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Intervention Summary

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Multi-Family Psychoeducational Psychotherapy (MF-PEP)

Multi-Family Psychoeducational Psychotherapy (MF-PEP) is a group treatment program for families of children and adolescents (ages 8-12) with depressive or bipolar spectrum disorders. Both children and parents participate in the 8-week program, attending separate group sessions. The goals of MF-PEP are to:

  • Educate children and parents about mood disorders and their treatments
  • Provide social support for both parents and children, and social skills building for children
  • Develop symptom management skills, including emotion regulation, problem solving, and communication strategies
  • Increase parents' understanding of the available educational and mental health systems of care so they can become more active consumers and effective advocates for their children's needs

The rationale for MF-PEP derives from the literature on expressed emotion and psychoeducation for adults with schizophrenia and major mood disorders, which suggests that improving family climate provides a healthier environment in which an individual can recover from an acute mood (or psychotic) episode. The intervention also focuses on increasing parents' awareness of how unipolar depression can lead to bipolar disorder and how to recognize the signs of this conversion process.

MF-PEP groups meet for eight 90-minute weekly sessions. The recommended group size is 6-8 children and 12-16 adults (both parents of each child are encouraged to attend). Other primary caregivers such as stepparents also may participate. Sessions begin and end with parents and children together, but the majority of treatment time is spent in separate child and parent sessions. The child sessions include in vivo social skills training related to each week's topic, as well as collaborative learning and relaxation exercises. Parent sessions cover the same topics as the child sessions, with additional material relevant to adults only. Families are assigned projects to complete between sessions.

MF-PEP is delivered by trained psychotherapists. One therapist conducts the parent sessions, which are informational and discussion-based. Two therapists lead the child sessions, a lead therapist to deliver treatment content and another therapist (or trainee) to assist the lead and manage children's behavior.

In the studies reviewed for this summary, MF-PEP was provided through the outpatient facilities of a university medical center.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: July 2012
1: Knowledge of mood disorders
2: Expressed emotion
3: Severity of manic and depressive symptoms
4: Conversion from depressive spectrum disorders to bipolar spectrum disorders
Outcome Categories Mental health
Ages 6-12 (Childhood)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History The first randomized controlled trial (RCT) of MF-PEP was conducted in 1997. A second RCT took place in 2001–2006. An efficacy-to-effectiveness trial is currently underway. As of 2013, more than 400 children have been treated in clinical trials to date using either MF-PEP or Individual-Family Psychoeducational Psychotherapy (IF-PEP), a related program designed for families who need or prefer one-on-one sessions with a therapist. All studies of MF-PEP to date have been conducted in Ohio.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: No
Adaptations MF-PEP has been adapted for use with children with autism spectrum disorder. A Spanish-language version of the manual and a version for use with adolescents are in development.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: July 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2003). Multi-family psychoeducation groups in the treatment of children with mood disorders. Journal of Marital and Family Therapy, 29(4), 491-504.  Pub Med icon

Study 2

Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. (2009). Impact of Multifamily Psychoeducational Psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66(9), 1013-1021.  Pub Med icon

Nadkarni, R. B., & Fristad, M. A. (2010). Clinical course of children with a depressive spectrum disorder and transient manic symptoms. Bipolar Disorders. 12(5), 494-503.  Pub Med icon

Supplementary Materials

Gavazzi, S. M., Fristad, M. A., & Law, J. C. (1997). The Understanding Mood Disorders Questionnaire. Psychological Reports, 81(1), 172-174.  Pub Med icon

Outcomes

Outcome 1: Knowledge of mood disorders
Description of Measures Parents' knowledge of mood disorders was measured using the Understanding of Mood Disorders Questionnaire (UMDQ). The first part of the UMDQ contains 20 true/false statements that assess attributions about mood disorders and knowledge of symptoms, course, and treatment of such disorders (e.g., "It is easy to predict who will get depressed and when that person will have their next depressive episode" and "Mood stabilizing medications are addictive"). The second part of the UMDQ is a 19-item checklist that assesses knowledge about symptoms of depression and mania. A total score of 0-39 is derived by summing scores on the two parts of the UMDQ, with higher scores indicating more accurate knowledge.
Key Findings Participating children and their parents were randomly assigned to an intervention group or a wait-list control group. Assessments were conducted at baseline, immediately after the intervention (2 months after baseline), and 4 months after baseline.

