Parental expressed emotion and suicidal ideation in adolescents with bipolar disorder

doi:10.1016/j.psychres.2014.02.013

Psychiatry Research

Volume 216, Issue 2, 15 May 2014, Pages 213-216

https://doi.org/10.1016/j.psychres.2014.02.013 Get rights and content

Abstract

Family environmental variables are risk factors for recurrent courses of mood disorder in adolescents. The present study examined the association between parental expressed emotion (EE)—critical, hostile and/or emotionally overinvolved attitudes toward a concurrently ill offspring—and suicidal ideation in adolescents with bipolar disorder. The sample consisted of 95 adolescents with a bipolar I or II diagnosis who had experienced a mood episode in the prior 3 months. Participants (mean age=15.54 years, S.D.=1.4) were interviewed and completed questionnaires regarding current and past suicidal ideation prior to their participation in a treatment trial. Parents completed five-minute speech samples from which levels of EE were assessed. High EE attitudes in parents were associated with current suicidal ideation in adolescents. This relationship was independent of the effects of age, gender, current depressive or manic symptoms, comorbid diagnoses, bipolar I/II subtypes, family adaptability, and family cohesion. These results underscore the importance of addressing the emotional reactivity of caregivers in treating adolescents with bipolar disorder who have suicidal ideation.

Introduction

Suicide ranks as the third leading cause of death among adolescents (Center for Disease Control and Prevention, 2010). Among children and adolescents with bipolar disorder, approximately 20–30% report suicide attempts (Goldstein et al., 2005, Goldstein and Ha, 2012), and over 50% report one or more periods of suicidal ideation (Lewinsohn et al., 2003). Thus, bipolar disorder has one of the highest rates of suicide completion (Baldessarini and Tondo, 2003).

Family contextual variables are strongly related to the course of depressive symptoms in bipolar disorder. High levels of expressed emotion (EE) among parents – defined as high levels of criticism, hostility, or emotional involvement toward the offspring – are prospectively associated with illness recurrences and more severe depressive symptoms in bipolar adults (Kim and Miklowitz, 2004, Miklowitz et al., 1988, Yan et al., 2004). Adolescents with bipolar disorder who had high EE parents had higher depression and mania symptom ratings over 2 years than those with low EE parents (Miklowitz et al., 2006). Although there is evidence to suggest high EE family environments increase mood symptoms in bipolar adolescents, the association between parental EE and suicidal ideation has not been examined in bipolar disorder.

Dimensions of the family system such as cohesion, conflict and adaptability are also related to the course of mood symptoms in bipolar disorder (Robertson et al., 2001, Sullivan et al., 2012). Adaptability involves the roles, leadership, discipline and flexibility of the family, while cohesion involves the closeness of the family through assessment of the amount of time spent together, boundaries, and emotional bonding (Tiesel and Olson, 1992). Parents of adolescents with bipolar disorder report lower levels of cohesion and adaptability, than parents of healthy adolescents, and high EE parents of bipolar youth report lower levels of adaptability and cohesion than low EE parents (Sullivan and Miklowitz, 2010). Low cohesion and adaptability have also been longitudinally associated with higher depression scores in bipolar adolescents (Sullivan et al., 2012). Low family cohesion, low family support and high family conflict differentiate adolescents with suicidal ideation from non-suicidal patients and non-clinical controls (Wagner et al., 2003). Further, bipolar adolescents with suicidal ideation endorse lower family adaptability and more conflict with their mothers than those who do not endorse suicidal ideation (Goldstein et al., 2009). Combined, these results suggest an association between symptom presentation and the family environment.

This study examined the relationships between EE, family cohesion, and family adaptability and suicidal ideation in adolescents with bipolar disorder. We hypothesized that low family cohesion, low adaptability, and high EE would be independently associated with suicidal ideation beyond the effects of other demographic or clinical variables, including age, sex, socioeconomic status (SES), current manic or depressive symptoms and the presence of comorbid axis I disorders.

Section snippets

Participants

Ninety-five youth meeting DSM-IV-TR (APA, 2000) criteria for bipolar I or II disorder were evaluated to determine eligibility for a randomized trial of family-focused treatment. Of the 145 adolescents who participated in the trial, parents of 95 adolescents completed a taped five-minute speech sample (FMSS) that could be evaluated for EE. Of these 95, 79 of the adolescents had both parent and self-reported measures of adaptability and cohesion. The 16 youths with incomplete data did not differ

Sample characteristics

Of the 95 adolescents, 40 (42.1%) endorsed suicidal ideation on the KSADS-DRS for at least 1 week of the prior month. Of these, 20 (50%) had mild thoughts (i.e., occasional thought of suicide but no method), 15 (37.5%) reported moderate thoughts (i.e., often thinks of suicide and has thought of a method), three (7.5%) had severe thoughts (i.e., often thinks of suicide, has thought of a method, and has mentally rehearsed a plan/made a suicidal gesture), and two (5%) reported extreme thoughts

Discussion

The current study is the first to examine the association between family EE and suicidal ideation in adolescents with bipolar I and II disorders. Our results indicate that high EE environments are associated with a greater likelihood of suicidal ideation in adolescents with bipolar disorder than are low EE environments. No other differences emerged between youth with and without significant SI in either demographic or symptom variables.

