Igor Galynker, MD

Many clinical factors associated with suicide in youth are well known, such as depression, substance abuse, conduct disorder, and poor social support. Less well-known risk factors include childhood and family adversity, such as witnessing domestic violence, and experiencing parental separation or divorce, and childhood physical and/or sexual abuse.

Psychiatrists and other mental health professionals should consider an additional factor when working with young patients in crisis: parental bonding style. In these families with a history of mental illness, children are at particular risk for psychopathology.

Parental bonding is a construct developed in the 1970s and 1980s by Australian psychiatrist Gordon Parker and his colleagues (Brit. J. Med. Psychology 1979;52:1-10). The concept is dichotomous, including level of care and level of control, or protection. It is not surprising that high-care parenting is considered optimal, while low-care, or neglectful parenting, is detrimental.

What might be more surprising is the overwhelming finding that high levels of control, or overprotection, are associated with higher levels of psychopathology than appropriate or under protection. Specifically, studies show that high levels of maternal overprotection are associated with generally higher levels of psychopathology in children and adolescents (Child Psychiatry Hum. Dev. 2012;43:102-12 and Behav. Ther. 2007;38:402-11), while overprotection in both parents is associated with anxiety disorders (Behav. Cogn. Psychother. 2012;40:287-96), social phobia (J. Anxiety Disord. 2012;26:608-16), eating disorders (J. Psychiatr. Ment. Health Nurs. 2011;18:728-35), and depression (Depress. Anxiety 2010;27:1149-57).

Furthermore, the combination of low care and overprotective parenting styles appears to be particularly detrimental. Not only is this parenting style associated with psychopathology. Studies agree, nearly unanimously, that parental affectionless control is associated with suicidality later in life, according to an analysis of 12 papers by Dr. Simona A. Goschin of Beth Israel Medical Center, New York; Jessica Briggs of the Family Center for Bipolar at Beth Israel; and their colleagues (J. Affect. Disord. 2013 June 29 [doi:10.1016/j.jad.2013.05.096]) This finding holds true with regard to maternal parental style in all cases.

However, the studies reviewed showed slightly more disagreement when it came to the effect of paternal style on suicidality. Some studies showed an association between paternal affectionless control and suicidality; others simply found no association between paternal style and suicidality.

Not unexpectedly, this difference could be related to the historically more dominant role of mothers relative to fathers within families.

A few years ago, a team of researchers examined the possible connections between perceived family problems and suicide ideation in a sample of Chinese adolescents in Hong Kong. Some studies have characterized Chinese parenting as "relatively controlling and even hostile," the researchers wrote (Int. J. Psychology 2001;36:81-7). The investigators in this study defined an authoritarian parenting style as one that emphasizes "control, maturity, obedience, and conformity" in children. Furthermore, the investigators examined the perceived lower role of fathers in the care and discipline of adolescents in Hong Kong. In Chinese families, "fathers tend to be perceived as more strict and disciplining and more concerned with the demands of propriety and necessity than with feelings, while mothers tend to be viewed as more kind, warm affectionate, and lenient," the authors wrote.

After getting students in the study to complete numerous questionnaires, including the Scale of Suicide Ideation, the investigators concluded that suicide ideation was significantly tied to "perceived authoritarian parenting, low parental warmth, high maternal over control, negative child-rearing practices, and a negative family climate."

It is difficult to ascertain from the research why deficient parental bonding in the form of affectionless control has such a strong association with suicidality. Several studies have attempted to answer this question by using nonsuicidal psychiatric patients as control subjects, most recently an investigation in Israel led by Ornit Freudenstein, Ph.D., and his colleagues (Eur. Psychiatry 2011;26:504-7). Dr. Freudenstein found that adolescents who exhibited severe suicidal behavior were more likely to perceive their mothers are less caring and more overprotective than their counterparts with either mild or no suicidal behavior. He and his colleagues concluded that maternal bonding might be an "important correlate of suicidal behavior in adolescents" and might in fact guide strategies we develop while working with these patients.

It is also worth noting that affectionless control has proven to be a significant risk factor for suicidality in both adolescents and adults. All of the studies using adolescent subjects only showed affectionless control to be a risk factor for suicidality, and the studies using adult populations were nearly as uniform. This suggests that poor parenting style has long lasting, possibly lifelong consequences. Again, the relationship between affectionless and controlling upbringing and age in suicide attempters deserves further study, as does the question of whether its pernicious effects ever dissipate.

