Open Journal of Psychiatry, 2012, 2, 258-261 OJPsych Published Online October 2012 (
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,
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,
6Department of Psychiatry, Mino Clinic, Okayama, Japan
Email: *
Received 4 September 2012; revised 1 October 2012; accepted 9 October 2012
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
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
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
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.
2.1. 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.
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.
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.
Copyright © 2012 SciRes. OPEN ACCESS
S. Shimodera et al. / Open Journal of Psychiatry 2 (2012) 258-261
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.
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
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
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-
Copyright © 2012 SciRes. OPEN ACCESS
S. Shimodera et al. / Open Journal of Psychiatry 2 (2012) 258-261
Copyright © 2012 SciRes.
[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.
cation, Science, Sports and Culture (grant No. 17390191).
[11] Fukuzawa, K., et al. (2011) Family psychoeducation for
major depression: Randomized controlled trial. British
Journal of Psychiatry, 198, 385-390.
[1] Leff, J. and Vaughn, C. (1985) Expressed emotion in
families. Guilford Press, New York.
[2] Butzlaff, R.L. and Hooley, J.M. (1998) Expressed emo-
tion and psychiatric relapse, a meta-analysis. Archives of
General Psychiatry, 55, 547-552.
[12] World Health Organization (1992) The ICD-10 classifi-
cation of mental and behavioural disorders, clinical de-
scription and diagnostic guidelines. WHO, Geneva.
[3] Tanaka, S., Mino, Y. and Inoue, S. (1995) Expressed emo-
tion and schizophrenic course in Japan. British Journal of
Psychiatry, 167, 794-798. doi:10.1192/bjp.167.6.794
[13] American Psychiatric Association (1994) Diagnostic and
statistical manual of mental disorders. 4th Edition, APA,
Washington DC.
[4] Mino, Y., Inoue, S., Tanaka, S. and Tsuda T. (1997) Ex-
pressed emotion among families and course of schizo-
phrenia in Japan: A 2-year cohort study. Schizophrenia
Research, 24, 333-339.
[14] Mino, Y., et al. (1995) Training in evaluation of ex-
pressed emotion using the Japanese version of Camber-
well Family Interview. Acta Psychiatrica Scandinavica,
92, 183-186. doi:10.1111/j.1600-0447.1995.tb09565.x
[15] Overall, J.E. and Gorham, D.R. (1962) The brief psychi-
atric rating scale. Psychological Reports, 10, 799-812.
[5] Mino, Y., et al. (1998) Expressed emotion of families and
negative/depressive symptoms in schizophrenia: A cohort
study in Japan. Schizophrenia Research, 34, 159-168. [16] Hamilton, M. (1967) Development of a rating scale for
primary depressive illness. British Journal of Social &
Clinical Psychology, 6, 278-296.
[6] Hooley, J.M., Orley, J. and Teasdale, J.D. (1986) Levels
of expressed emotion and relapse in depressive patients.
British Journal of Psychiatry, 148, 642-647.
doi:10.1192/bjp.148.6.642 [17] Kim, E.Y. and Miklowitz, D.J. (2004) Expressed emotion
as a predictor of outcome among bipolar patients under-
going family therapy. Journal of Affective Disorders, 82,
[7] Miklowitz, D., et al. (1988) Family factors and the course
of bipolar affective disorder. Archives of General Psy-
chiatry, 45, 225-231.
doi:10.1001/archpsyc.1988.01800270033004 [18] Yan, L.J., et al. (2004) Expressed emotion versus rela-
tionship quality variables in the prediction of recurrence
in bipolar patients. Journal of Affective Disorders, 83,
199-206. doi:10.1016/j.jad.2004.08.006
[8] Priebe, S., Wildgrube, C. and Muller-Oerlinghausen, B.
(1989) Lithium prophylaxis and expressed emotion. Brit-
ish Journal of Psychiatry, 154, 396-399.
doi:10.1192/bjp.154.3.396 [19] Macneil, C., et al. (2011) Psychological needs of adoles-
cents in the early phase of bipolar disorder: Implications
for early intervention. Early Intervention in Psychiatry, 5,
100-107. doi:10.1111/j.1751-7893.2011.00273.x
[9] Okasha, A.E.L., et al. (1994) Expressed emotion, per-
ceived, and relapse in depression: A replication in an
Egyptian community. American Journal of Psychiatry,
151, 1001-1005.