Expressed emotion as a predictor of outcome among bipolar patients undergoing family therapy

Background: Levels of expressed emotion (EE) in relatives are consistent predictors of relapse among bipolar and other mood disordered patients followed naturalistically. However, few studies have examined whether levels of EE predict the course of illness for patients engaged in psychosocial interventions. Methods: This study examined whether EE levels among caregivers moderated the success of family-based psychosocial interventions for patients with bipolar disorder. EE was examined as a predictor of symptomatic outcome in two groups: (1) bipolar patients receiving family-focused psychoeducational treatment (FFT) or integrated family and individual treatment (IFIT), and (2) bipolar patients receiving crisis management (CM), a less intensive intervention designed to emulate community care. Bipolar patients (N=125) began the study in an acute illness episode, were stabilized on standard pharmacotherapy regimens, and followed for up to 2 years. Results: Family EE status was not associated with time to relapse in either group. However, patients with high EE relatives reported higher levels of depression over the 2-year term of follow-up, regardless of treatment condition. An examination of the dimensions of EE (critical comments and emotional overinvolvement) indicated that a higher frequency of critical comments predicted higher levels of mania and depression at follow-up. Additionally, the association between EE criticism and levels of mania symptoms was stronger among patients in CM than among patients in family treatment. Limitations: The participants were recruited from two separate treatment protocols. Patients in the IFIT protocol were not randomly assigned to treatments. Conclusions: EE is a predictor of symptom severity among bipolar patients undergoing pharmacological and psychosocial treatments, but family intervention may mitigate this association.