Children are affected most by the style of the parent who has the greatest involvement in raising them. Higher levels of overprotection during childhood associate with higher levels of pathology in adolescence and adulthood, particularly in parents who also are less caring. We clinicians should use these findings to guide our adult patients toward an optimal parenting style, and to recognize and intervene when we see signs of low care, overprotection, or both – particularly in families with a history of affective disorders.

Recognizing affectionless control as a risk factor for suicide might help us identify at-risk patients, so that we might better focus our treatment plans and/or intervene before the suicidal behavior occurs.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also is associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, New York, and is director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.

Many clinical factors associated with suicide in youth are well known, such as depression, substance abuse, conduct disorder, and poor social support. Less well-known risk factors include childhood and family adversity, such as witnessing domestic violence, and experiencing parental separation or divorce, and childhood physical and/or sexual abuse.

Psychiatrists and other mental health professionals should consider an additional factor when working with young patients in crisis: parental bonding style. In these families with a history of mental illness, children are at particular risk for psychopathology.

Parental bonding is a construct developed in the 1970s and 1980s by Australian psychiatrist Gordon Parker and his colleagues (Brit. J. Med. Psychology 1979;52:1-10). The concept is dichotomous, including level of care and level of control, or protection. It is not surprising that high-care parenting is considered optimal, while low-care, or neglectful parenting, is detrimental.

What might be more surprising is the overwhelming finding that high levels of control, or overprotection, are associated with higher levels of psychopathology than appropriate or under protection. Specifically, studies show that high levels of maternal overprotection are associated with generally higher levels of psychopathology in children and adolescents (Child Psychiatry Hum. Dev. 2012;43:102-12 and Behav. Ther. 2007;38:402-11), while overprotection in both parents is associated with anxiety disorders (Behav. Cogn. Psychother. 2012;40:287-96), social phobia (J. Anxiety Disord. 2012;26:608-16), eating disorders (J. Psychiatr. Ment. Health Nurs. 2011;18:728-35), and depression (Depress. Anxiety 2010;27:1149-57).

Furthermore, the combination of low care and overprotective parenting styles appears to be particularly detrimental. Not only is this parenting style associated with psychopathology. Studies agree, nearly unanimously, that parental affectionless control is associated with suicidality later in life, according to an analysis of 12 papers by Dr. Simona A. Goschin of Beth Israel Medical Center, New York; Jessica Briggs of the Family Center for Bipolar at Beth Israel; and their colleagues (J. Affect. Disord. 2013 June 29 [doi:10.1016/j.jad.2013.05.096]) This finding holds true with regard to maternal parental style in all cases.

However, the studies reviewed showed slightly more disagreement when it came to the effect of paternal style on suicidality. Some studies showed an association between paternal affectionless control and suicidality; others simply found no association between paternal style and suicidality.

Not unexpectedly, this difference could be related to the historically more dominant role of mothers relative to fathers within families.

A few years ago, a team of researchers examined the possible connections between perceived family problems and suicide ideation in a sample of Chinese adolescents in Hong Kong. Some studies have characterized Chinese parenting as "relatively controlling and even hostile," the researchers wrote (Int. J. Psychology 2001;36:81-7). The investigators in this study defined an authoritarian parenting style as one that emphasizes "control, maturity, obedience, and conformity" in children. Furthermore, the investigators examined the perceived lower role of fathers in the care and discipline of adolescents in Hong Kong. In Chinese families, "fathers tend to be perceived as more strict and disciplining and more concerned with the demands of propriety and necessity than with feelings, while mothers tend to be viewed as more kind, warm affectionate, and lenient," the authors wrote.

After getting students in the study to complete numerous questionnaires, including the Scale of Suicide Ideation, the investigators concluded that suicide ideation was significantly tied to "perceived authoritarian parenting, low parental warmth, high maternal over control, negative child-rearing practices, and a negative family climate."

It is difficult to ascertain from the research why deficient parental bonding in the form of affectionless control has such a strong association with suicidality. Several studies have attempted to answer this question by using nonsuicidal psychiatric patients as control subjects, most recently an investigation in Israel led by Ornit Freudenstein, Ph.D., and his colleagues (Eur. Psychiatry 2011;26:504-7). Dr. Freudenstein found that adolescents who exhibited severe suicidal behavior were more likely to perceive their mothers are less caring and more overprotective than their counterparts with either mild or no suicidal behavior. He and his colleagues concluded that maternal bonding might be an "important correlate of suicidal behavior in adolescents" and might in fact guide strategies we develop while working with these patients.

