***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: 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 design ed to emulate community care .  Bipolar patients ( N = 125 ) began the study in an acute illness episode , were stabilized on  st and ard 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 protocol s. Patients in the IFIT protocol were not r and omly 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 In a sample of 62 patients with Bipolar I disorder , the authors used a repeated measures longitudinal design to examine whether global family functioning was associated with the presence of a concurrent bipolar episode as well as whether global family functioning was associated with the presence of manic and depressive episodes in the following 3 months . Participants were recruited for a r and omized clinical trial examining the efficacy of family treatments combined with pharmacotherapy for bipolar disorder .  Global family functioning was repeatedly measured with both clinician-rated and patient-rated assessment instruments over the 28-month study period . Results indicated that mood episodes were associated with concurrent global family functioning within individuals , but global family functioning was not associated with episode status in the subsequent 3 months . The repeated measures nature of these results suggests that global family functioning and bipolar episodes may fluctuate in concert with each other but that global family functioning is not associated with subsequent change in episode status The present study investigated the greater symptom severity and poorer treatment response found in patients with bipolar illness and anxiety comorbidity , and examined depression as a potential mediator of this relationship . The sample consisted of 92 patients in an acute episode of Bipolar I Disorder with a current or past history of an anxiety disorder . Diagnoses were based on structured clinical interview , and participants were assessed at pre-treatment and then r and omly assigned to pharmacotherapy alone or pharmacotherapy plus family intervention . Patients were assessed on a monthly basis by blind assessors over 28 months . Compared to patients without anxiety comorbidity , individuals with bipolar disorder and an anxiety disorder possessed greater current symptom severity , even after controlling for depression severity . Logistic regression analysis identified that being female and having higher current depression but not manic severity predicted comorbid anxiety . Comorbid anxiety was associated with poorer treatment response in the sample regardless of treatment type , particularly in subsequent depressive symptoms . Multiple regression analyses indicated that current depression but not manic severity partially mediated the relationship between comorbid anxiety and treatment outcome . Results from the current study investigating comorbid anxiety disorders are consistent with past research limited to anxiety symptoms . Depression only partially accounted for the link between comorbid anxiety and greater symptom severity and poorer treatment response , and examination of other factors is warranted . Because of the clinical relevance of comorbid anxiety in severe affective disorders , treatments design ed to specifically address both concerns are needed Bipolar disorder ( BPD ) has received increasing attention from public and professional sources . Although pharmacologic treatments are considered the sine qua non in the treatment of youth with BPD , psychosocial interventions are critical to assist the child and family cope with symptoms that carry with them significant morbidity and mortality . Treatments developed to date are few in number ; all are psychoeducationally based , using cognitive-behavioral and family systems interventions within a biopsychosocial framework . This paper review s possible mediators of outcome , including caregiver concordance , children 's social skills , hopelessness , and family stress . The author has developed two family-based psychoeducational interventions for the treatment of youth with BPD : multifamily psychoeducation groups ( MFPG ) and individual family psychoeducation ( IFP ) . These treatments are both described and the results from a previously published r and omized clinical trial ( RCT ) of MFPG are summarized . Then , new findings from an RCT of IFP are presented , along with preliminary pilot data from an exp and ed version of IFP . The paper concludes with recommendations for future research In recent years , lower serum levels have been recommended for maintenance therapy with lithium . We studied 94 patients with bipolar disorder in a r and omized , double-blind , prospect i ve trial of two different doses of lithium for maintenance therapy : the " st and ard " dose , adjusted to achieve a serum lithium concentration of 0.8 to 1.0 mmol per liter , and a " low " dose , result ing in a serum concentration of 0.4 to 0.6 mmol per liter . The group medians of the patients ' average serum lithium levels were 0.83 mmol per liter for the patients in the st and ard-range group and 0.54 mmol per liter for those in the low-range group . Six of 47 patients ( 13 percent ) assigned to receive lithium doses that would produce serum levels in the st and ard range had relapses while on protocol , as compared with 18 of 47 ( 38 percent ) assigned to the low-dose range . The risk of relapse was 2.6 times higher ( 95 percent confidence interval , 1.3 to 5.2 ) among patients in the low-range group than among those in the st and ard-range group . Side effects , including tremor , diarrhea , urinary frequency , weight gain , and a metallic taste in the mouth , were more frequent in the st and ard-range group . We conclude that doses result ing in serum lithium levels from 0.8 to 1.0 mmol per liter are more effective in treating bipolar disorder than those that result in lower serum lithium concentrations , although the higher doses are associated with a higher incidence of side effects . Recent findings about the limited nephrotoxicity of lithium , along with our observations , suggest that physicians should attempt to maintain serum lithium levels between 0.8 and 1.0 mmol per liter in most patients with bipolar disorder and that they should attempt to enhance patients ' underst and ing of and compliance with this regimen BACKGROUND Family therapy is sometimes used as adjunctive treatment to pharmacotherapy to help patients recover from mood episodes of bipolar I disorder . However , the efficacy of this practice is not known . METHODS Ninety-two patients meeting criteria for a current bipolar I mood episode were r and omly assigned to family therapy plus pharmacotherapy , multifamily psychoeducational group therapy plus pharmacotherapy , or pharmacotherapy alone . Time to recovery was