1. Background
Bipolar disorder type I (BD-I) is characterized by periodic mood swings, including mania and depression (1, 2). It affects approximately 1% of the general population, with a 12-month prevalence of 0.6% in the United States. Typically, the first manic episode occurs around the age of 18, and about 90% of those who experience one manic episode are likely to have subsequent episodes (3). Research indicates that 30% of these individuals suffer significant declines in occupational and functional areas. Within six months of onset, one-third of individuals with BD-I are unable to work, and only two-fifths function as expected (2, 4).
Mania often involves loss of concentration, restlessness, and impaired judgment, leading to difficulties in social functioning. This not only causes distress but also negatively impacts family stability and marital relationships, imposing substantial costs on healthcare systems and insurers and diminishing the patient’s quality of life and economic productivity (5-7). The social stigma associated with BD-I diagnosis leads to frustration among patients and their families, often resulting in social isolation and increased environmental stress, along with symptoms of depression and anxiety (3).
Therapeutically, emotional swings may affect cognitive accessibility and insight in bipolar patients (BPs), leading to frequent medication non-adherence; statistics show that 60% of individuals with this disorder either do not follow their prescribed therapies or do so poorly. Consequently, rapid relapse due to medication discontinuation poses a significant challenge in treatment (8). Additional factors contributing to relapse include environmental stress, family conflicts, lack of social support, and socio-economic factors such as celibacy, divorce, and separation (2, 4).
One important social factor influencing the relapse of bipolar disorder (BD) is the role and functioning of the family. Although general findings suggest a relationship between mental health and family and interpersonal relationships (9), more specific studies indicate that family attitudes and interactions can affect the course of BD and, in turn, family functioning. When close relatives lack adequate information, support, and training in adaptive coping strategies, the patient's symptoms may worsen, increasing the risk of relapse (10). Several studies have identified a negative family emotional climate post-discharge as a significant predictor of complications in individuals with BD. Severe negative emotional expressions, criticism, hostility, and conflicts disrupt family dynamics and heighten the likelihood of relapse. Additionally, these disturbed interactions adversely affect the mental and physical health of caregivers and other family members (11, 12). Neglecting the dynamic role of the family can delay functional improvement relative to other components (11). Considering the high relapse rate of BD, it is crucial to assist patients and their families in identifying relapse risk factors and initiating necessary therapeutic interventions promptly upon symptom emergence (13). Given the reciprocal relationship between this disorder and family functioning, interventions that include both the patient and the family are essential for BPs.
For decades, various types of psychotherapy have been central to BD treatment. Interventions such as psychoeducation, cognitive behavioral therapy (CBT), and interpersonal and social rhythm therapy (IPSRT) are recognized as effective treatments (1, 14). Family-focused therapy (FFT) is another evidence-based treatment that concentrates on the present and enhances trust between the patient and family members. The primary components of FFT include psychoeducation (to increase knowledge about BD) and training in communication and problem-solving skills for both patients and their families. This treatment significantly improves BD outcomes by reducing the disorder's burden, preventing relapse, diminishing suicidal ideations, enhancing medication adherence, improving family cohesion, reducing isolation and depression, decreasing hospitalization rates, enhancing daily functioning, and improving quality of life (4, 12, 15, 16). Additionally, a study comparing the effectiveness of FFT with psychoeducation reported enhanced quality of life and reduced symptom severity in patients who received FFT (17).
In another study, the likelihood of BD relapse was estimated at 12% in patients treated with FFT versus 66% in the control group (4). However, one major limitation of this treatment is the lack of attention to the patients’ cognitive defects; thus, authors of this treatment protocol have recommended cognitive interventions to enhance recovery post-disease (18). Since cognitive defects are identified as risk factors for BD and can precede the onset of the disorder, disrupting the patient’s daily life and social functioning, they should be targeted in therapeutic interventions. Although FFT does not address these defects directly, the need for more specific interventions is evident, as enhancing patients’ cognitive skills, coupled with family education, can significantly impact the outcomes of BD (19, 20).
Research over the past 15 years has shown that cognitive dysfunction is a prevalent characteristic of BD, affecting a significant percentage of patients (1). These cognitive defects not only increase the risk of relapse but also cause substantial issues in occupational settings and interpersonal relationships (21). Among these, defects in social cognition are particularly significant. Social cognition involves the mental operations that underpin social interactions (22, 23), including the ability to perceive others' intentions and emotional states. It encompasses a range of capabilities such as theory of mind, social perception, social knowledge, attribution bias, and the perception and processing of emotions (24, 25).
Studies have demonstrated that social cognition acts as a moderating factor for cognitive defects and social functioning (26) and significantly influences the outcomes of this disorder and the patient’s response to treatment. Deficits in social cognition impair a patient's ability to perform daily activities, solve problems, maintain interpersonal relationships, perform occupation-related tasks, and improve their quality of life (27-29). Patients with these deficits may struggle with recognizing facial expressions, empathizing with others, and may incorrectly attribute negative events to the intentions of others, leading to improper social interactions. Additionally, these deficits can result in aggressive behavior, social withdrawal, and anxious behavior (28, 29). Some studies suggest that impaired social cognition can be more persistent in patients with BD than in those with schizophrenia (30).
Limited studies have compared the social-cognitive functioning of BPs with and without psychotic symptoms; results suggest that BPs with psychotic symptoms exhibit social functioning similar to that of schizophrenia patients (31). These findings underscore the importance of addressing key determinants of poor social functioning to improve functional deficits. One such intervention is social cognition and interaction training (SCIT), an evidence-based treatment designed to enhance various aspects of social cognition. Initially developed for schizophrenia, SCIT is also applicable to other disorders that impair social cognition. This treatment comprises three core components: Theory of mind, enhancement of emotional perception, and attributional style, all rooted in a conceptual model that links social cognition disorders with social ineffectiveness (29, 32).
