Children of parents with bipolar disorder or depression areat high risk for developing anxiety disorders, depression, and bipolar-likemood lability.  Data show that FamilyFocused Therapy (FFT) is very helpful in reducing depression and behavioraldysregulation.

We recommend FFT or a similar program for all high riskchildren who are beginning to have mood or behavioral dysregulationproblems.  The problem is that it isoften difficult to access a clinician who is informed about giving FFT, butasking a therapist to use FFT principles could still be very helpful.

Another suggestion is for the parents to begin to try outFFT skills even without the knowledgeable clinician.

Here is AI summary;

Family-focused therapy (FFT) is 

an evidence-based, short-term intervention primarilydesigned for individuals with bipolar disorder, depression, or psychosis andtheir families. It involves conjoint sessions focusing on psychoeducation,communication training, and problem-solving to reduce high-expressed emotion,manage symptoms, and improve family functioning. FFT is an effective adjunct tomedication, helping to stabilize moods and reduce relapse rates in both adultsand youth. 

Key Components and Goals

• Psychoeducation: Educating the family about the disorder, its     symptoms, and treatment options to reduce confusion and stigma.
• Communication Enhancement Training: Teaching family members to express positive     and negative emotions constructive, reducing criticism, hostility, and     emotional over-involvement.
• Problem-Solving Skills Training: Equipping the family to identify, address,     and resolve problems together, reducing daily stress.
• Reducing Relapse: A core goal is to decrease symptom severity     and prevent future episodes by altering dysfunctional interaction     patterns. 

Applications and Effectiveness

• Bipolar Disorder: Highly effective for adults and adolescents     with bipolar disorder, especially when combined with medication.
• Childhood Depression: Associated with faster symptom reduction and     improved caregiver skills.
• Family Functioning: Improves     overall family relationships, builds empathy, and creates a more     supportive home environment. 

Differences in "Family-Focused" Models
While traditional Family-Focused Therapy (FFT) focuses on psychoeducation formood disorders, other similar models exist: 

• Functional     Family Therapy (FFT): A short-term,     high-intensity intervention for at-risk youth (11-18) with     behavioral/emotional problems, focusing on systemic change.
• Family Centered Treatment (FCT): Uses a     system-based approach, focusing on attachment, emotional expression, and     trauma. 

FFT sessions are typically conducted weekly or biweekly andare designed to be practical, focusing on actionable skills to manage chronicconditions. 

A more detail manuel is available fordown load at

appendix bfamily-focused treatment manual.  Aclinician can use this to learn FFT techniques, but parents and families canalso make use of these principles.

One of the key components of the psychoeducational componentis to learn about and encourage the concomitant use medications and to evaluatethere effectiveness by parents doing either weekly ratings of anxiety,depression, ADHD, oppositional behavior, and mania on a form available at www.bipolar-news.org.  The combined use of drugs and medications isoften the optimal approach to these at risk children who are often highlysymptomatic.

Medications for children with depression and highly variedand manic-like symptoms include well tolerated atypicals (such as lurasidone,cariprazine, and lumateperone); mood stabilizing anticonvulsants (such aslamotrigine, oxcarbazepine, and carbamazepine with valproate not used forfemales); and lithium.

For depression, starting with lurasidone and if needed forresidual depression and anxiety adding lamotrigine very slowly to avoid aserious rash is often helpful.  If thereare residual manic-like adding lithium into the regimen often provides an idealway of achieving full mood stabilization with what is called triple “L” therapy(lurasidone, lamotrigine, and lithium) even for those with BP-NOS, theprecursor to full-blown bipolar disorder.

Starting with supplements from ahealth food store is often additionally helpful.  Thesupplements could include:

1.  Starting N- acetylcysteine(NAC) 500mg caps, one cap BID for one week, then increase to 2 caps in am and 2caps in pm, after another week, 2 caps in AM and 3 HS.   NAC is a glutathione precursor andanti-oxidant that decreases synaptic glutamate which drives fast firing neuronsthat are associated with depression, anxiety, and irritability (M. Berk et alBiol.Psychiatry, 2008a).  It takes timeto grow glutamate transporters to clear the excitatory neurotransmitterglutamate out of the synapse and into glial cells in the habit/reward system ofthe brain (nucleus accumbens) and thus takes about 6-8 weeks to kick in overplacebo.  It helps stop many habits,addictions, and intrusive thoughts likely by decreasing glutamate in theautomatic habit memory system and allowing better control from the cerebralcortex.  

  2. Add acetyl-L-carnitine (LAC)500mg caps, one cap 3 times/day. It decreases glutamate release by anepigenetic mechanism that increases the production of the inhibitory mGluR-2receptor.  LAC is low in the blood ofadult depressed patients, especially those with early onset  depression and a history of adversity inchildhood (Nasca et al., PNAS, 2018).  Ithas AD effects in humans and in animal models of depression, such as defeatstress, where it works faster than regular ADs.

3.  Start Vitamin D3 at 2,000 IUfor antidepressant effects and improved cognition on higher than lower doses.

4.  Add folate (which helpsADs  and Li work better) asL-methylfolate 1mg tabs, 2 tabs in the AM as the child could have a MTHFRdeficiency.

If things remain difficult, having a consultation can be helpful.  This editor may be available and can bereached at Robert.postmd@gmail.com.

Remember praise positive behaviors, remain calm and constructive, andavoid anger and punitive responses. Propose and work on solutions everyone in the family can agree to.

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