Can family-focused cognitive behavior therapy reduce suicidal ideation in young children with bipolar disorder?

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pan-lisa-2013Background
Pediatric Bipolar Disorder (PBD) is an extremely complex and debilitating condition. These youths must contend with unpredictable mood swings, sleep problems, difficulty interacting with others, and poor self-image, among other symptoms. Management of the condition often affects the entire family.

Especially troubling is the fact that nearly one half of young people with this condition will attempt suicide before age 18, with the riskiest period being the first 12 months following the onset of suicidal ideation. The rate of attempt in this group is 15 times higher than that of the general population, and the risk is higher in youth with the earliest ages of onset of PBD. However, the research on risk factors and treatments for affected youth, especially the youngest, is scant. Remarkably, no previous studies have investigated the treatment of suicidal ideation and behavior in these youths.

A treatment that has previously been developed for treating PBD is Child- and Family-focused Cognitive Behavioral Therapy (CFF-CBT). It uses psychoeducation (an evidence-based therapeutic intervention that teaches patients and their families problem-solving and communication skills), and intensive individual therapy with the youth and their parents to specifically target improving the youth’s self-esteem and ability to control behavior. It also fosters positive family functioning and emotional health, especially related to PBD.

Question
Can family-focused cognitive behavior therapy reduce suicidal ideation in very young children with bipolar disorder?

Study
In her AFSP-funded study, Dr. Sally M. Weinstein at the University of Illinois at Chicago studied 69 youths ages 7-13 (average age 9) diagnosed with PBD, along with their families. Study aims were to:

  1. determine what individual and family factors associated with suicidal ideation in these youths may be amenable to treatment;
  2. develop a treatment manual;
  3. And examine whether CFF-CBT can reduce or prevent suicidal ideation by targeting these factors.

41 percent of the children had current thoughts about taking their lives, and almost a third had suicidal ideation that included a method and/or intent to die.

Dr. Weinstein found that youth considered to be cognitively vulnerable, i.e. with higher hopelessness and lower self-esteem, and emotionally vulnerable, i.e. having higher depression and lower quality of life, had more severe suicidal thoughts. Problems with self-esteem were a primary factor. In terms of family relations, the strongest factors contributing to ideation were parental stress and family rigidity (i.e. being overly rules-bound). Family rigidity remained the most consistent predictor of suicidal ideation. Thus, two potential target factors for treatment were low self-esteem in the youth, and rigidity among their parents.

In a subsequent study, youth and families were then randomly assigned to two treatment groups, one with CFF-CBT and one with treatment as usual, which consisted of nonspecific unstructured psychotherapy. Both groups participated in 12 weekly sessions followed by six monthly sessions. Youth participants were assessed for mania, depression, suicidal ideation, and overall psychiatric severity at baseline, 4, 8, and 12 weeks, with a follow-up at six months.

While suicidal ideation was reduced for youth in both groups, the effect was stronger among youth in the CFF-CBT group. In addition, treatment completion and satisfaction was greater in the CFF-CBT group.

In Phase Two, 13 additional individuals received the manualized treatment of MBCT+SPI, measuring their level of mindfulness, attention, and cognitive reactivity.

Takeaway

  • Suicidal ideation often accompanies pediatric bipolar disorder. Therefore, assessing and treating suicidal ideation and behavior in children with PBD is important.
  • Youth with lower self-esteem and greater family rigidity appear to have more severe suicidal ideation.
  • Child- and Family-focused Cognitive Behavioral Therapy can help reduce suicidal ideation in very young children with bipolar disorder.

Given the above, we may be able to prevent suicidal ideation from evolving into suicidal behaviors in high-risk youth with pediatric bipolar disorder.

Grant-Related Publications

  • Weinstein, S.M., Van Meter, A., Katz, A.C., Peters, A., & West, A.E. (2015). Cognitive and family correlates of current suicidal ideation in children with bipolar disorder. Journal of Affective Disorders, 173: 15-21. doi: 10.1016/j.jad.2014

  • Weinstein, S.M., Henry, D.B., Katz, A.C., Peters, A.T., and West, A.E. (2015). Treatment moderators of child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 54: 116-25. Doi:10.1016/j.aac.2014.11.007.

  • West, A.E., Weinstein, S.M., Peters, A., Katz, A., Cruz, R., & Pavuluri, M.N. and Henry, D. (2014). Child- and family-Focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53: 1168-78. Doi: 10.1016/j.jaac.2014.08.013.

Click here to read about Dr. Weinstein’s Young Investigator Grant.

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