Few studies have assessed the effectiveness of social cognition interventions for BPs. One such study demonstrated significant improvements in social cognition and functioning in the experimental group compared to a control group. However, this study was limited by sample homogeneity and the absence of follow-up (33). Despite the critical role of social cognition in BPs, research on social cognition training for these patients remains sparse. By focusing solely on the social functioning of BPs and neglecting their cognitive deficits, there is a risk of exacerbating the disorder and increasing relapse rates.
2. Objectives
The current study seeks to address this gap in the research.
3. Methods
3.1. Study Design
This experimental study employed a controlled, pretest-posttest design with a three-month follow-up, involving three groups: One control group and two experimental groups. Group therapy was the treatment method for the patients. The follow-up period, set at three months post-intervention, aligns with current literature trends and was limited by time constraints. Bipolar disorder relapse prevention was assessed by monitoring the patients during the intervention and follow-up periods, with a Young Mania Rating Scale (YMRS) score above 12 indicating a relapse. Additionally, the Social Functioning Scale (SFS) was used to evaluate social functioning and interpersonal relationships.
3.2. Study Population
The study population consisted of BD-I patients hospitalized at a psychiatric hospital in XXX and their primary caregivers. Therapeutic interventions commenced during hospitalization and continued on an outpatient basis after discharge.
3.3. Sample Size, Sampling Method, and Procedure
The sample size was determined using G*POWER 3.1, based on an effect size of 0.44 (from a pilot study), a 5% type I error rate, and 80% power, resulting in 54 participants. To account for a potential 10% attrition rate, the final sample size was set at 60 individuals, divided evenly across the three groups.
Purposeful sampling was used at baseline, and random sampling was employed during the intervention phase. This study was conducted with three groups, recruiting patients hospitalized in the psychiatric ward of a hospital in Baharan since October 2020, who met the inclusion criteria. A sample size of 60 people was calculated, and the sample size of primary caregivers was 20 in the FFT group. Overall, 20 patients were assigned to the control group (only taking medications), 20 patients together with their primary caregivers were assigned to the FFT group, and 20 patients were assigned to the SCIT group. In the FFT experimental group, family members were also involved in the sessions per the protocol. However, data were collected solely from the patients across all groups, with primary caregiver information not considered.
The inclusion criteria for the patient group included a BD-I diagnosis based on a psychiatrist’s evaluation, experiencing no more than three relapse episodes, having an educational level above secondary school, and being aged 18 - 45 years. The exclusion criteria for patients were a history of alcohol or drug abuse, any mental disorder other than BD-I, a severe personality disorder diagnosed by the treating psychiatrist, and receiving concurrent psychological treatment from other clinics. Patients who missed more than three sessions, had changes in their drug therapy, or withdrew consent were also excluded.
For the caregiver group, inclusion criteria were a willingness to participate, being a family member and primary caregiver (spending 7 - 8 hours a day with the patient), aged 25 - 50 years, and having an education level above secondary school. Exclusion criteria included a severe mental disorder, a history of substance abuse, or brain damage. Primary caregivers who withdrew from the intervention or missed more than three sessions were removed from the study.
After confirming eligibility and randomly assigning the participants, all patients completed the study instruments prior to starting treatment. Participants were recruited from BD-I patients hospitalized at Baharan of Zahedan, Iran. A semi-structured clinical interview based on the structured clinical interview for the diagnostic and statistical manual of mental disorders (SCID-5) was conducted by a clinical psychologist. The cognitive complaints in bipolar disorder rating assessment (COBRA) was administered to ensure comparability in cognitive defects, and patients were also matched based on medication use, primarily sodium valproate and carbamazepine. Patients diagnosed with delusions of persecution were excluded from the study; however, delusions of grandeur were reported in 30% of the participants. Participation was voluntary. Ethical considerations were addressed by explaining the study's objectives to participants and their primary caregivers and informing them that their data would be analyzed anonymously.
After conducting interviews and recording baseline data, participants were randomly assigned to three groups. A research associate generated the random allocation sequence, enrolled participants, and assigned them to interventions. The random allocation rule, a simple restricted randomization method, was used. This method ensures a balanced number of individuals in each group at the study's conclusion. After calculating the total sample size, participants were randomly assigned to groups A, B, and C.
Due to COVID-19 restrictions, a lottery container was used for the random assignment. Three balls each were placed in the container for experimental groups 1 and 2, and for the control group. The balls, each bearing a participant’s number, were mixed and drawn without replacement. The sequence of numbers was recorded, with the first number drawn assigned to group 1, the second to group 2, and the third to the control group. This process was repeated until all participants were assigned.
The study comprised one control group and two experimental groups. The control group (n = 20) included only patients taking medications. Group 1 (FFT, n = 20) consisted of BPs undergoing FFT along with their primary caregivers. Group 2 (SCIT, n = 20) consisted of BPs receiving SCIT. Interventions began after patients reached clinical stability in the hospital and continued post-discharge. All groups were maintained on medication.
Given the large sample size and the need for social distancing, treatments were conducted in small groups of three. Before sessions, masks and disinfectants were provided to all participants. The treatment protocols were administered by a clinical psychologist. In Group 1, two patients and two family members withdrew from the study. In Group 2, one patient discontinued participation, and in the control group, one participant failed to complete follow-up questionnaires and was excluded from the analysis.
