Approximately 90% of bipolar adolescents in two groups (intense family-focused therapy versus less-intense enhanced care) had a full recovery at two years from their original mood episode, David J. Miklowitz, Ph.D., of the University of Colorado, and colleagues reported in the September issue of the Archives of General Psychiatry.

However, teens in the family-focused therapy group recovered faster, spent fewer weeks in other depressive episodes, and had a more favorable trajectory of depressive symptoms than those given less intense therapy, the researchers said.

But, they said, neither intervention improved mania symptoms.

Of bipolar patients, 50% to 60% have illness onset before age 18, and 13% to 28% before age 13, the researchers wrote.

Early onset is associated with an unremitting course of illness, frequent switches of polarity, mixed episodes, psychosis, a high suicide rate, and poor functioning or quality of life.

In the past decade, they added, there's been a remarkable increase in drug trials for patients with early-onset disorder, but comparatively little controlled study of psychotherapy.

Their randomized controlled trial with two-year follow-up included 58 bipolar adolescents, mean age 14.5, who'd had a mood episode in the prior three months.

Of the participants, 38 had bipolar I, six had bipolar II, and 14 had no otherwise specified disorder. Among the patients, 25 had subsyndromal episodes, 18 had depressive episodes, and 12 had manic episodes.

The family-focused therapy lasted for nine months and consisted of 21 50-minute sessions (weekly for 12 weeks, every other week for another 12 weeks, then one a month for six months). Sessions were attended by the patient, parents, and available siblings.

Patients and family members were encouraged to understand the symptoms, etiology, course of the illness, and precipitants for recurrence. They were also encouraged to adhere to drug therapy and to conduct a relapse-prevention drill.

Later phases of the intervention focused on training in which participants learned, through role playing, for example, to implement solutions to problems in the family's daily life.

The enhanced-care group also got family therapy, but had only three weekly 50-minute sessions with their parents and siblings. The sessions focused on relapse prevention, medication adherence, and keeping the home environment low in conflict.

The pharmacotherapy plans included lithium, anticonvulsants, and second-generation antipsychotics plus adjunctive antidepressants and pharmacotherapy for comorbid attention-deficit disorder or anxiety symptoms when needed.

From 2002 to 2005, 30 patients were randomly assigned to intense family therapy and protocol pharmacotherapy while 28 were assigned to enhanced care and pharmacotherapy. Independent blinded evaluators assessed patients every three to six months for two years.

A total of 60% of the intense family therapy group and 64.3% of the enhanced therapy group completed the two-year follow-up.

Although there were no group differences in rates of recovery from the index episode, patients in the intense therapy group recovered from their baseline depressive symptoms 15% faster than patients in the enhanced therapy group (hazard ratio 1.85, 95% confidence interval 1.04 to 3.29, P=0.04).

The groups did not differ in time to recurrence of depression or occurrence of mania, but patients given intense family therapy spent fewer weeks in other episodes of depression and had a more favorable course of symptom severity scores for two years.

On the other hand, the groups did not differ in the unimproved trajectory of mania or hypomania symptoms over 24 months (P=0.96).

The researchers did not study whether the intense family-focused intervention translated into differences in functioning or quality of life. Future studies they said, should consider adolescent functioning, notably during the transition to adulthood.

Study limitations included the considerable variability in the clinical status of the patients at study entry, not atypical in samples of bipolar youth. For example, 18 had depressive episodes, 12 had manic episodes and 38 had bipolar I disorder.

By design, this study did not equate the treatment conditions with the number of therapy contacts, and the contributions of treatment content versus frequency were not clear.

Finally, drug treatment followed best-practice guidelines, but group differences in drug dosages or adherence might have emerged at any point during the two-year follow-up.

To enhance full symptomatic and functional recovery among adolescents, family-focused therapy may need to be supplemented with collaborative care interventions effective for mania symptoms, the researchers concluded.