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David Baxter PhD

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Psychotherapy to Stabilize Daily Routines Is Beneficial in Bipolar Disorder
by Marlene Busko, Medscape Medical News
December 27, 2007

Interpersonal and social rhythm therapy to stabilize sleep, wake, and meal times improved outcomes in bipolar patients in 2 studies discussed by Ellen Frank, MD, from the University of Pittsburgh School of Medicine, in Pennsylvania, in a presentation at the American College of Neuropsychopharmacology 46th Annual Meeting.

"The clinical implications are that without necessarily trying to provide patients with the full interpersonal and social rhythm therapy protocol, which so far only a small number of people in the United States are trained to do, any clinician treating someone with bipolar disorder can encourage them to lead lives characterized by regular routines, and in particular, regular wake times, bedtimes, and mealtimes," Dr. Frank told Medscape Psychiatry.

Interpersonal and Social Rhythm Therapy
Individuals with bipolar disorder or recurring unipolar disorder have particularly sensitive biological clocks, so that events that disrupt their daily routines and sleep-wake cycles are associated with new onsets of illness, said Dr. Frank. "We hypothesized that a treatment that helped patients lead lives with very regular wake times, bedtimes, mealtimes, and other routines could protect these delicate clocks, and paying attention to potential changes in routine and avoiding drastic changes could protect patients from new episodes."

They developed a treatment called "interpersonal and social rhythm therapy," in which social rhythm therapy is added to Klerman and Weissman's interpersonal psychotherapy. The social rhythm therapy attempts to help the patient develop and maintain regular daily routines. The interpersonal psychotherapy focuses on 4 interpersonal problem areas: bereavement, transition in a major life role, a major dispute with an important person (particularly someone with whom the patient lives), and interpersonal relationship deficits.

"We've now shown in 2 studies that there are benefits to this approach," said Dr. Frank.

The first study, a randomized controlled trial of 175 patients with bipolar I disorder, showed that compared with participants who received intensive clinical management, those who received acute interpersonal and social rhythm therapy had a significantly longer time before a new episode of mania or depression during a 2-year follow-up (Frank E et al. Arch Gen Psychiatry 2005;62:996-1004).

In the second study, interpersonal and social rhythm therapy was 1 of 3 intense psychotherapies that resulted in better outcomes than collaborative care, in a 1-year randomized study that was part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial (Miklowitz DJ et al. Arch Gen Psychiatry 2007;64:419-426). A total of 293 outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomized to up to 30 sessions of intensive psychotherapy with 1 of 3 methods ? interpersonal and social rhythm therapy, family-focused therapy, or cognitive behavior therapy ? or to 3 sessions of collaborative care treatment. Compared with patients treated with brief collaborative care, patients receiving intensive psychotherapy attained remission of depression within a shorter time.

Mouse Model of Bipolar Disease
In a related presentation, Colleen McClung, PhD, from the University of Texas Southwest Medical Center, in Dallas, reported that mice with a clock-gene mutation displayed behavior that was similar to symptoms of mania in patients, which makes this a useful model to study bipolar disease. There is a very strong link with patient studies and this animal model, said Dr. Frank.

Practical Change, Easy to Implement
Establishing and maintaining a regular routine take discipline but require less effort than making and keeping health-related changes in diet and exercise, especially with the support of family members or other people living with the patient, said Dr. Frank.

"Patients will often say, 'You are trying to make my life boring,' and we always say, 'You can have as many interesting and exciting experiences as you want, as long as you manage to get to bed at the same time pretty much every night and get up at the same time pretty much every morning,' " she said. They found that patients who understand this message and are able to make the changes are quite happy with the improvement that they see.

Night Owls, Not Morning Larks
In another presentation, Vishwajit L. Nimgaonkar, MD, also from the University of Pittsburgh School of Medicine, discussed how individuals with bipolar disorder are much more likely than people in the general population to have a body clock that runs late, which reinforces findings from Dr. Frank's studies. "One of the things that we learned . . . is that if individuals who have bipolar disorder don?t have family or work demands that require that they get up early, they are much better off staying on their own natural schedule, as long as they get enough sleep," she said.

"As long as it doesn't interfere with work or family obligations, individuals with bipolar disorder should be encouraged to have a regular routine that is consistent with their body's own natural clock," she summarized.

STEP-BD is sponsored by the National Institute of Mental Health. No financial disclosures were reported.

Source: American College of Neuropsychopharmacology 46th Annual Meeting. December 9-13, 2007.
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