From baseline to 2 months after baseline, parents in the intervention group showed a greater increase in knowledge of mood disorders compared with parents in the control group, and this gain was sustained at 4-month follow-up (p = .009). From baseline to 4-month follow-up, UMDQ scores increased from 31.9 to 36.9 for the intervention group, and decreased from 35.1 to 34.6 for the control group.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.0 (0.0-4.0 scale)
Outcome 2: Expressed emotion
Description of Measures The Expressed Emotion Adjective Checklist (EEAC) was used to measure the emotional climate of the home by characterizing the quality of parent-child interaction from the parents' perspective. The EEAC is a 20-item questionnaire that lists 10 adjectives associated with positive emotional expression (e.g., "loving," "cooperative," "clear," "accepting") and 10 adjectives associated with negative emotional expression (e.g., "mean," "irritable," "irresponsible," "hostile"). Parents rated each adjective on a Likert scale from 1 ("never") to 8 ("always") to indicate how frequently their behavior toward their children matched that adjective. Parents also rated the expressed emotion of their child over the same period using the same 20 items. Separate subscale scores were calculated for positive and negative expressed emotion. If both parents completed the instrument, the lowest (worst) subscale scores were used.
Key Findings Participating children and their parents were randomly assigned to an intervention group or a wait-list control group. Assessments were conducted at baseline, immediately after the intervention (2 months after baseline), and 4 months after baseline.  

At each assessment point, parents in the intervention group endorsed higher ratings on the EEAC subscale for positive expressed emotion (suggesting better parent-child communication) relative to control group parents (p < .01). In addition, from baseline to 4-month follow-up, parents in the intervention group showed a gain in EEAC ratings of positive expressed emotion, whereas control group parents showed a decrease in positive ratings over the same period (p < .05).

Similarly, at each assessment point, parents in the intervention group endorsed lower ratings on the EEAC subscale for negative expressed emotion relative to control group parents, suggesting better parent-child communication in the intervention group (p < .04). However, there was no significant difference between groups in the change in negative expressed emotion from baseline to 4-month follow-up.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.1 (0.0-4.0 scale)
Outcome 3: Severity of manic and depressive symptoms
Description of Measures Severity of manic and depressive symptoms was measured using the Mood Severity Index (MSI), an algorithm that combines the clinician's evaluation of the patient's depression (using the Children's Depression Rating Scale--Revised) and mania (using the Mania Rating Scale). The scores for these two scales are combined using a mathematical formula to produce a single mood score ranging from 0 to 116. Scores are interpreted as follows: less than 10 indicates minimal symptoms, 11-20 indicates mild symptoms, 21-35 indicates moderate symptoms, and greater than 35 indicates severe symptoms.
Key Findings Participating children and their parents were randomly assigned to the intervention group, which received MF-PEP plus treatment as usual (any other psychosocial, psychopharmacological, and educational interventions the family desired), or to a wait-list control group, which received treatment as usual for the first 12 months of the study. Assessments were conducted at baseline and 6, 12, and 18 months after baseline. The intervention group received the intervention between baseline and 6 months, and the control group received the intervention between 12 and 18 months. 

From baseline to 12-month follow-up, children in the intervention group experienced a decrease in mean MSI scores that was 6.48 points more than that of children in the control group, indicating greater improvement in manic and depressive symptoms (p < .05). This difference was associated with a medium effect size (Cohen's d = 0.53). Among the smaller sample of children completing treatment, the effect was larger, with the intervention group averaging a decrease in mean MSI scores that was 8.17 points more than that of the control group from baseline to 12-month follow-up. 

MSI scores also decreased for the control group after receiving the intervention; the control group's change score from pre- to posttreatment (between 12 and 18 months) was comparable to that of the intervention group between baseline and 6-month follow-up.
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 4: Conversion from depressive spectrum disorders to bipolar spectrum disorders
Description of Measures At each assessment, child participants were interviewed by study personnel, who recorded detailed descriptions of all mood symptoms, including severity of symptoms and time course. Two clinicians independently reviewed the interview reports and established a consensus diagnosis and rating of severity. The principal diagnostic instrument used in this process was the Children's Global Assessment Scale (C-GAS). Conversion rates were obtained for each study group by calculating the percentage of participants whose diagnosis progressed (worsened) between assessments from depressive spectrum disorder to bipolar spectrum disorder.
Key Findings Participating children and their parents were randomly assigned to the intervention group, which received MF-PEP plus treatment as usual (any other psychosocial, psychopharmacological, and educational interventions the family desired), or to a wait-list control group, which received treatment as usual for the first 12 months of the study. Assessments were conducted at baseline and 6, 12, and 18 months after baseline. The intervention group received MF-PEP between baseline and 6 months, and the control group received the intervention between 12 and 18 months. 

