Engaging the Family in the Treatment of Bipolar Disorder

As many as half of people with chronic psychiatric disorders such as bipolar disorder (BD) don’t consistently take their prescribed medications. The consequences—an increased risk of suicide, hospitalizations, social and work impairment, and medical problems—can be quite damaging, not only for the patient but for their families. What can be done?

The psychosocial treatment that my colleagues and I developed for bipolar illness, family-focused therapy (FFT), engages the patient and family members in an ongoing process of psychoeducation about BD and training in communication and problem-solving skills (Miklowitz, 2010, 2019). One of its subsidiary goals is to enhance the patients’ acceptance of mood-stabilizing medications. In this article, I offer suggestions as to how psychologists, in conjunction with the treating physician, can work with the family to enhance the goals of pharmacological treatments.

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Causes of nonadherence

Why would a person stop taking medications that would almost certainly reduce their risk of illness recurrences? The research literature emphasizes intolerable side effects (e.g., weight gain, hand tremors), financial burden, lack of insight into the condition, questions about the effectiveness of medications, or reactions to the physician or treatment environment. In our view, the patient’s relationships with family members (and their different views about the illness and its treatments) are potent factors in determining why some individuals accept medications and others reject them entirely.

When a clinician encounters a person with BD who has refused medications, it is useful to start with a chain analysis: What sequence of thoughts, feelings, and events prompted the decision to stop medications (or to refuse them when first recommended)? What were the contributions of side effects, disbelief in the diagnosis, or societal stigma? Are there family dynamics contributing to this decision? Usually, family caregivers are supportive and recognize the need for the patient to be on board with their treatments. However, in their attempts to assure the patient’s commitment to medications, some caregivers unwittingly contribute to nonadherence.

Engaging the family as an ally in treatment

The first module of FFT consists of four or more sessions of psychoeducation, where clinicians explore the meaning of the bipolar diagnosis to the patient and family members: how are episodes of mania and depression experienced by the patient, and how is that different from what parents or spouses see? What are the early warning signs of recurrences, and what can the patient, the family, and the treatment team do when these early signs appear? In the context of this discussion, the patient’s feelings about medications like lithium, valproate, lamotrigine, or antipsychotics (e.g., risperidone) often come to the fore. Consider the following clinical scenario:

Liam, an 18-year-old former patient with bipolar I disorder (name and identifying details changed), was hospitalized for two weeks with a manic episode. He was discharged from the hospital to live with his mother and sisters. He was ambivalent about taking his daily regimen of four 300 mg lithium tablets and depended on his mother to fill his prescriptions and arrange psychiatry appointments. He was still symptomatic when he came home, and his mother reacted by asking him, almost compulsively, whether he had taken his lithium that day. In what he described as “a blow for freedom,” he began leaving lithium tablets around the house for her to find: on the counters, behind the toilets, even underneath her pillow. When they began attending FFT, she was threatening to kick him out of the house.

Liam acknowledged that he needed lithium but was only willing to take it if he could decide for himself. His mother wondered aloud how she would know if he was being adherent. Through a structured problem-solving exercise in FFT, they agreed that: (1) taking lithium was fully his decision; (2) she was only to ask him about the tablets if she found any around the house, and then at most once a day; (3) he agreed to let her know when he was running out; and (4) he allowed her to communicate with his physician to exchange information about his compliance and lithium levels. Although Liam never fully warmed to taking lithium, his mother’s willingness to back off from over-monitoring helped him remain adherent after his hospital discharge.

In this example, lithium nonadherence became a proxy battle for Liam’s quest for independence and autonomy. Ironically, his unwillingness to be adherent increased the chances that he would have another illness recurrence and be even more under his mother’s thumb. But he knew of no other way to express his resentment.

What if caregivers don’t agree on the need for medications?

Sometimes, a patient’s unwillingness to take medications reflects an alliance with one of two parents against the other. Greta, a 13-year-old patient (name and identifying details changed), had “unspecified BD,” a common diagnosis in adolescent patients. She had a history of recurrent hypomanic episodes lasting one or two days each, during which she became irritable, spoke and ate rapidly, slept little, became highly distractible, and seemed full of energy. Her “crashes” involved full withdrawal into her bedroom, often missing school for weeks at a time.

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Greta’s parents were separated and on their way to a divorce. She lived with her mother for one week and then with her father for the next in a 50/50 custody arrangement. FFT sessions were arranged separately for the two dyads. Conflict and tension between the parents, and between Greta and each parent, were salient.

About four weeks into FFT, during a session with her mother, Greta announced that she was no longer taking lamotrigine, which had been prescribed at a low dose of 50 mg. With gradual inquiry, she revealed that her father did not believe she had BD and had told her that she didn’t have to take lamotrigine or any other medication at his house. In a follow-up phone call between the FFT clinician and the father, he said, “I don’t think she gets along with her mother. That’s why she has mood swings. She doesn’t need pills.”

A conjoint session was arranged for the two parents without Greta present. The clinician made clear why they needed a collaborative plan for her psychiatric treatments (both the FFT and the medication sessions) in the same way that they seemed able to coordinate her diet, schoolwork, and social activities. The clinician did not challenge the father’s beliefs directly but provided him with a recap of Greta’s diagnostic evaluation and explained why lamotrigine had been recommended for her mood stability. The clinician also encouraged the father to discuss the matter with the physician and then with Greta. After two parent-only sessions, the father agreed that he would encourage Greta to take lamotrigine when she was at his house, provided that the couple could reevaluate the issue in three months.

This case illustrates how nonadherence in a younger patient can reflect a larger battle between parents, seemingly over health care but also over unresolved marital issues. Observations like these have led us to wonder how often young patients who are medically nonadherent have parents who inadvertently aid and abet their decisions.

The importance of psychoeducation

Committing to medications is difficult for people with BD due to side effects, costs, disbelief in the diagnosis, and the stigma of taking psychiatric drugs. It is much harder when families unwittingly contribute to the patient’s nonadherence due to misunderstandings about mood-stabilizing medications, excessive monitoring, or critical and blaming attitudes. Encouraging caregivers and patients to develop a cohesive approach to pharmacological treatment is critical to the patient’s mood stability and quality of life.