3.4. Interventions for the Groups
The control group received no interventions and continued with their prescribed medications only. In group 1, the pretest was followed by FFT sessions for both patients and their primary caregivers, adhering to the established treatment protocol (9). Subsequently, a posttest and a three-month follow-up were conducted. In group 2, following the pretest, patients participated in group SCIT, as outlined by Roberts et al. (32), followed by a posttest and follow-up.
3.5. Treatment Monitoring and Ethical Considerations
All study procedures were conducted under the supervision of a guiding supervisor. Every two months, progress reports were submitted to all supervisors and advisors for review and implementation of their recommendations. The study adhered to the declaration of Helsinki principles. Upon completion of the study, interventions were also offered to the control group, adhering to ethical standards. Participants were informed about the study’s principles such as confidentiality, commitment to the intervention, and the importance of regular attendance at group sessions, as well as the general processes of interventions and training sessions. The interventions lasted six months, from October 2020 to April 2021, with a follow-up conducted in August 2021.
3.6. Research Tools
The following questionnaires were employed to assess demographic and clinical characteristics.
3.6.1. Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID5)
The SCID5 is a semi-structured interview based on DSM-5 diagnostic criteria. The semi-structured nature of SCID5 requires the interviewer to exercise clinical judgment regarding the interviewee’s responses. Therefore, interviewers must possess clinical knowledge and experience in psychopathology. In domestic studies, the diagnostic agreement for the current diagnosis of BD-I was 87.3%, with a kappa coefficient of 0.54. For lifetime diagnoses of this disorder, the overall agreement was 84.6%, with a kappa coefficient of 0.58. In international studies, its reliability was above 0.70, as determined by the test-retest method (9).
3.6.2. Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA)
Developed by Rosa et al. in 2013, the COBRA is a 16-item self-report tool designed to identify subjective cognitive deficits, including executive functioning, processing speed, working memory, verbal learning and memory, and attention/concentration. Responses are scored on a four-point Likert Scale ranging from 0 (never) to 3 (always). The scale items relate to everyday cognitive functions, with a maximum possible score of 48; higher scores indicate greater levels of subjective complaints. This questionnaire was utilized in this study to match patients based on cognitive deficits. Internationally, the COBRA exhibits a robust factor structure, high internal consistency with a Cronbach’s alpha of 0.91. Its validity and reliability were assessed by Momeni et al. in Iran in 2018, with results pending publication.
3.6.3. Social Functioning Scale (SFS)
The SFS assesses social skills and functioning in psychiatric patients, differentiating between a lack of skills (incompetence) and a failure to utilize available skills (impaired functioning). This self-administered questionnaire comprises 76 items with varied response formats, including two-part questions, items rated on three- or five-point Likert Scales, and most on a four-point frequency or ability scale. Higher scores denote better social competencies. The SFS includes seven subscales: Social conflict/isolation, interpersonal behaviors, social behaviors, recreation, independence/competence, independence/functioning, and employment/occupation. The reliability of this tool was measured at 0.81 (34).
3.6.4. Young Mania Rating Scale (YMRS)
The YMRS consists of 11 items used to assess the severity of manic symptoms, rated by a clinical specialist or nurse based on patient observations. Scores range from 0 to 60. The reliability of this scale was in the range of 0.41 - 0.85, and its validity was equal to 0.88 (35). The YMRS is noted for its high internal consistency (alpha = 0.82) within the specified population. Factor analysis identified three factors correlating with DSM-5 criteria: Increased activity, risky behaviors, and prognosis. The optimal clinical cutoff point is 7.5, providing 62.5% sensitivity and 89% specificity in distinguishing patients with unipolar disorder from those with BD (36).
3.7. Statistical Analyses
All analyses were performed using IBM SPSS Statistics 24 (IBM Corp, Armonk, NY, USA). The demographic characteristics of completers and non-completers were compared using the chi-square test for categorical data and independent samples t-tests for continuous data. Baseline differences in outcomes were evaluated using independent samples t-tests for completers vs. non-completers and analysis of variance (ANOVA) for the three intervention groups. Due to missing data, linear mixed models with restricted maximum likelihood estimation (REML) and unstructured covariance were employed. Comparisons between intervention groups and the control group were made at baseline, post-intervention, and follow-up.
4. Results
This study assessed 60 patients with BD-I, aged 18 - 44 years (M = 31.88, SD = 7.46). The majority of participants were male (n = 44, 73.4%), married (n = 28, 46.6%), and self-employed (n = 33, 55%), with most holding a high school diploma (n = 31, 51.7%). Fifty-six participants completed all assessments up to follow-up (93.3%), resulting in a 6.7% attrition rate.
There were no significant differences between completers and non-completers at baseline in terms of functioning (t (58) = -1.56, P = 0.123), social conflict (t (58) = -1.19, P = 0.238), interpersonal relationships (t (58) = -1.62, P = 0.110), social behaviors (t (58) = 0.12, P = 0.908), recreation (t (58) = -1.43, P = 0.118), competence in functioning (t (58) = 1.36, P = 0.179), independence in functioning (t (58) = -1.61, P = 0.111), employment (t (58) = 0.41, P = 0.687), and relapse prevention (t (58) = -0.34, P = 0.733). There were also no significant differences in gender (χ2 (2, N = 60) = 1.19, P = 0.551), marital status (χ2 (2, N = 60) = 0.95, P = 0.622), occupation (χ2 (2, N = 60) = 2.19, P = 0.334), education (χ2 (2, N = 60) = 1.74, P = 0.420), or age (F (2,57) = 0.69, P = 0.505).