It is also worth noting that affectionless control has proven to be a significant risk factor for suicidality in both adolescents and adults. All of the studies using adolescent subjects only showed affectionless control to be a risk factor for suicidality, and the studies using adult populations were nearly as uniform. This suggests that poor parenting style has long lasting, possibly lifelong consequences. Again, the relationship between affectionless and controlling upbringing and age in suicide attempters deserves further study, as does the question of whether its pernicious effects ever dissipate.

Children are affected most by the style of the parent who has the greatest involvement in raising them. Higher levels of overprotection during childhood associate with higher levels of pathology in adolescence and adulthood, particularly in parents who also are less caring. We clinicians should use these findings to guide our adult patients toward an optimal parenting style, and to recognize and intervene when we see signs of low care, overprotection, or both – particularly in families with a history of affective disorders.

Recognizing affectionless control as a risk factor for suicide might help us identify at-risk patients, so that we might better focus our treatment plans and/or intervene before the suicidal behavior occurs.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also is associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, New York, and is director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.

Many clinical factors associated with suicide in youth are well known, such as depression, substance abuse, conduct disorder, and poor social support. Less well-known risk factors include childhood and family adversity, such as witnessing domestic violence, and experiencing parental separation or divorce, and childhood physical and/or sexual abuse.

Psychiatrists and other mental health professionals should consider an additional factor when working with young patients in crisis: parental bonding style. In these families with a history of mental illness, children are at particular risk for psychopathology.

Parental bonding is a construct developed in the 1970s and 1980s by Australian psychiatrist Gordon Parker and his colleagues (Brit. J. Med. Psychology 1979;52:1-10). The concept is dichotomous, including level of care and level of control, or protection. It is not surprising that high-care parenting is considered optimal, while low-care, or neglectful parenting, is detrimental.

What might be more surprising is the overwhelming finding that high levels of control, or overprotection, are associated with higher levels of psychopathology than appropriate or under protection. Specifically, studies show that high levels of maternal overprotection are associated with generally higher levels of psychopathology in children and adolescents (Child Psychiatry Hum. Dev. 2012;43:102-12 and Behav. Ther. 2007;38:402-11), while overprotection in both parents is associated with anxiety disorders (Behav. Cogn. Psychother. 2012;40:287-96), social phobia (J. Anxiety Disord. 2012;26:608-16), eating disorders (J. Psychiatr. Ment. Health Nurs. 2011;18:728-35), and depression (Depress. Anxiety 2010;27:1149-57).

Furthermore, the combination of low care and overprotective parenting styles appears to be particularly detrimental. Not only is this parenting style associated with psychopathology. Studies agree, nearly unanimously, that parental affectionless control is associated with suicidality later in life, according to an analysis of 12 papers by Dr. Simona A. Goschin of Beth Israel Medical Center, New York; Jessica Briggs of the Family Center for Bipolar at Beth Israel; and their colleagues (J. Affect. Disord. 2013 June 29 [doi:10.1016/j.jad.2013.05.096]) This finding holds true with regard to maternal parental style in all cases.

However, the studies reviewed showed slightly more disagreement when it came to the effect of paternal style on suicidality. Some studies showed an association between paternal affectionless control and suicidality; others simply found no association between paternal style and suicidality.

Not unexpectedly, this difference could be related to the historically more dominant role of mothers relative to fathers within families.

A few years ago, a team of researchers examined the possible connections between perceived family problems and suicide ideation in a sample of Chinese adolescents in Hong Kong. Some studies have characterized Chinese parenting as "relatively controlling and even hostile," the researchers wrote (Int. J. Psychology 2001;36:81-7). The investigators in this study defined an authoritarian parenting style as one that emphasizes "control, maturity, obedience, and conformity" in children. Furthermore, the investigators examined the perceived lower role of fathers in the care and discipline of adolescents in Hong Kong. In Chinese families, "fathers tend to be perceived as more strict and disciplining and more concerned with the demands of propriety and necessity than with feelings, while mothers tend to be viewed as more kind, warm affectionate, and lenient," the authors wrote.

