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Topics: Bipolar Disorder

The clinical presentation of bipolar disorder can vary substantially from patient to patient. However, in all cases, there is impaired functioning in one or more area of life; for example, disruption to school, work, and/or relationships. And in most cases, the affective episodes of bipolar disorder (eg, mania or hypomania, depression, mixed states) are recurrent in nature.

While medication plays a primary role in the management of symptoms, psychotherapy can also be a crucial tool for recovery. This article discusses pertinent features of bipolar disorder and describes an evidence-based form of psychotherapy, called interpersonal and social rhythm therapy (IPSRT).

Individuals with what is classified as bipolar I disorder have experienced at least one episode of mania. It is common for individuals with bipolar I disorder to have also experienced at least one major depressive episode. Major depressive episodes in bipolar disorder have the same features as unipolar major depressive episodes. When individuals experience a manic and a major depressive episode during the same period of time, this is categorized as a mixed episode or mixed state.

Those diagnosed with bipolar II disorder have experienced at least one major depressive episode and at least one episode of hypomania, an attenuated form of mania. While symptoms are less severe than in mania, individuals with hypomania can behave in a manner that is disruptive to work and home lives (eg, calling friends in the middle of the night to talk, or demonstrating irritability with coworkers and family members).

The average number of mood episodes per year ranges from 0.37 to 0.66, and patients with bipolar disorder spend, on average, about two months per year in affective episodes (Angst J and Sellaro R, Biol Psychiatry 2000;48(6):445–457). Additionally, many people do not experience a complete recovery to a euthymic state between mood episodes, with subsyndromal symptoms further impairing functioning and making patients more vulnerable to relapse. Not surprisingly, people with bipolar disorder often have difficulty maintaining employment and meeting family obligations as a result of their mood episodes. They also often describe feeling unable to predict these episodes or make plans for the future, feeling as though they are at the whim of mood symptoms with a tenuous sense of agency or stability.

Treatment with IPSRT

While medication is a central component of treatment, there is evidence supporting the adjunctive use of psychotherapy in the treatment of bipolar disorder (Hollom SD and Ponniah K, Depress Anxiety 2010;27(10):891–932). IPSRT was developed to address factors that contribute to the recurrence of mood episodes. For many years, we have recognized that disruptions in sleep and eating patterns predispose patients with mood disorders to recurrence of the illness. In other words, a disruption in biological rhythm leads to mood symptoms (Goodwin FK and Ghaemi SN, Dialogues Clin Neurosci 1999;1(1):41–51).

IPSRT is based on the theory that variability in daily activity disrupts circadian rhythm, predisposing patients to relapse (Swartz HA et al, Interpersonal and Social Rhythm Therapy. In: Power M ed. Mood Disorders: A Handbook of Science and Practice. Chi-chester, England: John Wiley & Sons Ltd.;2004:275–292). Using IPSRT, you will work with the patient to alleviate the effect of potentially disruptive life events by using behavioral techniques to stabilize daily routine. This treatment incorporates principles of interpersonal psychotherapy by proposing that interpersonal stressors place the patient at risk for recurrent mood episodes by causing a shift in daily routine and thus natural biological rhythm.

The Four Phases of IPSRT

IPSRT has four phases, and can be initiated with patients who are experiencing acute or subsyndromal symptoms, or are between episodes and euthymia (Frank E et al, Dialogues Clin Neurosci 2007;9(3):325–332).

The First Phase In the first phase, lasting three to five sessions, you will take a careful history to establish a correct diagnosis and identify factors that have contributed to mood episodes. For instance, a detailed history may reveal that your patient’s first manic symptoms occurred in college after three days of minimal sleep while preparing for midterm exams. Or perhaps the end of a relationship led to a change in eating habits and daily activity patterns, subsequently followed by a depressive episode.

In this phase you will educate your patient about bipolar disorder. You and the patient will also complete an interpersonal inventory, gathering information about important current and past relationships and together identifying a problematic area of interpersonal functioning (eg, unresolved grief, role transition, role disputes, or more pervasive interpersonal deficits), as noted in Swartz et al. The goal is to identify connections between interpersonal stressors and mood symptoms.

Finally, the patient will complete a Social Rhythm Metric (SRM), recording details about daily routine, including time awake, start of work or school, meal times, and time to bed. The SRM was developed by researcher Timothy J. Monk, PhD, and others (Monk TH et al, J Nerv Mental Dis 1990;178(2):120–126). You can find an updated sample SRM at http://1.usa.gov/11SOojo (Frank E et al, Dialogues Clin Neurosci 2007;9(3):325–332).

The Second Phase

The second phase of treatment—generally lasting through 10 to 12 weekly sessions—is focused on using the SRM to establish a regular daily routine and to work toward resolution of the identified interpersonal problem. Often, these goals overlap. For instance, you and your patient may identify that the amount of sleep she gets varies widely since starting a job as an ultrasound technician that requires her to answer calls and go into the emergency room in the middle of the night (ie, a role transition). Her SRM reveals that limited sleep for more than one night in a row leads to dysphoria and neurovegetative symptoms. Here, you help the patient to accept that her current job situation is increasing the risk that there will be a recurrence of a full-blown mood episode. You then help the patient find solutions to address this interpersonal problem and lessen the variation in her daily schedule (eg, requesting no overnight obligations from her employer, or finding a position in an office-based setting with regular hours).

Frank et al comment that the diagnosis of bipolar disorder can lead to anger and/or grief over the lost healthy self. Identifying these emotions, then addressing how this diagnosis has affected identity, personal goals, and relationships with significant others, and then modifying expectations, can lead to acceptance of the illness and can improve medication adherence, reducing the risk of future episodes.

The Third Phase

The third phase of IPSRT focuses on increasing your patient’s confidence in using the skills learned to stabilize daily routine and maintain regularity despite the inevitable occurrence of stressors. As patients become more facile at doing so, sessions are gradually spaced out from weekly to biweekly to monthly. This phase may last up to two years or longer. In concurrence with ongoing behavioral interventions, you should continue to focus on optimizing interpersonal functioning and minimizing distress in relationships. Techniques include communication analysis, role play, and decision analysis.

The Fourth Phase

The final phase of treatment is termination, often conducted over three to five monthly sessions. This phase focuses on reinforcement of learned skills and on the identification of further improvement that is needed. And although IPSRT may terminate, it is generally the case that medication treatment will continue, and the termination process can be used to encourage ongoing follow-ups with a psychiatric provider.

By harnessing behavioral and interpersonal techniques, IPSRT aims to reduce new affective episodes in patients with bipolar disorder by fostering regular, predictable daily routines and minimizing psychological distress. Including it in your practice can enhance your patients’ sense of stability and reduce the chaos often experienced by people who suffer from bipolar disorder.

TCRBH’s Take: Pharmacotherapy for bipolar disorder is generally accepted among researchers and clinicians as a necessary part of treatment for bipolar disorder. And there is mounting evidence that, when added to pharmacotherapy, psychosocial interventions (eg, IPSRT, cognitive behavior therapy, and family therapy) benefit patients by improving functioning in between episodes and by reducing the risk of relapse. Patients with bipolar disorder often describe feeling a lack of control over their mood and behavior. IPSRT, as an adjunct to medication, helps patients develop a valid sense of empowerment by helping them control aspects of their lives that can have a meaningful effect on the course of the bipolar disorder and, overall, by improving quality of life.