Furthermore, there were no significant baseline differences among the three groups in terms of functioning (F(2,57) = 0.63, P = 0.532), social conflict (F(2,57) = 0.38, P = 0.689), interpersonal relationships (F(2,57) = 0.15, P = 0.861), social behaviors (F(2,57) = 1.98, P = 0.147), recreation (F(2,57) = 0.07, P = 0.936), competence in functioning (F(2,57) = 0.99, P = 0.379), independence in functioning (F (2,57) = 1.87, P = 0.164), employment (F (2,57) = 0.15, P = 0.866), and relapse prevention (F(2,57) = 0.88, P = 0.419). The mean and standard deviations of the research variables for the intervention and control groups are presented in Table 1.
Table 1.Mean Value of Research Variables
| Variables and Groups | Pretest | Posttest | Follow-up | |||
|---|---|---|---|---|---|---|
| Mean ± SD | No. | Mean ± SD | No. | Mean ± SD | No. | |
| Social functioning | ||||||
| SCIT | 173.60 ± 12.48 | 20 | 240.10 ± 10.63 | 20 | 253.26 ± 10.06 | 19 |
| FFT | 170.50 ± 9.85 | 20 | 243.95 ± 13.79 | 20 | 254.47 ± 10.32 | 19 |
| Control | 175.05 ± 16.12 | 20 | 176.70 ± 15.89 | 20 | 174.77 ± 13.80 | 18 |
| Socialconflict | ||||||
| SCIT | 18.10 ± 3.94 | 20 | 28.35 ± 3.31 | 20 | 30.10 ± 3.57 | 19 |
| FFT | 17.30 ± 3.61 | 20 | 28.60 ± 3.43 | 20 | 30.36 ± 3.32 | 19 |
| Control | 18.25 ± 3.61 | 20 | 18.75 ± 3.86 | 20 | 18.72 ± 3.96 | 18 |
| Interpersonal relationships | ||||||
| SCIT | 17.80 ± 2.60 | 20 | 28.85 ± 3.36 | 20 | 30.78 ± 3.70 | 19 |
| FFT | 18 ± 2.90 | 20 | 25.85 ± 3.43 | 20 | 26.10 ± 3.92 | 19 |
| Control | 18.35 ± 3.97 | 20 | 18.65 ± 4.05 | 20 | 18.77 ± 4.37 | 18 |
| Social behaviors | ||||||
| SCIT | 27.50 ± 4.45 | 20 | 40.50 ± 3.73 | 20 | 42.10 ± 3.79 | 19 |
| FFT | 27.35 ± 5.65 | 20 | 38.90 ± 3.29 | 20 | 41 ± 3.10 | 19 |
| Control | 29.95 ± 3.57 | 20 | 30.50 ± 3.64 | 20 | 29.94 ± 3.79 | 18 |
| Recreation | ||||||
| SCIT | 31.75 ± 4.21 | 20 | 42.65 ± 5.82 | 20 | 41.89 ± 3.52 | 19 |
| FFT | 31.65 ± 5.13 | 20 | 39.40 ± 3.84 | 20 | 40.31 ± 3.33 | 19 |
| Control | 31.10 ± 8.17 | 20 | 31.05 ± 8.14 | 20 | 29.55 ± 6.35 | 18 |
| Functioning competence | ||||||
| SCIT | 27.70 ± 5.42 | 20 | 37.75 ± 4.32 | 20 | 41.84 ± 3.86 | 19 |
| FFT | 27.25 ± 5.47 | 20 | 37.45 ± 5.16 | 20 | 40.15 ± 5.09 | 19 |
| Control | 25.30 ± 6.28 | 20 | 25.45 ± 6.41 | 20 | 25.88 ± 6.43 | 18 |
| Functioning independence | ||||||
| SCIT | 31.30 ± 3.86 | 20 | 42.80 ± 3.51 | 20 | 44.36 ± 3.05 | 19 |
| FFT | 30.05 ± 3.31 | 20 | 41.05 ± 4.47 | 20 | 42.84 ± 3.56 | 19 |
| Control | 32.55 ± 4.92 | 20 | 32.45 ± 4.93 | 20 | 31.55 ± 3.86 | 18 |
| Employment | ||||||
| SCIT | 19.45 ± 4.17 | 20 | 26.05 ± 3.72 | 20 | 28.05 ± 3.86 | 19 |
| FFT | 18.90 ± 4.10 | 20 | 25.85 ± 2.60 | 20 | 27.78 ± 2.46 | 19 |
| Control | 19.55 ± 4.07 | 20 | 19.85 ± 4.01 | 20 | 20.33 ± 3.89 | 18 |
| Relapse prevention | ||||||
| SCIT | 6.55 ± 1.27 | 20 | 4.15 ± 1.18 | 20 | 4.31 ± 1.63 | 19 |
| FFT | 6.95 ± 0.99 | 20 | 3.45 ± 1.22 | 20 | 4.26 ± 1.14 | 19 |
| Control | 6.95 ± 0.99 | 20 | 6.90 ± 1.02 | 20 | 6.50 ± 1.24 | 18 |
Abbreviations: SCIT, social cognition and interaction training; FFT, family-focused therapy.
For the linear mixed-effects model to be valid, it is crucial that the covariance among repeated measures is properly modeled. Four common covariance structures were evaluated: Compound symmetric (CS), first-order autoregressive [AR(1)], unstructured (UN), and Toeplitz (TOEP). The model with the lowest Akaike information criterion (AIC) and Bayesian information criterion (BIC) values was selected, which was the unstructured (UN) covariance structure, as it showed the smallest AIC and BIC values compared to other structures (1) (Table 2).
