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Tina R. Goldstein, Ph.D.

Associate Professor of Psychiatry and Psychology

Western Psychiatric Hospital, University of Pittsburgh

www.pediatricbipolar.pitt.edu

Psychosocial Management

of Comorbid Conditions

in Youth with

Bipolar Spectrum Disorders

Disclosures

Source Research

Funding

Employee Books,

Intellectual

Property/

Royalties

National Institute of Mental Health X

University of Pittsburgh CTSI X

The Brain and Behavior Foundation X

The American Foundation for Suicide

PreventionX

Guilford Press X

University of Pittsburgh X

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Agenda

• Psychotherapy for Youth with Bipolar Disorder

• Comorbid conditions: Assessing and prioritizing

• Evidence-based strategies for treating

comorbidities

Agenda

• Psychotherapy for Youth with Bipolar Disorder

• Comorbid conditions: Assessing and prioritizing

• Evidence-based strategies for treating

comorbidities

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Psychosocial Treatment for Bipolar Disorder

Foundation of treatment is medication

Comprehensive treatment also includes psychotherapy

AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder, Work Group

on Quality Issues 2007

The ISBD Task Force Report on Pediatric Bipolar Disorder: Knowledge to Date and Directions for Future Research, Goldstein B

et al 2017

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What Are The Goals Of Psychotherapy

For Youth with Bipolar Spectrum Disorders?

Decrease Vulnerability Factors

Increase Protective Factors

Stress

Family conflict

Substance use

Irregular

daily routines

Poor

sleep patterns

Medication

adherence

Social support

Coping skills

Access to

resources

AACAP Practice Parameter for the Assessment and

Treatment of Children and Adolescents with BP 2007

Findling et al 2018

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What Are The Goals Of Psychotherapy

For Youth with Bipolar Spectrum Disorders?

• Empower educated consumers of mental health services

• Manage suicidal thoughts and behaviors

• Improve functioning

• Increase feelings of control over the illness

• Target symptoms associated with comorbid conditions

• Minimize negative consequences (eg, pregnancy)

• Provide hope, support, empathy

AACAP Practice Parameter for the Assessment and

Treatment of Children and Adolescents with BP 2007

Findling et al 2018

Psychotherapy Approaches for Youth with

Bipolar Spectrum Disorders

Well-Established Treatments:

Family-Focused Therapy (FFT-A; Miklowitz et al 2004, 2008, 2014)

Child & Family-Focused CBT (CFF-CBT; Pavuluri et al 2004; West & Pavuluri, 2009)

Multi-Family Psychoeducation Groups (MF-PEP; Fristad et al 2003, 2009)

Possibly Efficacious Treatments:

Dialectical Behavior Therapy (DBT; Goldstein et al 2007, 2014)

Experimental Treatments:

Interpersonal & Social Rhythm Therapy (IPSRT-A; Hlastala et al 2006, 2010)

Motivational Interviewing (MI; Goldstein et al, 2020)

For a review see Fristad et al 2014

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Common Elements of Psychotherapy

Approaches for Youth with Bipolar Spectrum Disorders

• Psychoeducation about bipolar disorderSymptoms

Course

Treatment

Heritability

• Mood Monitoring

• Skill BuildingCommunication

Problem Solving

Emotion Regulation

• Enhance family and social functioning

• Relapse preventionMedication adherence

Sleep hygiene

StressAACAP Practice Parameter for the Assessment

and Treatment of Children and Adolescents with

BP, 2007

Critical common components:

• Manualized

• Psychoeducational

• Family involvement

• Skill building (Findling et al 2018, Miklowitz et al 2020)

• Course of early-onset bipolar disorder is affected by

comorbid conditions

• Comorbidity associated with greater treatment

resistance and suicide risk

• Little remains known about:

how comorbid conditions impact response to

psychosocial treatments for bipolar disorder

which psychosocial treatments for early-onset

bipolar disorder are best suited for specific

comorbidities

What Do We Know About Psychotherapy for Youth with

Bipolar Spectrum Disorders & Comorbid Conditions?