The cross-sectional design of this study could not

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In the COBY study, youth with SI reported significantly more conflict with their mothers, lower levels of family adaptability, and more stressful family events than those without SI (Goldstein et al., 2009; Sewall et al., 2019). Adolescents with BD who have high levels of SI are more likely to have parents rated high on expressed emotion (i.e., highly critical or emotionally overinvolved attitudes) than adolescents with BD who have low levels of SI (Ellis et al., 2014). In the present study, we examined whether improvements in youths’ perceptions of family conflict mediated the relationship between treatment condition (FFT, EC) and reductions in SI among high-risk youth over 1-4 years.
Youth who are at clinical and familial risk for bipolar disorder (BD) often have significant suicidal ideation (SI). In a randomized trial, we examined whether family-focused therapy (FFT) is associated with reductions in SI and suicidal behaviors in high-risk youth.
Participants (ages 9–17 years) met diagnostic criteria for unspecified BD or major depressive disorder with active mood symptoms and had at least one relative with BD type I or II. Participants were randomly allocated to 12 sessions in 4 months of FFT or 6 sessions in 4 months of psychoeducation (enhanced care, EC), with pharmacotherapy as needed. Clinician- and child-rated assessments of mood, suicidal thoughts and behaviors, and family conflict were obtained at baseline and 4-6 month intervals over 1-4 years.
Participants (N=127; mean 13.2±2.6 yrs., 82 female) were followed over an average of 105.9±64.0 weeks. Youth with high baseline levels of SI who received FFT had lower levels of (and fewer weeks with) SI at follow-up compared to youth with high baseline SI who received EC. Participants in FFT had longer intervals without suicidal behaviors than participants in EC. Youths’ ratings of family conflict significantly mediated the effects of treatment on SI at follow-up.
Family conflict was based on questionnaires rather than observer ratings of family interactions.
Family psychoeducation with skill training can be an effective deterrent to suicidal thoughts and behaviors in youth at high risk for BD. Reducing parent/offspring conflict should be a central objective of psychosocial interventions for high-risk youth with SI.
Culture and family-based intervention for schizophrenia, bipolar, and other psychotic-related spectrum disorders
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This chapter reviews the literature on culture and family-based psychological interventions for schizophrenia, bipolar, and related (SBR) psychotic spectrum disorders. Several studies were examined across cultures and results seem to strongly and robustly indicate that incorporating the family into treatment reduces patient psychiatric symptoms and improves mental health of patients and their caregivers alike. Basic elements of psychotherapy that are likely to be helpful across cultures are discussed, and specific recommendations for working with multicultural populations with SBR are provided. A few examples include: incorporating the family into treatment whenever possible; systematically checking in with patients and their family members about how they understand the patient’s illness and what practices they view as useful (or detrimental); eliciting and discussing cultural differences in beliefs and values and recognizing and respecting those that differ from one’s own; and attempting to make treatments more accessible by offering them within the community and at religious institutions and other community settings, if possible.
Expressed emotion, emotional distress, and individual and familial history of affective disorder among parents of adolescents with bipolar disorder
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Parental expressed emotion (EE) attitudes are important prognostic indicators in the course of bipolar disorder (BD) in adolescents and adults. This study examined the hypothesis that parents’ own susceptibility to affective disturbances contributes to their likelihood of high-EE attitudes. We examined past-week levels of emotional distress, lifetime affective diagnoses, and family histories of affective disorder among high- and low-EE parents of 86 adolescents with bipolar I or II disorder who were recovering from an episode of depression or (hypo) mania. High EE parents endorsed higher concurrent levels of depression, anxiety, and anger/hostility than low EE parents, and reported a greater familial history of depression and BD. No differences between high and low EE parents were found in concurrent levels of interpersonal sensitivity, lifetime rates of affective disorders, or familial loading of anxiety disorder. Parents’ distress at the time of the EE assessment was the strongest correlate of EE. The results suggest that susceptibility to affective psychopathology may be an important contributor to the development of EE attitudes among parents of adolescents with BD.
Facial emotion recognition, socio-occupational functioning and expressed emotions in schizophrenia versus bipolar disorder
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Similarly, the study by Ayilara et al. (2017) found higher prevalence of expressed emotions in patients with schizophrenia and bipolar disorder. Furthermore, high expressed emotion, specifically critical comments and emotional over-involvement are positively associated with suicidal ideation in adolescents with bipolar disorder (Ellis et al., 2014). However, the relationship between facial emotion recognition abilities and expressed emotions and its influence on socio-occupational functioning in schizophrenia versus bipolar disorder has not been studied.