Table 2.Comparison of Covariance Structures for the Linear Mixed-Effects Model
| Variables and Covariance Structure | -2 Res. log-Likelihood | AIC | BIC |
|---|---|---|---|
| Social functioning | |||
| UN | 1261.210 | 1273.210 | 1291.918 |
| CS | 1292.862 | 1296.862 | 1303.098 |
| AR(1) | 1289.511 | 1293.511 | 1299.747 |
| TOEP | 1289.045 | 1295.045 | 1304.399 |
| Social conflict | |||
| UN | 780.140 | 782.140 | 789.848 |
| CS | 785.911 | 789.911 | 796.147 |
| AR(1) | 784.875 | 788.875 | 795.111 |
| TOEP | 782.097 | 788.097 | 797.451 |
| Interpersonal relationships | |||
| UN | 829.706 | 841.706 | 860.414 |
| CS | 874.706 | 878.706 | 884.942 |
| AR(1) | 861.110 | 865.110 | 871.346 |
| TOEP | 860.028 | 866.028 | 875.382 |
| Social behaviors | |||
| UN | 802.769 | 814.769 | 833.477 |
| CS | 858.980 | 862.980 | 869.216 |
| AR(1) | 853.049 | 857.049 | 863.285 |
| TOEP | 852.017 | 858.017 | 867.371 |
| Recreation | |||
| UN | 965.659 | 977.659 | 982.367 |
| CS | 975.483 | 979.483 | 985.719 |
| AR(1) | 989.623 | 993.623 | 999.859 |
| TOEP | 974.983 | 980.983 | 990.337 |
| Functioning competence | |||
| UN | 887.061 | 890.061 | 898.769 |
| CS | 909.124 | 913.124 | 919.360 |
| AR(1) | 890.272 | 894.272 | 900.508 |
| TOEP | 899.790 | 895.790 | 905.144 |
| Functioning independence | |||
| UN | 859.864 | 871.864 | 880.572 |
| CS | 872.957 | 876.957 | 883.193 |
| AR(1) | 877.483 | 881.483 | 887.719 |
| TOEP | 872.253 | 878.253 | 888.607 |
| Employment | |||
| UN | 702.583 | 714.583 | 733.291 |
| CS | 767.147 | 771.147 | 777.383 |
| AR(1) | 760.647 | 764.647 | 770.883 |
| TOEP | 759.339 | 765.339 | 774.693 |
| Relapse prevention | |||
| UN | 543.933 | 550.933 | 556.641 |
| CS | 548.547 | 552.547 | 558.783 |
| AR(1) | 547.361 | 551.361 | 557.597 |
| TOEP | 546.879 | 552.879 | 562.233 |
Abbreviations: CS, compound symmetric structure; UN, unstructured; AR(1), first-order autoregressive structure; TOEP, toeplitz structure.
Table 3 illustrates significant interaction effects between time and group on relapse prevention, social functioning, and its components in patients with BD-I (P < 0.001). The results of the Bonferroni correction test, displayed in Table 4, indicate that SCIT was effective in improving relapse prevention, social functioning, and its components during the post-test and follow-up phases (P < 0.001). Specifically, SCIT had a significant impact on social functioning (ƞ2 = 0.792), social conflict (ƞ2 = 0.572), interpersonal relationships (ƞ2 = 0.581), social behaviors (ƞ2 = 0.580), recreation (ƞ2 = 0.381), functioning competence (ƞ2 = 0.479), functioning independence (ƞ2 = 0.498), employment (ƞ2 = 0.356), and relapse prevention (ƞ2 = 0.501) at the posttest. Additionally, in the follow-up, SCIT's effects remained significant across all measures.
Table 3.The Main Effects of Group, Time, and Group-by-Time Interactions for the Variables
| Variables | Groups | Time | Group-by-Time | |||
|---|---|---|---|---|---|---|
| F | P-Value | F | P-Value | F | P-Value | |
| Social functioning | 109.327 | < 0.001 | 574.418 | < 0.001 | 136.009 | < 0.001 |
| Social conflict | 27.456 | < 0.001 | 456.098 | < 0.001 | 99.120 | < 0.001 |
| Interpersonal relationship | 28.132 | < 0.001 | 100.576 | < 0.001 | 27.651 | < 0.001 |
| Social behaviors | 18.121 | < 0.001 | 240.111 | < 0.001 | 59.211 | < 0.001 |
| Recreation | 11.270 | < 0.001 | 889.944 | < 0.001 | 25.014 | < 0.001 |
| Functioning competence | 24.462 | < 0.001 | 213.953 | < 0.001 | 51.413 | < 0.001 |
| Functioning independence | 19.016 | < 0.001 | 231.051 | < 0.001 | 59.405 | < 0.001 |
| Employment | 11.365 | < 0.001 | 282.589 | < 0.001 | 64.561 | < 0.001 |
| Relapse prevention | 28.402 | < 0.001 | 75.752 | < 0.001 | 18.846 | < 0.001 |
Table 4.Estimation of Fixed-Effect Parameters of the Regression Model for the Research Variables
| Parameters | Estimate | Std. Error | Df | t | P | ƞ2 a |
|---|---|---|---|---|---|---|
| Social functioning | ||||||