Yatham et al 2018

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Agenda

• Psychotherapy for Youth with Bipolar Disorder

• Comorbid Conditions: Assessing and prioritizing

• Evidence-based strategies for treating

comorbidities

Psychotherapy for Youth

with Bipolar Spectrum Disorders…

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Where to Start?

• Some comorbid conditions can be managed with the

same treatments used to target BP

• Others require distinct treatments

• Often a hierarchical approach

• Consider which disorder/symptom is most affecting:

morbidity

mortality

impairment in functioning

mood instability

suffering

Yatham et al 2018

AnxietySubstance

Use

ADHD

Disruptive behaviors

Eating

disorder

Autism

Mood

instability

Where to Start? Assessment

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What is Measurement-Based Care (MBC)?

Systematic administration of symptom rating scales

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Use of the results over time

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To inform clinical decision-making

Harding et al 2011

Fortney et al 2017

McGinn et al 2019

Research supports effectiveness of MBC in behavioral healthcare

Enhanced outcomes (meds & therapy):

• faster

• larger treatment effects

• better adherence

• across patient age, disorder, and provider type

Why Use Measurement-Based Care? Effectiveness

Harding et al 2011

Fortney et al 2017

Kennedy Forum Brief, 2015

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• Paper and pencil

• Text messaging

• Phone apps

• Commercial systems

• Embedded in electronic medical record

Select measures that are:

• Reliable and valid

• Sensitive to change

• Diagnostic / symptom-specific

See: Free, brief and validated: Standardized instruments for low-resource mental health settings.

Beidas et al 2015

How to Use MBC to Assess Common Comorbidities

Patient & parent complete questionnaires

Provider and patient / parent review results together

Results inform collaborative decision making

How to Use MBC to Prioritize Treatment

Fortney et al 2017

Kennedy Forum Brief, 2015

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Agenda

• Psychotherapy for Youth with Bipolar Disorder

• Common treatment targets: Assessing and

prioritizing

• Evidence-based strategies for treating

comorbidities

Evidence-Based Strategies

General Strategies:

• Psychoeducation

• Family Communication

• Motivational Interviewing

• Mindfulness

• Lifestyle Interventions

Specific Strategies:

• Anxiety Disorders

• Substance Use Disorder

• Autism Spectrum Disorder

• Behavioral Disorders (ADHD, ODD, CD)

Please see: www.effectivechildtherapy.org

Weisz & Kazdin (2017): Evidence Based Psychotherapy for Children and Adolescents

Do what works!

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General Strategies: Psychoeducation

• Review diagnosis, symptoms

• Symptom monitoring

• Risk / protective factors

• Model

• Treatment options

• Expected course / response

Findling et al 2018, Miklowitz et al 2020

General Strategies: Family Communication

• Active listening

• Validation

• Requests for change

• Family-Focused Therapy (FFT):

For comorbid ADHD:

Youth with BP+ADHD who received FFT-A vs EC showed better

family functioning and fewer hypomanic symptoms over 2 years

(Weintraub et al 2019)

No differential effect on DBDs or anxiety disorders

Findling et al 2018

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General Strategies: Motivational Interviewing (MI)

Evidence-based principle-driven treatment approach

• originally developed and tested for substance use behaviors

• collaborative

• flexible

• focus on enhancing intrinsic motivation to change

• targets ambivalence

• developmentally appropriateMiller & Rollnick 2002

Friedman & Litt 1987

General Strategies: Motivational Interviewing (MI)

• Effective for health behavior change among youth (eg Lemanek et al 2001; Colby et al 2008; Erickson et al 2005)

chronic medical conditions (diabetes, asthma)

substance use (tobacco, alcohol)

health risk behaviors (reproductive health)

• Potential treatment targets:

Medication-taking

Therapy attendance / participation

Lifestyle changes (diet, exercise, sleep, smoking,

alcohol/substance use)

