Bipolar I disorder and expressed emotion of families: A cohort study in Japan

doi:10.4236/ojpsych.2012.24035

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Open Journal of Psychiatry, 2012, 2, 258-261 OJPsych

http://dx.doi.org/10.4236/ojpsych.2012.24035 Published Online October 2012 (http://www.SciRP.org/journal/ojpsych/)

Bipolar I disorder and expressed emotion of families: A

cohort study in Japan

Shinji Shimodera1*, Yukiko Yonekura2, Sosei Yamaguchi3, Aoi Kawamura1, Masafumi Mizuno4,

Shimpei Inoue1, Toshi A. Furukawa5, Yoshio Mino6

1Department of Neuropsychiatry, Kochi Medical School, Kochi University, Kochi, Japan

2Department of Social Welfare, Kansai University of Social Welfare, Hyogo, Japan

3Department of Psychiatric Rehabilitation, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo,

Japan

4Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan

5Department of Cognitive-Behavioral Medicine, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto,

Japan

6Department of Psychiatry, Mino Clinic, Okayama, Japan

Email: *[email protected]

Received 4 September 2012; revised 1 October 2012; accepted 9 October 2012

ABSTRACT

The relationships between expressed emotion (EE) of

the families and the course of bipolar disorder have

been examined only in a limited number of cohort

studies. No study has yet been reported from Asia.

The subjects were 12 patients that had been diag-

nosed with bipolar I disorder according to DSM-IV

and their 12 key family members. The families of the

patients were interviewed using the Camberwell Fa-

mily Interview (CFI) within 2 weeks of the admission

of the patients, and their EE were evaluated. The pa-

tients were then followed up for 9 months after their

discharge from the hospital. The patients were di-

vided into a high-EE group and a low-EE group using

the cut-off based on the number of critical comments

(CC) and emotional overinvolvement (EOI), and the

9-month relapse risk was compared. When the sub-

jects with 3 or more CC or an EOI score of 3 or more

were regarded as the high-EE group, and the others

as the low-EE group, the 9-month relapse risk was

100% (3/3) for the high EE group and 0% (0/9) for

the low EE group. (Fisher’s exact test p = 0.005) EE

based on the CFI appear to be correlated with relapse

in bipolar I disorder in Japan.

Keywords: Expressed Emotion; Family; Bipolar

Disorder

1. INTRODUCTION

The expressed emotion (EE) of families of patients has

been studied in schizophrenia, and its effects on the

course of the disease have been confirmed in a number

of world regions [1,2]. The relationships between fami-

lies’ EE and relapse of schizophrenia, social functions,

and depressive symptoms have also been clarified in

Japan, which has a different culture than Western socie-

ties [3-5]. Studies on the relationships of EE with mood

disorders such as depression have also been reported

[6-9], and a similar study has been reported from Japan

[10].

Bipolar disorders are thought to have a weaker rela-

tionship with familial stress than other mental disorder

including depression [11]. However, there have been a

few EE studies that suggest that families’ EE effects on

the course of this illness [7,8]. This suggest that “stress

vulnerability model” may be applicable in bipolar disor-

der. However, there has been no study from Asia on this

topic.

Bipolar disorder is an important mood disorder. Epi-

demiologically, lifetime risk of bipolar I disorder has

varied from 0.4% to 1.6%, and it is a recurrent disorder.

Life time risk of bipolar II disorder is 0.5% [12]. Social

cost for the disorders has been considerable [13]. There-

fore it is important to clarify factors that affect the course

of the disorder.

The purpose of the current study is to evaluate the re-

lationships between families’ EE and the course of bipo-

lar I disorder using a cohort study design in Japan.

2. METHODS

2.1. Subjects and Procedure

Consecutive patients with bipolar I disorder admitted to

the department of neuropsychiatry, Kochi Medical

School between April, 1997 and April, 2002 and their

*Corresponding author.

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S. Shimodera et al. / Open Journal of Psychiatry 2 (2012) 258-261 259

families were enrolled. The diagnosis was based on

DSM-IV and ICD-10. All the patients and their family

members received explanation of the study purpose and

procedures and provided written consent to participate in

the study. The protocol for this study was approved by

the Japanese Association of Psychoeducation of Depres-

sion. This study conforms to the provisions of the Decla-

ration of Helsinki (as revised in Edinburgh 2000).

The classical cohort study that examined the relation-

ship between bipolar disorder and relapse found the re-

lapse rate of 9/10 among those with high EE families and

that of 7/13 among those with low EE families [7]. In

order to detect this much difference at alpha = 0.05 and

power = 0.80, we would need 25 patients in each group.

