This application is in response to RFA MH-12-050, Optimizing Fidelity of Empirically-Supported Behavioral Treatments. Despite impressive results in laboratory settings, there has been a significant lag in the community adoption and sustainability of family interventions for early-onset mood and psychotic disorders. Our objective is to determine the optimal methods of training and monitoring the delivery of an evidence-based family-focused treatment (FFT) in community providers who treat young patients (ages 13-25) with bipolar disorder (BD), psychosis, or """"""""high-risk"""""""" conditions. FFT is administered in 21 sessions of psychoeducation, communication training, and problem-solving skills training. There are six RCTs indicating that, among adults or adolescents with BD, bipolar spectrum, or psychosis-risk disorders, FFT and pharmacotherapy are associated with more rapid stabilization of symptoms, delayed recurrences, enhanced functioning, better medication adherence, and improvements in family interaction relative to comparison treatments over 1-2 years. Using a community partnered participatory approach, we will engage diverse stakeholders (clinicians, administrators, caregivers) at three community sites (Harbor-UCLA Medical Center, San Fernando MHC, Didi Hirsch MHC) that treat early-onset, lower SES, urban, and racially and ethnically diverse bipolar and psychosis patients. Stakeholders will provide input into all phases of the study. In Phase I, we will conduct meta-analyses of fidelity data from six RCTs of FFT - all of which used the observer-based Therapist Competence and Adherence scales - to identify fidelity components that are differentially associated with intermediate and long- term patient and family outcomes. We expect key fidelity domains to include: therapist directiveness, skillful teaching of conflict resolution strategies, encouraging patients'medication adherence and lifestyle adaptations, and skillful direction of symptom prevention planning. We will develop and pilot streamlined self-report measures and web-based clinician training materials relevant to the identified fidelity components. In phase II, we will partner with the 3 community sites to randomly assign 20 clinicians to low intensity (webinar, web- based training, social networking site, monthly group teleconferences) or high intensity training (live workshop, web-based training, weekly individual supervision with fidelity feedback). Clinicians will administer FFT to 80 patient (ages 13-25) with recent-onset mania, psychosis or high-risk conditions. Dependent variables will be empirically-derived fidelity component scores over time as measured by supervisors, caregivers, and clinicians. We hypothesize that after training, clinicians in both the high and low intensity groups will attain minimum levels of fidelity required for certification in the four components. However, clinicians in high intensity training will sustain higher levels of fidelity across subsequent treatment cases, and will be more satisfied and more likely to adopt the FFT model. This study will facilitate the translation of an evidence-based intervention and identify effective treatment components to inform larger-scale dissemination of FFT in community settings.

Public Health Relevance

There is robust evidence from randomized controlled trials for the efficacy of family-focused treatment (FFT) in conjunction with pharmacotherapy in hastening recovery, delaying recurrences and improving functioning among adults and adolescents with bipolar disorder, but there remains a significant """"""""science-to-service"""""""" gap in implementing this psychoeducational treatment in community settings. Our main objective is to identify optimal methods of training and monitoring the delivery of FFT among community mental health clinicians who treat young-onset (ages 13-25) bipolar and psychosis spectrum patients. We propose a partnership between the UCLA School of Medicine and three high volume community mental health centers that treat lower socioeconomic, urban, and diverse patient populations, to determine: (1) how to efficiently train community providers in the essential components of FFT, (2) when and under what conditions training leads to sustainable changes in practice, and (3) whether changes in practice lead to better short- and long-term outcomes for patients with early-onset bipolar disorder or psychosis spectrum disorders.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
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Study Section
Special Emphasis Panel (ZMH1-ERB-B (01))
Program Officer
Pringle, Beverly
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University of California Los Angeles
Schools of Medicine
Los Angeles
United States
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Miklowitz, David J; Schneck, Christopher D; Walshaw, Patricia D et al. (2017) Early intervention for youth at high risk for bipolar disorder: A multisite randomized trial of family-focused treatment. Early Interv Psychiatry :
Goldstein, Benjamin I; Birmaher, Boris; Carlson, Gabrielle A et al. (2017) The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord 19:524-543
Miklowitz, David J; Portnoff, Larissa C; Armstrong, Casey C et al. (2016) Inflammatory cytokines and nuclear factor-kappa B activation in adolescents with bipolar and major depressive disorders. Psychiatry Res 241:315-22
Marvin, Sarah E; Miklowitz, David J; O'Brien, Mary P et al. (2016) Family-focused therapy for individuals at clinical high risk for psychosis: treatment fidelity within a multisite randomized trial. Early Interv Psychiatry 10:137-43
O'Brien, Mary P; Miklowitz, David J; Cannon, Tyrone D (2015) Decreases in perceived maternal criticism predict improvement in subthreshold psychotic symptoms in a randomized trial of family-focused therapy for individuals at clinical high risk for psychosis. J Fam Psychol 29:945-51
Vallarino, Martine; Henry, Chantal; Etain, Bruno et al. (2015) An evidence map of psychosocial interventions for the earliest stages of bipolar disorder. Lancet Psychiatry 2:548-63
Miklowitz, David J (2015) Intervening early in children with bipolar disorder: is there a pot at the end of the Rainbow? Evid Based Ment Health 18:65-6
Miklowitz, David J; O'Brien, Mary P; Schlosser, Danielle A et al. (2014) Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. J Am Acad Child Adolesc Psychiatry 53:848-58
Chung, Bowen; Mikesell, Lisa; Miklowitz, David (2014) Flexibility and structure may enhance implementation of family-focused therapy in community mental health settings. Community Ment Health J 50:787-91
O'Brien, Mary P; Miklowitz, David J; Candan, Kristin A et al. (2014) A randomized trial of family focused therapy with populations at clinical high risk for psychosis: effects on interactional behavior. J Consult Clin Psychol 82:90-101

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