especially effective in preventing relapse after acute episodes of bipolar symptoms, particularly when dealing with depressive symptoms. Medication and early appreciation of symptoms are more effective when dealing with mania, while cognitive and interpersonal treatments such as family therapy are more effective when dealing with depression.

g. Miklowitz, D. J. (2012). Family-focused treatment for children and adolescents with bipolar disorder. Israel Journal of Psychiatry and Related Sciences, 49(2), 95-101.

Miklowitz reviewed the adaptation of traditional family-focused treatment to children and adolescents with bipolar disorder. Typically administered in 21 sessions over a 9-month period following an acute episode of hypomania, family-focused treatment involves: meeting; psychoeducation; training in communications enhancement; and development of problem-solving skills. Through randomized trials, researchers find that the addition of family-focused treatment assists children, adolescents and adults in more rapid recovery from bipolar episodes and longer periods of remission between episodes. However, there are problems in propagating family interventions in community situations.

h. Morris, C. D., Miklowitz, D. J., & Waxmonsky, J. A. (2008, January 13). Family-focused treatment for bipolar disorder in adults and youth. Retrieved from www.ncbi.nlm.nih.gov: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2194806/

Electronic research led to this peer-reviewed article on the web site sponsored by the National Center for Biotechnical Information. Morris et al. explore effect of high EE (expressed emotion) family members on bipolar patients. High EE individuals are deemed those who express a high number of criticisms, hostile statements and/or emotional over-involvement (such as being overprotective, exhibiting exaggerated responses or exhibiting inordinate self-sacrifice) in discussing their relatives with bipolar disorder. Not surprisingly, High EE family members hamper the treatment of bipolar patients. The most effective "biopsychosocial" family-focused approach to bipolar disorder balances risks with protective factors by: stable routines; consistency in caretaking and external structure. This balance assists children with bipolar disorder in developing internal controls and emotional self-regulation. The researchers also describe the application of the "biopsychosocial" approach to bipolar patients, ideally in early stages.

i. Nadkarni, R. B., & Fristad, M. A. (2012). Stress and support for parents of youth with bipolar disorder. Israel Journal of Psychiatry and Related Sciences, 49(2), 104-10.

Nadkarni and Fristad explored the exceptional stress associated with parenting children with bipolar disorder, and the association of that stress with immunological abnormalities. Though the study sample was small and demographically restricted, researchers tested 26 parents of children with bipolar disorder and found they experienced stress, depression and illness/immune abnormalities. When tested, those parents showed associations between parenting children with bipolar disorder and stress, immune abnormalities, health conditions and mental health difficulties. The researchers conclude by calling for further study to develop greater support for these caregivers.

j. Parikh, S. V. (2014). Brief versus intensive psychosocial treatments for bipolar disorder: Time for stepped care? American Journal of Psychiatry, 171(12), 1335.

Dr. Parikh espouses a centralized stepped-care approach to treating patients with bipolar disorder. He argues that studies show brief psychoeducational intervention to be often as effective as family-focused therapy but with significantly lower cost, greater standardization, greater access, fewer staff and less training. Parikh suggests three to six sessions delivered from a central location via telephone or the internet for every bipolar patient, requiring fewer staff, less training, uniformity, lower costs and greater access to all patients. Screening after these sessions can identify patients requiring higher intensity treatment, such as family-focused treatment and cognitive behavioral therapy, due to persistent dysfunction or family problems.

k. Prasko, J., Ociskova, M., Kamaradova, D., Sedlackova, Z., Cerna, M., Mainerova, B., & Sandoval, A. (2013). Bipolar affective disorder and psychoeducation. Neuroendocrinology Letters, 34(2), 83-96.

Prasko et al. conducted an electronic search of PUBMED, Web of Science, Scopus and published reviews to determine treatments that should augment the use of medications to treat bipolar disorder. Using the search terms of "bipolar disorder," "psychoeducation," "psychotherapy," "psychosocial treatment,," "family therapy" "individual therapy," "group therapy," and "psychoeducation" in the abovementioned databases, researchers found strong…