Facial emotion recognition deficits have been consistently demonstrated in patients with severe mental disorders. Expressed emotion is found to be an important predictor of relapse. However, the relationship between facial emotion recognition abilities and expressed emotions and its influence on socio-occupational functioning in schizophrenia versus bipolar disorder has not been studied. In this study we examined 91 patients with schizophrenia and 71 with bipolar disorder for psychopathology, socio occupational functioning and emotion recognition abilities. Primary caregivers of 62 patients with schizophrenia and 49 with bipolar disorder were assessed on Family Attitude Questionnaire to assess their expressed emotions. Patients of schizophrenia and bipolar disorder performed similarly on the emotion recognition task. Patients with schizophrenia group experienced higher critical comments and had a poorer socio-occupational functioning as compared to patients with bipolar disorder. Poorer socio-occupational functioning in patients with schizophrenia was significantly associated with greater dissatisfaction in their caregivers. In patients with bipolar disorder, poorer emotion recognition scores significantly correlated with poorer adaptive living skills and greater hostility and dissatisfaction in their caregivers. The findings of our study suggest that emotion recognition abilities in patients with bipolar disorder are associated with negative expressed emotions leading to problems in adaptive living skills.
The Influence of Trauma, Life Events, and Social Relationships on Bipolar Depression
2016, Psychiatric Clinics of North America
Association between history of suicide attempts and family functioning in bipolar disorder
2016, Journal of Affective Disorders
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As expected, these individual difficulties related to the BD symptomatology and functional impairment might be associated with significant burden among families of BD patients (Pompili, 2014). Recent studies suggest that there may be a bi-directional relationship between some clinical aspects of BD and family environment or functioning (Ellis et al., 2014; Weinstein et al., 2015). Indeed, mounting evidence suggests that BD patients report worse family functioning when compared with healthy subjects and with patients suffering from other psychiatric disorders (Friedmann et al., 1997, Koyama et al., 2004, Unal et al., 2004, Uebelacker et al., 2006, Townsend et al., 2007).
To investigate the association between history of suicide attempts (SA) and family functioning in bipolar disorder (BD) patients.
Thirty-one BD type I patients with lifetime history of SA, 31 BD type I with no lifetime history of SA, participating in the Outpatient Clinic of the Bipolar Disorder Program at the Institute of Psychiatry of the University of São Paulo Medical School were recruited for this study. We used the Family Assessment Device (FAD) to evaluate family functioning. We compared these two groups on demographic and clinical variables to identify which variables were associated with family functioning impairment. Fifty-one relatives of the same patients were also asked to complete a FAD.
BD patients with SA presented more psychiatric hospitalizations, higher frequency of psychotic symptoms, and higher scores on depressive, manic, and suicidal ideation than BD patients without SA. BD patients with SA presented significantly higher scores in several subscales of the FAD, including Problem Solving (p=0.042), Communication (p=0.009), Roles (p=0.006), and General Functioning (p=0.025), when compared with BD patients without SA. Relatives of BD patients with SA presented significantly higher scores in Communication, Roles, Affective Responsiveness, and General Functioning than relatives of BD patients without SA.
Cross-sectional study and long time elapsed since last SA.
History of SA in BD is associated with worse family functioning in several domains of FAD, including Problem Solving, Communication, Roles, and General Functioning. As suicide attempts are routinely assessed in clinical practice, these findings may help to identify patients with poorer family functioning and may suggest a role for environmental risk factors in suicidal behavior among BD patients.

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Parental expressed emotion and suicidal ideation in adolescents with bipolar disorder

Abstract

Introduction

Section snippets

Participants

Sample characteristics

Discussion

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Affective Disorders

Psychiatry Research

Journal of the American Academy of Child & Adolescent Psychiatry

Biological Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Affective Disorders

Behavior Therapy

Clinical Psychology Review

Journal of Affective Disorders

Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation?

Bipolar Disorders

Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision) (Diagnostic & Statistical Manual of Mental Disorders, 4 Sub. ed.)

An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment

Psychiatric Services

A preliminary study of the kiddie schedule for affective disorders and schizophrenia for school-age children mania rating scale for children and adolescents

Journal of Child and Adolescent Psychopharmacology