However we were able to recruit only 12 patients during

the 5-year study period, and this study focuses on these

12 patients and their families.

The Camberwell Family Interview (CFI) [1] was per-

formed with key family members within 2 weeks of the

patients’ admission and the interviews were recorded on

cassette tapes. EE was evaluated using the recorded tapes

and their transcriptions with regard to critical comments

(CCs), hostility (H), emotional overinvolvement (EOI),

warmth (W), and positive remarks (PRs) [14]. The eva-

luation was performed by investigators who were for-

mally trained and authorized for EE evaluation. If two or

more interviews were carried out within one family, the

evaluation with the highest number of CCs or EOI score

was regarded as the EE state of the family.

The patients were treated primarily with medications

including lithium carbonate and supportive psychother-

apy during hospitalization and the follow-up period after

discharge. Psychiatric symptoms were evaluated on ad-

mission and discharge according to the Brief Psychiatric

Rating Scale (BPRS) [15] and Hamilton Depression Ra-

ting Scale (HRS) [16].

A cohort study in which the subjects were followed up

for 9 months after discharge of the patients was carried

out. Evaluation of symptoms by the BPRS and HRDS

was performed if the attending physician suspected exa-

cerbation of symptoms or if there were changes in the

therapeutic circumstances such as readmission. The dis-

ease was regarded as having relapsed when the findings

in an interview were consistent with the characteristics of

a major depressive or manic episode according to DSM-

IV. Trained psychiatrists who were blind to the results of

the EE evaluation performed these symptom evaluations.

2.2. Analysis

The distribution of the EE of the families studied was

evaluated. Also, the subjects with 3 or more CCs or an

EOI score of 3 or higher were classified as the high-EE

group, and the characteristics of patients were compared

between the high- and low-EE groups.

The subjects were classified into 2 groups according to

the number of CC with the cut-off points varying from 1

to 3, and the risk of relapse during the 9 months was

compared. When EOI was 3 or more, the patient was

classified into the high EE group. Given the small sam-

ple size, exact tests were carried out using the SPSS 9.0

for Windows.

3. RESULTS

During the study period, 12 patients with ICD-10 bipolar

disorder (re-diagnosed as DSM-IV bipolar I disorder

according to their case notes) and their 12 family mem-

bers were entered into the study. Of the 12 patients, 8

(66.7%) were males and 4 were females (33.3%), and

their mean age (standard deviation) was 49.7 (13.3) years.

All the patients were admitted to the hospital because of

their depressive state.

From the evaluation of the EE in each of the patients’

families, the distribution of CC is shown in the Tabl e 1 .

The number of CC was most frequently 0, accounting for

58.3%. The number of CC was 3 or more in 3 cases

(25.0%). The H score was 0 in all cases. The EOI score

was 3 or above in 1 subject (9.4%), for whom the num-

ber of CC was 3.

Table 2 shows the results of comparison of the pa-

tients’ characteristics between the high EE (number of

CCs ≥ 3 or EOI score ≥ 3) and low EE groups. There

were no significant differences.

Table 1. Distribution of Critical Comments (CC).

Number of CC N %

0 7 58.3

1 2 16.7

2 0 0

3 2 16.7

4 1 8.3

Total 12 100

Table 2. Comparison of the high and low EE groups.

High EE (n = 3) Low EE (n = 9)

n (%)

Sex (male) 2 (66.7) 6 (66.7)

Mean ± SD

Age (years) 49.7 ± 14.0 49.8 ± 11.2

Duration of illness

(years) 8.3 ± 4.6 5.0 ± 6.7

BPRS score at

admission 21.7 ± 9.1 20.2 ± 8.6

No significant difference by Fisher’s test (2-tailed) or t-test (2-tailed); BPRS:

Brief Psychiatric Rating Scale; High EE: (3 or more CC) or (3 or more EOI);

CC: Critical comments; EOI: Emotional overinvolvement.

S. Shimodera et al. / Open Journal of Psychiatry 2 (2012) 258-261

260

Table 3 shows a comparison of the number of pre-

vious manic/depressive episodes according to EE. In the

high EE group raw figures are presented, as the subject

number was too small.

In Ta b le 4, the association between EE and relapse is

shown. When we adopted 3 CCs as the cutoff point, the

9-month relapse risk was 100% (3/3) for the high EE

group and 0% (0/9) for the low EE group (Fisher’s exact

test p = 0.005), with 100% sensitivity and specificity.