After getting students in the study to complete numerous questionnaires, including the Scale of Suicide Ideation, the investigators concluded that suicide ideation was significantly tied to "perceived authoritarian parenting, low parental warmth, high maternal over control, negative child-rearing practices, and a negative family climate."

It is difficult to ascertain from the research why deficient parental bonding in the form of affectionless control has such a strong association with suicidality. Several studies have attempted to answer this question by using nonsuicidal psychiatric patients as control subjects, most recently an investigation in Israel led by Ornit Freudenstein, Ph.D., and his colleagues (Eur. Psychiatry 2011;26:504-7). Dr. Freudenstein found that adolescents who exhibited severe suicidal behavior were more likely to perceive their mothers are less caring and more overprotective than their counterparts with either mild or no suicidal behavior. He and his colleagues concluded that maternal bonding might be an "important correlate of suicidal behavior in adolescents" and might in fact guide strategies we develop while working with these patients.

It is also worth noting that affectionless control has proven to be a significant risk factor for suicidality in both adolescents and adults. All of the studies using adolescent subjects only showed affectionless control to be a risk factor for suicidality, and the studies using adult populations were nearly as uniform. This suggests that poor parenting style has long lasting, possibly lifelong consequences. Again, the relationship between affectionless and controlling upbringing and age in suicide attempters deserves further study, as does the question of whether its pernicious effects ever dissipate.

Children are affected most by the style of the parent who has the greatest involvement in raising them. Higher levels of overprotection during childhood associate with higher levels of pathology in adolescence and adulthood, particularly in parents who also are less caring. We clinicians should use these findings to guide our adult patients toward an optimal parenting style, and to recognize and intervene when we see signs of low care, overprotection, or both – particularly in families with a history of affective disorders.

Recognizing affectionless control as a risk factor for suicide might help us identify at-risk patients, so that we might better focus our treatment plans and/or intervene before the suicidal behavior occurs.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also is associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, New York, and is director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.

It is impossible to underestimate the extent to which bipolar disorder affects the family members and caregivers of our patients.

First of all, bipolar disorder has a strong genetic component. Up to 67% of children with at least one affected parent will go on to develop an affective disorder (Bipolar Disord. 2001;3:325-34 and Bipolar Disord. 2006;8:710-20). In bipolar disorder, multiple neurotransmitter systems as well as the limbic corticostriatal systems are dysfunctional. The dysfunction of the latter is manifested by increased activity in the amygdala and decreased activity in frontal cortical regions (Annu. Rev. Clin. Psychol. 2006;199-235), which might impair the brain’s capacity to regulate emotion. The extremely high prevalence of affective disorders in the children of affected parents might be attributable to this dysfunction.

Second, bipolar disorder affects the family members and caregivers of patients through the family environment. About 90% of family members of patients with bipolar disorder experience subjective burden (for example, feelings of emotional distress) that correlates with the severity of the patient’s illness symptoms (Bipolar Disord. 2007;9:262-73). Family members with higher subjective burden are less likely to practice appropriate health behaviors and, as a result, are in poorer physical health than are family members of patients without mental illness. Higher levels of caregiver burden also are also associated with more emotion-focused coping and lower mastery among caregivers of patients with bipolar disorder (J. Nerv. Ment. Dis. 2008;196:484-91).

Because of this high subjective burden and to other factors such as objective (financial) burden, stigma, and turmoil in bipolar families, family members of patients with bipolar disorder exhibit high rates of depression, anxiety, and other psychiatric symptoms. In fact, caring for relatives with bipolar disorder doubles the risk of recurrence of a major depressive episode in those with a preexisting diagnosis of major depressive disorder.

Additionally, since these depressed or anxious family members usually appear in psychiatrists’ offices in their caregiver roles for their relatives with bipolar disorder, their psychiatric disability is often either unappreciated or unnoticed by clinicians (Bipolar Disord. 2010;12:627-37).

This is unfortunate, because rates of psychiatric disability in family members of patients with bipolar disorder are high (J. Affect. Disord. 2010;121:10-21). Specifically, up to 40% of caregivers qualify for more than one current psychiatric diagnosis, while 60%-80% had at least one lifetime psychiatric diagnosis. Of note, nonbiological relatives had substantially higher rates of psychiatric disability than did biological relatives, indicating that partners of patients with bipolar disorder were more likely to have a familial mental illness themselves. This indicates that patients with bipolar disorder might tend to choose partners who also suffer from mental illness, a pattern known as assortative mating.

