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Including family members in psychoeducation for bipolar disorder: is it worth it?

We read with extreme interest the recently published review by Bond and Anderson (1) on the efficacy of psychoeducation for relapse prevention in bipolar disorder. The results of this systematic review clearly show that medications alone do not guarantee a positive outcome in bipolar disorder, and that adjunctive long-term psychosocial interventions are needed in order to improve patients’ adherence to treatments and their quality of life. Among the several existing psychosocial interventions, we have recently argued (2) that too many approaches are labelled psychoeducation, and that some confusion exists in the literature about what exactly is meant by this term. Bond and Anderson refer to Smith et al.’s (3) definition which identified psychoeducation as ‘any intervention that educates patients and their families about their illness with a view to improving their longterm outcome’. The authors are correct when they state that targets, focus, and approaches change, and that there is a considerable overlap between psychoeducation and many psychotherapies. In their review, which was carried out using a robust and solid methodology, Bond and Anderson (1) assessed the efficacy of individual and group psychoeducation for patients with bipolar disorder who are not in an acute episode. Unfortunately, they did not consider psychoeducational interventions in which relatives were involved. These approaches have produced consistent positive results in preventing relapses and reducing hospitalization (4). In fact, the influence of family environment on the long-term outcome of bipolar disorder has been well documented (5), and most international guidelines recommend the use of such approaches for treating bipolar disorder in clinical practice (6, 7). Higher levels of family burden and of expressed emotion, as well as a reduced social network and dysfunctional coping strategies are all associated with increased relapse rates, higher numbers of hospitalizations, and a worse general outcome (8). In our recent trial (2), we tested the effectiveness of a single family psychoeducational intervention approach, developed on the basis of the Falloon model for schizophrenia (9), in 11 Italian randomly selected mental health centres, compared to treatment as usual (TAU). After a six-month intervention period, patients receiving the psychoeducational family intervention had a significant improvement on the Brief Psychiatric Rating Scales (BPRS) global subscale, moving from 35.1 9.5 (mean standard error) at baseline (T0) versus 31.9 8.5 at follow-up (T1; p < 0.001) and depressive anxiety subscale, from 2.0 0.7 at T0 versus 1.7 0.6 at T1 (p < 0.001). Moreover, the intervention also provided a significant improvement in patients’ social functioning, as shown by the improvements in the Disability Assessment Schedule (DAS) global score (2.9 1.0 at T0 versus 1.7 0.7 at T1, p < 0.01), and in patients’ objective (2.1 0.9 at T0 versus 1.7 0.7 at T1, p < 0.0001) and subjective (2.3 0.8 at T0 versus 2.0 0.8 at T1, p < 0.01) burdens of illness. Finally, our experimental approach also yielded significant positive results for relatives participating in the intervention, with reductions in family subjective (1.9 0.6 versus 1.7 0.5, p < 0.0001) and objective (1.6 0.7 versus 1.5 0.5, p < 0.05) dimensions of burden. We could not analyse the effect of the intervention on relapse rates given the short follow-up. For this reason, we are now collecting data on patients’ clinical status and social functioning after five years from completion of the intervention. Preliminary findings, not yet published, indicate that the relapse rate is significantly higher in the control group. We believe that our findings complement those reported by Bond and Anderson (1). There is no doubt that psychoeducation is effective in preventing relapses in bipolar disorder. The evidence is stronger for group psychoeducation than for the individual approach—the psychoeducational family approach can lead to even better results, since it