Two of the 3 were defined as having relapsed into a

manic state, and 1 as having relapsed into a depressive

state. When we used only CCs for the analysis, the result

was the same as in Ta b l e 4 . A similar analysis only for

EOI was impossible because of the small number of the

subjects scoring 2 or 3 for EOI.

4. DISCUSSION

We will briefly review the previous literature. Miklowitz

et al. conducted a cohort study to investigate the associ-

ation between the course of bipolar disorder and EE,

affective style, and lithium therapy among 24 patients [7].

Table 3. Comparison of past episodes by high and low EE.

Depressive Manic Total numbers

Mean (range)

Low EE (n = 9) 1.7 (1 - 3) 1.9 (1 - 6) 3.6 (2 - 8)

High EE (n = 3)* 1 (1 - 1) 2 (1 - 4) 3 (2 - 5)

High EE: (3 or more CC) or (3 or more EOI); CC: Critical comments; EOI:

Emotional overinvolvement.

*in detail

High EE (n = 3)*

Depressive Manic Total

Case 1 1 1 2

Case 2 1 4 5

Case 3 1 1 2

Table 4. Families’ EE and relapse of bipolar disorder.

Relapse (%)

None Relapsed

Total

Low 7 (100) 0 (0) 7

High 2 (40) 3 (60) 5 EEE1*1

Total 9 (75) 3 (25) 12

Low 9 (100) 0 (0) 9

High 0 (0) 3 (100) 3 EEE2*2

Total 9 (75) 3 (25) 12

*1p = 0.045 by Fisher’s exact test, sensitivity = 100%, specificity = 77.8%.

*2p = 0.005 by Fisher’s exact test, sensitivity = 100%, specificity = 100%;

High EE1: (1 or more CC) or (3 or more EOI); High EE2: (3 or more CC) or

(3 or more EOI); CC: Critical comments; EOI: Emotional overinvolvement.

They found a positive association between the families’

EE and relapse. Priebe et al. also conducted a cohort

study in 21 patients with bipolar and schizoaffective dis-

orders treated by lithium [8]. They observed an associa-

tion between EE and relapse. Kim et al. studied the ef-

fects of families’ EE on the course of 125 bipolar disor-

dered patients [17]. They followed-up the patients for 2

years, and found no relationship between EE and relapse.

In these 3 studies, the families’ EE was evaluated by CFI.

On the other hand, Yan et al. used FMSS (Five-Minute

Speech Sample) and conducted a 1-year cohort study

among bipolar I disordered patients [18]. They found that

the families’ EE was related to depressive relapse.

These previous studies suggest that the family envi-

ronment as evaluated by EE affects the course of bipolar

disorders, although one study showed negative findings.

In the current study, we support these findings and sub-

mit the first report from East Asia, where different cul-

tures and religions exist.

Concerning the CC cut-off point, the validity was best

when the subjects were divided between 3 or more and 2

or less. In this case, both sensitivity and specificity were

100%. However Miklowitz et al. used 6 CC as the cut-

off point [7]. This means that, in Japan, the CC cut-off

point for high EE should be changed, as families’ emo-

tional expression may be less salient in this culture.

If the high EE group has experienced more previous

manic/depressive episodes than the control group, this

would explain the current results. However, we found no

evidence for it (Table 3).

As the relapse during the follow-up period, in the high

EE group, 2 out of 3 were defined as having relapsed

into a manic state, and 1 into a depressive state. Because

of the small number of subjects, we could not find alter-

native reason for the 2 types of relapse.

Finally, we will discuss the limitations of the current

study. 1) Small sample size: We could not examine the

EE’s effect on the bipolar I disorder compared to the

bipolar II disorder; 2) The subjects were inpatients. There-

fore, the findings might be valid only among more se-

verely affected patients. Because the number of outpa-

tients is larger than that of inpatients, further studies are

required in outpatients including those with bipolar II

disorder. Also studies with adolescents are required since

this study was conducted mainly on middle-aged patients

[19].

5. ACKNOWLEDGEMENTS

The authors express their thanks to the patients and their families who

kindly participated in this study, and to Dr. Koichiro Sudo, Tosa Hospi-

tal for his assistance and discussion. This study was partly funded by a

grant-in-aid for scientific research (B) from the Japan Ministry of Edu-

S. Shimodera et al. / Open Journal of Psychiatry 2 (2012) 258-261

261

[10] Mino, Y., et al. (2001) Expressed emotion of families and

the course of mood disorders: A cohort study in Japan.

Journal of Affective Disorders, 63, 43-49.

doi:10.1016/S0165-0327(00)00185-3

cation, Science, Sports and Culture (grant No. 17390191).

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