Most of the psychiatric diagnoses in caregivers reflect high levels of mood and anxiety symptoms. Depending on the study populations selected, 30%-40% of primary caregivers reported significant depressive symptoms or qualified for a mood disorder (Bipolar Disord. 2005;7:126-36 and Fam. Process 2002;41:645-57). Most of those diagnoses were major depressive disorder (69%), while 20% of caregivers qualified for a diagnosis on the bipolar spectrum (J. Affect. Disord. 2010;121:10-21).

The severity of depression in family members or caregivers might be related to either or both bipolar disorder severity and the stigma associated with it. In other words, family members’ moods might fluctuate with that of the patient; they might be more depressed during acute episodes and find that their depression lifts between episodes.

Finally, 40%-60% of caregivers qualify for a diagnosis of generalized anxiety disorder; as with depression, the nonbiological relatives were more symptomatic than were the blood relatives, lending support to the theory of assortative mating.

Just as mood symptoms of bipolar disorder influence depression and anxiety levels in the family members of patients, the reverse is also true, and the symptom load in caregivers affects the course and the outcome of the illness in their relatives with bipolar disorder. Subjective burden and/or depression compromise caregivers’ ability to effectively manage the demands associated with caregiving, which in turn leads to less favorable patient outcomes. Some of this process is mediated by the increased stress level in the family, which in turn is a reflection of high expressed emotion (EE) (Br. J. Psychiatry 1972;121:241-58). High EE refers to high levels of criticism, hostility, and emotional overinvolvement from a caregiving family member during or immediately after a patient’s acute episode of illness. Patients with bipolar disorder who return to high-EE families after an acute episode are two to three times more likely to relapse in the subsequent 9 months than are patients who return to low-EE families.

In conclusion, rapidly accumulating evidence suggests that family members of patients with bipolar disorder experience high rates of depression, anxiety, and psychiatric distress in general. Because of their caregiving role with respect to the affected relative, their symptom level is not fully appreciated – and mental health needs often go unmet.

Most published interventions for family members are psychoeducational and aim to improve their function as caregivers (with the goal of reducing relapse rates in patients with bipolar disorder), rather than to relieve psychiatric symptoms in the family members themselves. Thus, family members of patients with bipolar disorder are often "hidden patients."

In practice, clinicians should directly inquire about and treat mood and anxiety symptoms in family members of their patients with bipolar disorder. New effective family interventions that target BOTH patients and caregivers using a family approach need to be developed and implemented.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also serves associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, in New York, and as director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.

It is impossible to underestimate the extent to which bipolar disorder affects the family members and caregivers of our patients.

First of all, bipolar disorder has a strong genetic component. Up to 67% of children with at least one affected parent will go on to develop an affective disorder (Bipolar Disord. 2001;3:325-34 and Bipolar Disord. 2006;8:710-20). In bipolar disorder, multiple neurotransmitter systems as well as the limbic corticostriatal systems are dysfunctional. The dysfunction of the latter is manifested by increased activity in the amygdala and decreased activity in frontal cortical regions (Annu. Rev. Clin. Psychol. 2006;199-235), which might impair the brain’s capacity to regulate emotion. The extremely high prevalence of affective disorders in the children of affected parents might be attributable to this dysfunction.

Second, bipolar disorder affects the family members and caregivers of patients through the family environment. About 90% of family members of patients with bipolar disorder experience subjective burden (for example, feelings of emotional distress) that correlates with the severity of the patient’s illness symptoms (Bipolar Disord. 2007;9:262-73). Family members with higher subjective burden are less likely to practice appropriate health behaviors and, as a result, are in poorer physical health than are family members of patients without mental illness. Higher levels of caregiver burden also are also associated with more emotion-focused coping and lower mastery among caregivers of patients with bipolar disorder (J. Nerv. Ment. Dis. 2008;196:484-91).

Because of this high subjective burden and to other factors such as objective (financial) burden, stigma, and turmoil in bipolar families, family members of patients with bipolar disorder exhibit high rates of depression, anxiety, and other psychiatric symptoms. In fact, caring for relatives with bipolar disorder doubles the risk of recurrence of a major depressive episode in those with a preexisting diagnosis of major depressive disorder.