| Time (pretest vs. follow-up) | -1.63 | 2.82 | 55.406 | 18.99 | < 0.001 | |
| Time (posttest vs. follow-up) | 0.012 | 1.50 | 51.485 | 0.009 | 0.993 | |
| Time1 × group (SCIT vs. control) | -1.450 | 4.136 | 57 | -0.351 | 0.727 | 0.002 |
| Time2 × group (SCIT vs. control) | 63.400 | 4.304 | 57 | 14.729 | < 0.001 | 0.792 |
| Time3 × group (SCIT vs. control) | 77.110 | 4.029 | 51.735 | 20.787 | < 0.001 | 0.891 |
| Time1 × group (FFT vs. control) | -4.550 | 4.136 | 57 | -1.100 | 0.276 | 0.021 |
| Time2 × group (FFT vs. control) | 67.250 | 4.304 | 57 | 15.623 | < 0.001 | 0.811 |
| Time 3 × group (FFT vs. control) | 76.505 | 4.029 | 51.735 | 21.108 | < 0.001 | 0.894 |
| Social conflict | ||||||
| Time (pretest vs. follow-up) | -0.608 | 0.543 | 56.051 | -1.120 | 0.268 | |
| Time (posttest vs. follow-up) | -0.108 | 0.420 | 54.080 | -0.258 | 0.797 | |
| Time1 × group (SCIT vs. control) | -0.150 | 1.179 | 57 | -0.127 | 1 | 0.00 |
| Time2 × group (SCIT vs. control) | 9.600 | 1.100 | 57 | 8.731 | < 0.001 | 0.572 |
| Time3 × group (SCIT vs. control) | 11.274 | 1.129 | 58.169 | 9.551 | < 0.001 | 0.633 |
| Time1 × group (FFT vs. control) | -0.950 | 1.179 | 57 | -0.806 | 0.424 | 0.011 |
| Time2 × group (FFT vs. control) | 9.850 | 1.100 | 57 | 8.958 | < 0.001 | 0.585 |
| Time 3 × group (FFT vs. control) | 11.495 | 1.129 | 58.169 | 9.772 | < 0.001 | 0.645 |
| Interpersonal relationships | ||||||
| Time (pretest vs. follow-up) | -0.467 | 0.896 | 56.886 | -0.521 | 0.604 | |
| Time (posttest vs. follow-up) | -0.167 | 0.421 | 53.025 | -0.397 | 0.693 | |
| Time1 × group (SCIT vs. control) | -0.550 | 1.017 | 57 | -0.541 | 0.591 | 0.005 |
| Time2 × group (SCIT vs. control) | 10.200 | 1.148 | 57 | 8.882 | < 0.001 | 0.581 |
| Time3 × group (SCIT vs. control) | 12.085 | 1.266 | 57.313 | 9.119 | < 0.001 | 0.611 |
| Time1 × group (FFT vs. control) | -0.350 | 1.017 | 57 | -0.344 | 0.732 | 0.002 |
| Time2 × group (FFT vs. control) | 7.200 | 1.148 | 57 | 6.270 | < 0.001 | 0.408 |
| Time 3 × group (FFT vs. control) | 7.042 | 1.266 | 57.313 | 5.563 | < 0.001 | 0.369 |
| Social behaviors | ||||||
| Time (pretest vs. follow-up) | -0.254 | 0.747 | 57.588 | -0.340 | 0.735 | |
| Time (posttest vs. follow-up) | 0.295 | 0.297 | 53.098 | 0.995 | 0.324 | |
| Time1 × group (SCIT vs. control) | -2.450 | 1.467 | 57 | -1.670 | 0.301 | 0.047 |
| Time2 × group (SCIT vs. control) | 10 | 1.127 | 57 | 8.874 | < 0.001 | 0.580 |
| Time3 × group (SCIT vs. control) | 11.529 | 1.159 | 56.414 | 10.331 | < 0.001 | 0.668 |
| Time1 × group (FFT vs. control) | -2.600 | 1.467 | 57 | -1.772 | 0.245 | 0.052 |
| Time2 × group (FFT vs. control) | 8.400 | 1.127 | 57 | 7.454 | < 0.001 | 0.494 |
| Time 3 × group (FFT vs. control) | 10.944 | 1.159 | 56.414 | 9.392 | < 0.001 | 0.625 |
| Recreation | ||||||
| Time (pretest vs. follow-up) | .218 | 0.829 | 55.730 | 0.263 | 0.793 | |
| Time (posttest vs. follow-up) | 0.168 | 0.790 | 53.345 | 0.213 | 0.832 | |
| Time1 × group (SCIT vs. control) | 0.650 | 1.923 | 57 | 0.338 | 1 | 0.002 |
| Time2 × group (SCIT vs. control) | 11.600 | 1.958 | 57 | 5.926 | < 0.001 | 0.381 |
| Time3 × group (SCIT vs. control) | 10.803 | 1.666 | 49.188 | 8.196 | < 0.001 | 0.559 |
| Time1 × group (FFT vs. control) | 0.550 | 1.923 | 57 | 0.286 | 1 | 0.001 |
| Time2 × group (FFT vs. control) | 8.350 | 1.958 | 57 | 4.265 | < 0.001 | 0.242 |
| Time 3 × group (FFT vs. control) | 9.528 | 1.666 | 49.188 | 7.147 | < 0.001 | 0.491 |
| Functioning competence | ||||||
| Time (pretest vs. follow-up) | -0.201 | 0.826 | 58.539 | -0.244 | 0.808 | |
| Time (posttest vs. follow-up) | -0.051 | 0.538 | 53.752 | -0.096 | 0.924 | |
| Time1 × group (SCIT vs. control) | 2.400 | 1.816 | 57 | 1.321 | 0.575 | 0.030 |
| Time2 × group (SCIT vs. control) | 12.300 | 1.698 | 57 | 7.243 | < 0.001 | 0.479 |
| Time3 × group (SCIT vs. control) | 16.032 | 1.666 | 56.796 | 9.309 | < 0.001 | 0.620 |
| Time1 × group (FFT vs. control) | 1.950 | 1.816 | 57 | 1.074 | 0.862 | 0.020 |