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General Strategies: Mindfulness

Mindfulness Based Ineterventions (MBIs) promising for youth with:

•Psychosis (Perlini et al 2020)

•Suicidal / non-suicidal self-injury / emotion dysregulation (McCauley et al 2018)

•ADHD (meta-analysis Oliva et al 2021)

•Internalizing symptoms (Yu et al 2021; Volanen et al 2019)

Mindfulness-Based Stress Reduction (MBSR):

•Transdiagnostic adolescents (Biegel et al 2009)

Mindfulness-Based Cognitive Therapy (MBCT) for anxious youth at-risk for BP

Increases in mindfulness associated with improved emotion

regulation and anxiety post-treatment (Cotton et al 2020)

Changes in brain function in at-risk youth (Hafeman et al 2020; Strawn et al 2016; Qin et al 2021)

General Strategies: Lifestyle Interventions

In transdiagnostic samples of individuals with psychiatric disorders

across development, physical activity improves:

• Anxiety

• Depression

• ADHD

• Eating disorder

• SUD

• Sleep difficultiesAshdown-Franks et al 2020

Vancampfot et al 2020

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• Sleep

Improving sleep in youth associated with improved health across

emotional, behavioral, cognitive, social and physical domains (eg Harvey 2016 Transdiagnostic Sleep and Circadian Intervention; Dong et al 2019)

• Nutrition

• General wellness / self-care (eg Sylvia et al 2019; Fagiolini et al 2009)

General Strategies: Lifestyle Interventions

Specific Strategies: Anxiety Disorders

• Cognitive Behavioral Therapy

• GAD: Coping CAT for anxiety

• OCD: Exposure and response prevention

• Panic disorder: Panic control treatment

• PTSD: Trauma-Focused CBT

For a review see Essau et al 2013

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Specific Strategies: Substance Use Disorder

• Address as early as possible

• Likely to destabilize mood

• General recommendation to treat simultaneously with bipolar disorder

• STEP-BD study in adults with BP:

Comorbid SUD at intake (vs not) more likely to recover from mood

episode with ANY psychosocial treatment (Gold et al 2018)

• CBT + Motivational Enhancement Therapy (MET)

+ Family-Based Behavioral Treatment

• FFT-A (Miklowitz et al 2012)

modest reductions in use;

less effective when aren’t has SUD (Goldstein B et al 2014)

• Functional Family Therapy (Waldron et al 2017)

Specific Strategies: Autism Spectrum Disorder

• Applied behavior analysis:

Uses learning principles to teach socially significant

behaviors in real-life settings

• Social skills training

Enhance interpersonal skills

For a review see Kasari et al 2014

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Specific Strategies: Behavioral Disorders (ADHD, ODD, CD)

• Family Psychoeducation + Skill Building associated

with improvements in behavioral disorder symptoms (Boylan et al 2013)

• Parent Management Training for ODD (Kazdin 2005)

• Parent-Child Interaction Therapy (PCIT) (eg Wagner et al 2008)

• Behavioral Parent Training for ADHD (eg McMahon & Forehand 2003)

Teach parent(s) how to reinforce desirable child behaviors

and discourage unwanted behaviors

• Organizational Skills Training for ADHD (eg Gallagher et al 2014)

Teach child time management, organization & planning skills

• Multisystemic therapy (MST) for CD, SUD (for review see www.mstservices.com)

Considers multiple social-ecological factors

Therapists work in community, available 24/7

Adjunctive Strategies

Apps

Online psychoeducation

Peer Support

The 2020 Royal Australian and New Zealand College of psychiatrists clinical

practice guidelines for mood disorders: Bipolar disorder summary, 2020

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• Importance of assessment to inform treatment planning

• More research needed to determine effective treatments

for common comorbid conditions

• Which psychotherapy approach is best for whom?

• Technology enhancements

• Broad-based dissemination and implementation

• Prevention

Conclusions and Future Directions

www.pediatricbipolar.pitt.edu

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