Additionally, since these depressed or anxious family members usually appear in psychiatrists’ offices in their caregiver roles for their relatives with bipolar disorder, their psychiatric disability is often either unappreciated or unnoticed by clinicians (Bipolar Disord. 2010;12:627-37).

This is unfortunate, because rates of psychiatric disability in family members of patients with bipolar disorder are high (J. Affect. Disord. 2010;121:10-21). Specifically, up to 40% of caregivers qualify for more than one current psychiatric diagnosis, while 60%-80% had at least one lifetime psychiatric diagnosis. Of note, nonbiological relatives had substantially higher rates of psychiatric disability than did biological relatives, indicating that partners of patients with bipolar disorder were more likely to have a familial mental illness themselves. This indicates that patients with bipolar disorder might tend to choose partners who also suffer from mental illness, a pattern known as assortative mating.

Most of the psychiatric diagnoses in caregivers reflect high levels of mood and anxiety symptoms. Depending on the study populations selected, 30%-40% of primary caregivers reported significant depressive symptoms or qualified for a mood disorder (Bipolar Disord. 2005;7:126-36 and Fam. Process 2002;41:645-57). Most of those diagnoses were major depressive disorder (69%), while 20% of caregivers qualified for a diagnosis on the bipolar spectrum (J. Affect. Disord. 2010;121:10-21).

The severity of depression in family members or caregivers might be related to either or both bipolar disorder severity and the stigma associated with it. In other words, family members’ moods might fluctuate with that of the patient; they might be more depressed during acute episodes and find that their depression lifts between episodes.

Finally, 40%-60% of caregivers qualify for a diagnosis of generalized anxiety disorder; as with depression, the nonbiological relatives were more symptomatic than were the blood relatives, lending support to the theory of assortative mating.

Just as mood symptoms of bipolar disorder influence depression and anxiety levels in the family members of patients, the reverse is also true, and the symptom load in caregivers affects the course and the outcome of the illness in their relatives with bipolar disorder. Subjective burden and/or depression compromise caregivers’ ability to effectively manage the demands associated with caregiving, which in turn leads to less favorable patient outcomes. Some of this process is mediated by the increased stress level in the family, which in turn is a reflection of high expressed emotion (EE) (Br. J. Psychiatry 1972;121:241-58). High EE refers to high levels of criticism, hostility, and emotional overinvolvement from a caregiving family member during or immediately after a patient’s acute episode of illness. Patients with bipolar disorder who return to high-EE families after an acute episode are two to three times more likely to relapse in the subsequent 9 months than are patients who return to low-EE families.

In conclusion, rapidly accumulating evidence suggests that family members of patients with bipolar disorder experience high rates of depression, anxiety, and psychiatric distress in general. Because of their caregiving role with respect to the affected relative, their symptom level is not fully appreciated – and mental health needs often go unmet.

Most published interventions for family members are psychoeducational and aim to improve their function as caregivers (with the goal of reducing relapse rates in patients with bipolar disorder), rather than to relieve psychiatric symptoms in the family members themselves. Thus, family members of patients with bipolar disorder are often "hidden patients."

In practice, clinicians should directly inquire about and treat mood and anxiety symptoms in family members of their patients with bipolar disorder. New effective family interventions that target BOTH patients and caregivers using a family approach need to be developed and implemented.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also serves associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, in New York, and as director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.

It is impossible to underestimate the extent to which bipolar disorder affects the family members and caregivers of our patients.

First of all, bipolar disorder has a strong genetic component. Up to 67% of children with at least one affected parent will go on to develop an affective disorder (Bipolar Disord. 2001;3:325-34 and Bipolar Disord. 2006;8:710-20). In bipolar disorder, multiple neurotransmitter systems as well as the limbic corticostriatal systems are dysfunctional. The dysfunction of the latter is manifested by increased activity in the amygdala and decreased activity in frontal cortical regions (Annu. Rev. Clin. Psychol. 2006;199-235), which might impair the brain’s capacity to regulate emotion. The extremely high prevalence of affective disorders in the children of affected parents might be attributable to this dysfunction.