| Time2 × group (FFT vs. control) | 12 | 1.698 | 57 | 7.067 | < 0.001 | 0.467 |
| Time 3 × group (FFT vs. control) | 14.878 | 1.666 | 56.796 | 8.326 | < 0.001 | 0.567 |
| Functioning independence | ||||||
| Time (pretest vs. follow-up) | 0.142 | 0.687 | 57.964 | 0.207 | 0.837 | |
| Time (posttest vs. follow-up) | 0.042 | 0.525 | 54.427 | 0.080 | 0.936 | |
| Time1 × group (SCIT vs. control) | -1.250 | 1.294 | 57 | -0.966 | 1 | 0.016 |
| Time2 × group (SCIT vs. control) | 10.350 | 1.376 | 57 | 7.522 | < 0.001 | 0.498 |
| Time3 × group (SCIT vs. control) | 11.703 | 1.230 | 51.135 | 11.112 | < 0.001 | 0.700 |
| Time1 × group (FFT vs. control) | -2.500 | 1.294 | 57 | -1.932 | 0.175 | 0.061 |
| Time2 × group (FFT vs. control) | 8.600 | 1.376 | 57 | 6.250 | < 0.001 | 0.407 |
| Time 3 × group (FFT vs. control) | 10.288 | 1.230 | 51.135 | 9.788 | < 0.001 | 0.644 |
| Employment | ||||||
| Time (pretest vs. follow-up) | -0.309 | 0.488 | 58.038 | -0.633 | 0.529 | |
| Time (posttest vs. follow-up) | -0.009 | 0.181 | 53.739 | -0.053 | 0.958 | |
| Time1 × group (SCIT vs. control) | -0.100 | 1.302 | 57 | -0.077 | 1 | 0.00 |
| Time2 × group (SCIT vs. control) | 6.200 | 1.105 | 57 | 5.611 | < 0.001 | 0.356 |
| Time3 × group (SCIT vs. control) | 8.299 | 1.108 | 56.916 | 6.774 | < 0.001 | 0.464 |
| Time1 × group (FFT vs. control) | -0.650 | 1.302 | 57 | -0.499 | 1 | 0.004 |
| Time2 × group (FFT vs. control) | 6 | 1.105 | 57 | 5.430 | < 0.001 | 0.341 |
| Time3 × group (FFT vs. control) | 8.088 | 1.108 | 56.916 | 6.543 | < 0.001 | 0.447 |
| Relapse prevention | ||||||
| Time (pretest vs. follow-up) | 0.438 | 0.359 | 57.055 | 1.219 | 0.228 | |
| Time (posttest vs. follow-up) | 0.388 | 0.329 | 55.983 | 1.179 | 0.243 | |
| Time1 × group (SCIT vs. control) | -0.400 | 0.348 | 57 | -1.151 | 0.764 | 0.023 |
| Time2 × group (SCIT vs. control) | -2.750 | 0.363 | 57 | -7.566 | < 0.001 | 0.501 |
| Time3 × group (SCIT vs. control) | -2.203 | 0.443 | 54.828 | -4.876 | < 0.001 | 0.310 |
| Time1 × group (FFT vs. control) | 0.001 | 0.348 | 57 | 0.00 | 1 | 0.00 |
| Time2 × group (FFT vs. control) | -3.450 | 0.363 | 57 | -9.492 | < 0.001 | 0.613 |
| Time3 × group (FFT vs. control) | -2.237 | 0.443 | 54.828 | -4.994 | < 0.001 | 0.320 |
Abbreviations: Time 1, pretest; Time 2, posttest; Time 3, follow-up.
a Partial eta squared.
Similarly, FFT was also effective in enhancing relapse prevention, social functioning, and its components, as indicated by the Bonferroni correction test in Table 4 (P < 0.001). In the posttest, FFT significantly affected social functioning (ƞ2 = 0.811), social conflict (ƞ2 = 0.585), interpersonal relationships (ƞ2 = 0.408), social behavior (ƞ2 = 0.494), recreation (ƞ2 = 0.242), functioning competence (ƞ2 = 0.467), functioning independence (ƞ2 = 0.407), employment (ƞ2 = 0.341), and relapse prevention (ƞ2 = 0.613). These effects were maintained or improved in the follow-up, with significant impacts on social functioning (ƞ2 = 0.894), social conflict (ƞ2 = 0.645), interpersonal relationships (ƞ2 = 0.369), social behaviors (ƞ2 = 0.625), recreation (ƞ2 = 0.491), functioning competence (ƞ2 = 0.567), functioning independence (ƞ2 = 0.644), employment (ƞ2 = 0.447), and relapse prevention (ƞ2 = 0.320). Overall, the main effects of group and time on the variables of relapse prevention, social functioning, and its components were found to be significant (Table 3).
Social cognition and interaction training was more effective than FFT in improving the component of interpersonal relationships at the post-test (β = 3, P = 0.034) and follow-up (β = 5.043, P = 0.001), showing differences of three and 5.043 points between the SCIT and FFT groups at these stages, respectively. However, SCIT and FFT were equally effective in enhancing social functioning and its components (except for interpersonal relationships) and in reducing relapse rates in BPs during both the post-test and follow-up periods (Table 5).