From baseline to 12-month follow-up, among children completing the study, those in the intervention group showed lower rates of conversion from depressive to bipolar disorders compared with those in the control group (p = .03). At 12-month follow-up, the control group had a conversion rate that was 4 times higher than that of the intervention group. This difference was associated with a large effect size (Cramer's V = 0.50).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 6-12 (Childhood)
26-55 (Adult)
77.1% Male
22.9% Female
88.6% White
2.9% American Indian or Alaska Native
2.9% Asian
2.9% Black or African American
2.9% Hispanic or Latino
Study 2 6-12 (Childhood)
26-55 (Adult)
73.3% Male
26.7% Female
90.9% White
9.1% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Knowledge of mood disorders 1.5 3.0 0.5 1.5 3.0 2.8 2.0
2: Expressed emotion 2.0 4.0 0.5 1.5 2.0 2.8 2.1
3: Severity of manic and depressive symptoms 4.0 3.5 3.8 3.0 3.5 4.0 3.6
4: Conversion from depressive spectrum disorders to bipolar spectrum disorders 3.5 4.0 3.8 2.0 3.5 3.0 3.3

Study Strengths

The Understanding of Mood Disorders Questionnaire and the Expressed Emotion Adjective Checklist have strong and independently verified psychometric properties. In one of the two studies reviewed, the instruments were shown to have good reliability over repeated uses and between raters. In one study, study staff reviewed sessions with the implementers, which was an effective procedure for maintaining intervention fidelity. Attrition was within normally accepted standards in both studies, and the use of intent-to-treat analysis techniques in one study reduced the impact of missing data. Appropriate statistical analyses were used.

Study Weaknesses

Some measures lacked evidence of specific psychometric properties, such as test-retest reliability. In the first study, no details were reported regarding the methods used to ensure intervention fidelity. Attrition presents some concerns in both studies, although the use of intent-to-treat analysis in one study helped to reduce its impact. In the other study, the investigators did not report the results of tests to show that the dissimilar attrition rates of the study groups did not result in meaningful differences in the composition of these groups.

Readiness for Dissemination
Review Date: July 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Fristad, M. A., & Danner, S. (2011). Multi-Family Psychoeducational Psychotherapy (MF-PEP) therapist workbook: Children's groups. Columbus, Ohio: Child & Family Psychological Services, Inc.

Fristad, M. A., & Goldberg, J. S. (2011). Multi-Family Psychoeducational Psychotherapy (MF-PEP) parent workbook. Columbus, Ohio: Child & Family Psychological Services, Inc.

Fristad, M. A., Goldberg, J. S., & Leffler, J. M. (2011). Multi-Family Psychoeducational Psychotherapy (MF-PEP) child workbook. Columbus, Ohio: Child & Family Psychological Services, Inc.

Fristad, M. A., Goldberg, J. S., & Leffler, J. M. (2011). Psychotherapy for children with bipolar and depressive disorders. New York, NY: Guilford Press.

Presentations by M. A. Fristad [PowerPoint slides]:

  • Evidence-Based Practices for Bipolar Spectrum Disorders (BPSD) in Youth
  • Evidence-Based Treatment for Children With Bipolar Disorder
  • Psychotherapy for Children With Bipolar and Depressive Disorders

Program Web site, http://www.moodychildtherapy.com/

Other materials:

  • Abstracts on treatment of bipolar and depressive disorders in children
  • Sample workshop agenda

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 2.5 2.5 2.8

Dissemination Strengths

The therapist manual is detailed and well organized. It provides clear instruction for implementing the program, including descriptions of each session, therapist guidelines, scripts, and tips on handling situations that may arise. The parent and child workbooks contain high-quality session handouts. The program Web site is easy to navigate and provides free, downloadable tools such as pre- and posttreatment measures, fidelity measures (therapist adherence checklists), and participant evaluation forms. The Web site also includes information on training opportunities, online ordering of program materials, and resources for additional information and learning. On-site training is available throughout the United States.

Dissemination Weaknesses

The therapist manual discusses factors to consider in treatment group composition but does not discuss how to adapt the program to address cultural differences. A written training curriculum is not available. While Web-based consultation is available, the extent and nature of this service is unclear. Guidance on administering the adherence checklists and program evaluation forms is limited. Supervisory tools to monitor and measure the quality of the therapist's delivery of the program are not provided. There are no instructions on how to use data from the therapist adherence checklist and participant evaluation forms to ensure quality and improve program delivery. No standardized assessment measures are built into the program to assess treatment outcomes.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Psychotherapy for Children with Bipolar and Depressive Disorders therapist manual $40 each Yes
Parent workbook $25 each No
Child workbook $25 each No
Therapist workbook $25 each No
1- to 2-day, on-site training workshop $3,000 per day for unlimited number of participants, plus travel expenses No
6-hour, Web-based training workshop $90 for APA Division 53 members or $120 for nonmembers No
Description of PEP and Mood Disorders [DVD] $90 each No
Questions About Bipolar Disorder in Youth [DVD] $30 each No
Web-based consultation $75 per 30 minutes of consultation No
Pre- and posttreatment measures Free No
Therapist adherence checklists Free No
Participant evaluation forms Free No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

MacPherson, H. A., Fristad, M. A., & Leffler, J. M. (in press). Implementation of Multi-Family Psychoeducational Psychotherapy for childhood mood disorders in an outpatient community setting. Journal of Marital and Family Therapy.

Contact Information

To learn more about implementation or research, contact:
Mary A. Fristad, Ph.D., ABPP
(614) 293-4572
mary.fristad@osumc.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):