analyzed with survival analysis . RESULTS The proportion of subjects within each treatment group who recovered did not significantly differ , nor did time to recovery . LIMITATIONS The analyses did not include other outcomes such as psychosocial functioning , prophylaxis against recurrences of mood episodes , or compliance with pharmacotherapy . CONCLUSIONS Neither adjunctive family therapy nor adjunctive multifamily psychoeducational group therapy significantly improves the rate of recovery from mood episodes of bipolar I disorder , compared to treatment with pharmacotherapy alone Family psychoeducational programs are efficacious adjuncts to pharmacotherapy for patients with schizophrenic and bipolar disorders , but little is known about what these programs change about families . The authors assessed changes in face-to-face interactional behavior over 1 year among families of bipolar patients who received a 9-month family-focused psychoeducational therapy ( FFT ; n = 22 ) or crisis management with naturalistic follow-up ( CMNF ; n = 22 ) , both administered with maintenance pharmacotherapy . Members of families who received FFT showed more positive nonverbal interactional behavior during a 1-year posttreatment problem-solving assessment than families who received CMNF , although no corresponding decreases were seen in negative interactional behaviors . The positive effect of family treatment on patients ' symptom trajectories over 1 year was partially mediated by increases in patients ' positive nonverbal interactional behaviors during this same interval CONTEXT Evidence of psychosocial disability in bipolar disorder is based primarily on bipolar I disorder ( BP-I ) and does not relate disability to affective symptom severity and polarity or to bipolar II disorder ( BP-II ) . OBJECTIVE To provide detailed data on psychosocial disability in relation to symptom status during the long-term course of BP-I and BP-II . DESIGN A naturalistic study with 20 years of prospect i ve , systematic follow-up . SETTING Inpatient and outpatient treatment facilities at 5 US academic centers . Patients One hundred fifty-eight patients with BP-I and 133 patients with BP-II who were followed up for a mean ( SD ) of 15 ( 4.8 ) years in the National Institute of Mental Health Collaborative Depression Study . MAIN OUTCOME MEASURES The relationship , by r and om regression , between Range of Impaired Functioning Tool psychosocial impairment scores and affective symptom status in 1-month periods during the long-term course of illness from 6-month and yearly Longitudinal Interval Follow-up Evaluation interviews . RESULTS Psychosocial impairment increases significantly with each increment in depressive symptom severity for BP-I and BP-II and with most increments in manic symptom severity for BP-I. Subsyndromal hypomanic symptoms are not disabling in BP-II , and they may even enhance functioning . Depressive symptoms are at least as disabling as manic or hypomanic symptoms at corresponding severity levels and , in some cases , significantly more so . At each level of depressive symptom severity , BP-I and BP-II are equally impairing . When asymptomatic , patients with bipolar disorder have good psychosocial functioning , although it is not as good as that of well controls . CONCLUSIONS Psychosocial disability fluctuates in parallel with changes in affective symptom severity in BP-I and BP-II . Important findings for clinical management are the following : ( 1 ) depressive episodes and symptoms , which dominate the course of BP-I and BP-II , are equal to or more disabling than corresponding levels of manic or hypomanic symptoms ; ( 2 ) subsyndromal depressive symptoms , but not subsyndromal manic or hypomanic symptoms , are associated with significant impairment ; and ( 3 ) subsyndromal hypomanic symptoms appear to enhance functioning in BP-II This clinical project compares the relative impact of two types of multiple family groups on psychiatric in patients and their families . Forty patients with a diagnosis of affective disorder , and their family members , were r and omly assigned to a traditional multiple family group with a process orientation that emphasized support , destigmatization , and self-help about common problems ; or to a psychoeducational multiple family group that emphasized the provision of information about the patient 's illness and methods of coping with it effectively . Both groups , which met for four hours on a Saturday afternoon , were an integral part of an ongoing inpatient program specializing in the treatment of affective disorders . Pre- and post- measures were obtained regarding family and patient knowledge about affective disorders , level of personal distress , attitudes about the illness , and dyadic adjustment . In addition , both patients and family members were asked to rate their satisfaction with the group experience . A number of differences in knowledge , attitude and dyadic adjustment were found in the participants of both groups immediately following their respective group sessions , but there were only a few statistically significant differences between the two groups . Those who attended the psychoeducational session , however , reported significantly more satisfaction with the experience Family affect was examined as a predictor of difficulty implementing a 9-month , manual-based , psychoeducational family therapy for recently manic bipolar patients . Prior to therapy , family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task . Following family treatment , both therapists and independent observers rated the overall difficulty of treating the family , and therapists also rated each participant 's problem behaviors during treatment , in the areas of affect , communication , and resistance . Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family . Relatives ' critical behavior toward patients during the pretreatment interaction task predicted both independent observers ' ratings of overall treatment difficulty and therapists ' perceptions of relatives ' affective problems during treatment . Moreover , patients ' residual symptoms predicted independent observers ' ratings of overall difficulty and therapists ' perceptions of patients ' resistance to the family intervention . Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic , pretreatment family and clinical assessment BACKGROUND Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder . This study used a r and omized , controlled design to examine a 9-month , manual-based program of family 
    Output:
    
To date there is only a small and heterogeneous body of evidence on the effectiveness of family oriented approaches for bipolar disorder , and it is not yet possible to draw any definite conclusions to support their use as an adjunctive treatment for bipolar disorder .