Second, bipolar disorder affects the family members and caregivers of patients through the family environment. About 90% of family members of patients with bipolar disorder experience subjective burden (for example, feelings of emotional distress) that correlates with the severity of the patient’s illness symptoms (Bipolar Disord. 2007;9:262-73). Family members with higher subjective burden are less likely to practice appropriate health behaviors and, as a result, are in poorer physical health than are family members of patients without mental illness. Higher levels of caregiver burden also are also associated with more emotion-focused coping and lower mastery among caregivers of patients with bipolar disorder (J. Nerv. Ment. Dis. 2008;196:484-91).

Because of this high subjective burden and to other factors such as objective (financial) burden, stigma, and turmoil in bipolar families, family members of patients with bipolar disorder exhibit high rates of depression, anxiety, and other psychiatric symptoms. In fact, caring for relatives with bipolar disorder doubles the risk of recurrence of a major depressive episode in those with a preexisting diagnosis of major depressive disorder.

Additionally, since these depressed or anxious family members usually appear in psychiatrists’ offices in their caregiver roles for their relatives with bipolar disorder, their psychiatric disability is often either unappreciated or unnoticed by clinicians (Bipolar Disord. 2010;12:627-37).

This is unfortunate, because rates of psychiatric disability in family members of patients with bipolar disorder are high (J. Affect. Disord. 2010;121:10-21). Specifically, up to 40% of caregivers qualify for more than one current psychiatric diagnosis, while 60%-80% had at least one lifetime psychiatric diagnosis. Of note, nonbiological relatives had substantially higher rates of psychiatric disability than did biological relatives, indicating that partners of patients with bipolar disorder were more likely to have a familial mental illness themselves. This indicates that patients with bipolar disorder might tend to choose partners who also suffer from mental illness, a pattern known as assortative mating.

Most of the psychiatric diagnoses in caregivers reflect high levels of mood and anxiety symptoms. Depending on the study populations selected, 30%-40% of primary caregivers reported significant depressive symptoms or qualified for a mood disorder (Bipolar Disord. 2005;7:126-36 and Fam. Process 2002;41:645-57). Most of those diagnoses were major depressive disorder (69%), while 20% of caregivers qualified for a diagnosis on the bipolar spectrum (J. Affect. Disord. 2010;121:10-21).

The severity of depression in family members or caregivers might be related to either or both bipolar disorder severity and the stigma associated with it. In other words, family members’ moods might fluctuate with that of the patient; they might be more depressed during acute episodes and find that their depression lifts between episodes.

Finally, 40%-60% of caregivers qualify for a diagnosis of generalized anxiety disorder; as with depression, the nonbiological relatives were more symptomatic than were the blood relatives, lending support to the theory of assortative mating.

Just as mood symptoms of bipolar disorder influence depression and anxiety levels in the family members of patients, the reverse is also true, and the symptom load in caregivers affects the course and the outcome of the illness in their relatives with bipolar disorder. Subjective burden and/or depression compromise caregivers’ ability to effectively manage the demands associated with caregiving, which in turn leads to less favorable patient outcomes. Some of this process is mediated by the increased stress level in the family, which in turn is a reflection of high expressed emotion (EE) (Br. J. Psychiatry 1972;121:241-58). High EE refers to high levels of criticism, hostility, and emotional overinvolvement from a caregiving family member during or immediately after a patient’s acute episode of illness. Patients with bipolar disorder who return to high-EE families after an acute episode are two to three times more likely to relapse in the subsequent 9 months than are patients who return to low-EE families.

In conclusion, rapidly accumulating evidence suggests that family members of patients with bipolar disorder experience high rates of depression, anxiety, and psychiatric distress in general. Because of their caregiving role with respect to the affected relative, their symptom level is not fully appreciated – and mental health needs often go unmet.

Most published interventions for family members are psychoeducational and aim to improve their function as caregivers (with the goal of reducing relapse rates in patients with bipolar disorder), rather than to relieve psychiatric symptoms in the family members themselves. Thus, family members of patients with bipolar disorder are often "hidden patients."

In practice, clinicians should directly inquire about and treat mood and anxiety symptoms in family members of their patients with bipolar disorder. New effective family interventions that target BOTH patients and caregivers using a family approach need to be developed and implemented.

Dr. Galynker is founder and director of the Family Center for Bipolar, New York. He also serves associate chairman of the department of psychiatry and behavioral sciences at the Beth Israel Medical Center, in New York, and as director of the division of biological psychiatry at the medical center. Ms. Briggs serves as program assistant at the Family Center for Bipolar.