Table 5.Comparison of the Two Methods of Social Cognition and Interaction Training (SCIT) and Family-Focused Therapy (FFT) in the Post-Test and Follow-Up Phases
| Variables and Parameters | Estimate | Std. Error | df | P-Value | Cohen’s d |
|---|---|---|---|---|---|
| Social functioning | |||||
| Time2 | -3.850 | 4.304 | 57 | 1 | 0.014 |
| Time3 | 0.605 | 4.016 | 51.236 | 1 | 0.002 |
| Social conflict | |||||
| Time2 | -0.250 | 1.100 | 57 | 1 | 0.001 |
| Time 3 | -0.221 | 1.125 | 57.602 | 1 | 0.001 |
| Interpersonal relationships | |||||
| Time2 | 3 | 1.148 | 57 | 0.034 | 0.107 |
| Time3 | 5.043 | 1.262 | 56.800 | 0.001 | 0.197 |
| Social behavior | |||||
| Time2 | 1.600 | 1.127 | 57 | 0.483 | 0.034 |
| Time3 | 0.585 | 1.157 | 56.084 | 1 | 0.017 |
| Recreation | |||||
| Time2 | 3.250 | 1.958 | 57 | 0.307 | 0.046 |
| Time3 | 1.275 | 1.661 | 48.687 | 1 | 0.021 |
| Functioningcompetence | |||||
| Time2 | 0.300 | 1.698 | 57 | 1 | 0.001 |
| Time3 | 1.151 | 1.661 | 56.334 | 1 | 0.018 |
| Functioning independence | |||||
| Time2 | 1.750 | 1.376 | 57 | 0.626 | 0.028 |
| Time3 | 1.415 | 1.226 | 50.604 | 0.761 | 0.033 |
| Employment | |||||
| Time2 | 0.200 | 1.105 | 57 | 1 | 0.001 |
| Time3 | 0.212 | 1.107 | 56.772 | 1 | 0.001 |
| Relapse prevention | |||||
| Time2 | 0.700 | 0.363 | 57 | 0.177 | 0.061 |
| Time3 | 0.034 | 0.438 | 54.540 | 1 | 0.00 |
Abbreviations: Time2, posttest; Time3, follow-up.
5. Discussion
The results of this study indicate that SCIT and FFT are similarly effective in improving social functioning and preventing relapse in BPs, with these effects persisting through the follow-up. Notably, SCIT demonstrated greater efficacy than FFT in enhancing interpersonal relationships, highlighting the importance of addressing both environmental and cognitive factors in treating patients with BD-I. These findings align with previous research that identifies FFT as an evidence-based treatment (10, 37, 38).
The effectiveness of FFT can be attributed to various factors associated with the high risk of relapse in BD. Key contributors to relapse include non-adherence to medication due to lack of disease knowledge, unfamiliarity with side effects, fears of drug dependence, alcohol and drug use, family and environmental stress, disturbed circadian rhythms, inadequate activity, and unrealistic expectations from others (11, 39, 40). Given these challenges, enhancing social functioning emerges as a critical need for BPs and their families, underscoring the relevance of interventions like FFT and SCIT (33).
Studies indicate that providing information to BPs and their families, maintaining regular habits, and early detection of relapse signs are crucial for reducing relapse (18, 41, 42). Previous research has highlighted the significant role of psychoeducation in decreasing BD relapse (43-45). A key component of FFT is psychoeducation, which addresses relapse triggers by educating individuals about the symptoms of the disease (both positive and negative), emphasizing the importance of a regular sleep-wake rhythm, explaining the role of stress in relapse, developing strategies for stress management, and encouraging patients to engage in daily and recreational activities. Moreover, adjusting family expectations through education and enhancing patient cooperation can also target relapse triggers (46).
Furthermore, the effectiveness of FFT in improving social functioning and interpersonal relationships can be attributed to its focus on communication skills training. This includes an effective communication model, active listening, encouraging assertive behavior, training in clarification techniques, instructions on how to express criticism constructively, and strategies for a balanced view of others’ behaviors rather than impulsive reactions, evaluating their actions based on the consequences for their mental health and others. This component also emphasizes appropriate emotional expression and demand articulation to minimize tension. These exercises strengthen and regulate the emotions of patients, boost their self-esteem during vulnerable periods, and teach them relaxation techniques, self-awareness, and mindfulness in their behaviors and relationships (47). These aspects explain the effectiveness of this treatment in enhancing social functioning and relationships.
The findings of this study align with previous research, suggesting that SCIT significantly enhances the social functioning of patients with schizophrenia and BD (48, 49). Social cognition and interaction training comprises three components: Emotion perception, theory of mind, and attributional style improvement. Consistent with prior studies (50, 51), these components are predictors of social functioning. Moreover, SCIT addresses cognitive distortions and enhances cognitive flexibility by focusing on cognitive bias modification, which fosters empathy and a better understanding of others' perspectives. When individuals view social interaction as a protective factor against disorders, rather than dwelling on past negative thoughts, they are more likely to see social engagement as a goal, thereby enhancing the interpersonal relationships of BPs.
A key feature of SCIT is the continuous involvement of a training partner, which underscores the treatment's focus on bolstering communication skills. Given the influence of social cognition on social functioning, SCIT appears capable of amending the social cognitive deficits of BPs, thereby enhancing their social functioning (32). The theoretical foundation of SCIT posits that optimal social functioning is best developed through real-life social interactions. A significant benefit of SCIT is its ability to increase positive social interactions among patients in real-world settings (52).
In conclusion, the findings from this study demonstrate that SCIT, through its distinct mechanisms that enhance social cognition and reduce cognitive biases, is more effective than FFT in improving the interpersonal relationships of BPs.
This study has some limitations. The predominance of male participants suggests caution in generalizing the results to female populations. Furthermore, due to its experimental design, it cannot be asserted that all confounding factors were controlled. Future studies should employ experimental designs with more stringent controls to address this limitation.
