Interpersonal and Social Rhythm Therapy (IPSRT) for Bipolar Disorder

Chairperson: Holly Swartz, MD, WPIC

Interpersonal and social rhythm therapy (IPSRT), developed by Frank and colleagues at the University of Pittsburgh as a treatment for bipolar (BP) disorder, combines elementsof Klerman and Weissman’s interpersonal psychotherapy with a behavioral intervention aimed at enhancing circadian system integrity through regularizing daily routines. The goals of the treatment are the recognitionof the relation of stable social rhythms and interpersonalproblems to mood, the achievement and maintenance ofstable social rhythms and the resolution of interpersonalproblems related to grief, role transitions or role disputes.IPSRT’s efficacy was demonstrated in a single-site acuteand maintenance trial in patients with BP I disorder whowere suffering from mania, depression or mixed episodesand in large a multi-site acute trial in patients with BPI and II disorder who were suffering from depression. Despite the demonstration of efficacy in these well-definedpatient populations, IPSRT’s role in other populations andsettings has not been established. Because of its clinicalappeal and compelling evidence-base to date, investigatorshave begun the process of systematically evaluating IPSRTfor groups who were necessarily excluded from the originaltrials.

The current symposium, in addition to providing a brief overview of the treatment by its creator, presented five novel applications of IPSRT. Although at early stagesof investigation, these proof of concept trials demonstratethe feasibility of using IPSRT in new populations(adolescents, at-risk offspring of adults with BP disorder,perinatal BP disorder) and in new formats (inpatient andoutpatient groups, as monotherapy for BP II disorder).

This symposium gave clinicians an understanding of the importance of circadian rhythm entrainment to promote mood stability as described in IPSRT across an expanding range of conditions.Introduction: Empirically validated psychotherapies such as IPSRT—despite showing benefit in randomized controlled trials—rarely transition to typical practice settings where they are likely to have broader impact.

To make IPSRT available to more patients, researchers and clinicians collaborated to develop group models of IPSRT for individuals receiving treatment across multiple levels of care within a single hospital system. Methods: IPSRT was adapted for delivery as daily inpatient (IP) groups, thrice-weekly intensive outpatient (IOP) groups, and weekly outpatient (OP) groups. IP groups focus primarily on developing skills required to promote social rhythm regularity and are highly structured/didactic. OP groups consist of 12 weekly closed sessions followed by open and open-ended weekly maintenance groups. Group content focuses on illness history timeline, interpersonal communication strategies, psychoeducation about BP, and maintenance of regular social rhythms. IOP groups are intermediate in content and structure to outpatient and inpatient groups. In all groups, members complete the Social Rhythm Metric to monitor and modulate social rhythms to promote biologic rhythm stability. Results: On the IP unit, rates of participation in all IP groups increased significantly during the 6 months following initiation of IPSRT compared to 6 months prior to IPSRT [t(388)=4.08; p=0.0001]. In the OP groups, among those who entered the group with elevated depression scores on the Quick Inventory of Depressive Symptoms (QIDS) (n=8), there was a statistically significant decline in mean scores over time [F(1,7)=14.84, p=0.006]. Similarly, analyses of data from individuals participating in the intensive outpatient (IOP) groups (n=55), using a mixed effect model,indicated a significant decline in QIDS scores (p=.0045). Conclusions: Group IPSRT is a feasible and promising approach to care in routine practice settings.

Comparison of IPSRT Monotherapy and Quetiapine for the Treatment of Bipolar II Depression: A Proof of Concept Trial

Holly Swartz, MD

Introduction: Bipolar II disorder is a common psychiatricillness associated with marked morbidity and impairment,yet few treatments for this disorder have been systematicallyevaluated. Psychotherapy may play an important role inthe management of this disorder as there may be someindividuals with the bipolar II phenotype (in contrast tothe bipolar I phenotype) who can be successfully managedwith psychotherapy alone. We conducted a proof of conceptstudy to determine the feasibility of using Interpersonaland Social Rhythm Therapy (IPSRT) as monotherapy forthe acute treatment of bipolar II depression. Methods:Unmedicated individuals (n=17) meeting DSM-IV criteriafor bipolar II disorder, currently depressed, were randomlyassigned to receive 20 weeks of treatment with IPSRT(n=9) or quetiapine (n=8) Subjects were followed for 20weeks. Results: Subjects were 65% female (n=11). Meanage was 34.4. At baseline, mean Hamilton Rating ScaleDepression scores (17 item) was 18.5 and mean YoungMania Rating Scale scores was 6.6. Seventy-four percent(n=7) of subjects assigned to IPSRT and 50% (n=4) ofsubjects assigned to quetiapine completed the protocol.Conclusions: IPSRT was acceptable to patients. Drop-outrates with quetiapine were high. It appears feasible to treat a subset of individuals with bipolar II depression withIPSRT monotherapy. We concluded that an adequatelypowered, randomized, controlled trial is indicated tosystematically evaluate the efficacy of IPSRT as an acutemonotherapy for bipolar II disorder.

Early Intervention for Adolescent Offspring of Parents with Bipolar Disorder: Pilot Study of Interpersonal and Social Rhythm Therapy (IPSRT)

Tina Goldstein, PhD

Objective: To describe an open treatment development study of Interpersonal and Social Rhythm Therapy (IPSRT) for adolescents at-risk for bipolar disorder by virtue of having a parent with the illness. Methods: Participants include adolescent (age 12-18) offspring of parents with bipolar disorder. Adolescents were evaluated for Axis I disorders via the K-SADS at intake. Those who met criteria for current or past bipolar disorder were excluded. The manualized IPSRT intervention consisted of 12 weekly individual sessions delivered over 3 months. Outcome variables including mood and sleep were assessed via objective (actigraphy) and subjective (interview, self-report) methods at intake, 3, and 6 month follow-up. Results: Of 17 eligible adolescents assessed, 13 (7 males; mean age = 15.2) attended at least one IPSRT session. Diagnostic heterogeneity characterized the treatment sample at intake: 3 participants met criteria for major depressive disorder, 1 oppositional defiant disorder, 2 anxiety disorder, 2 attention deficit hyperactivity disorder, 1 substance abuse, 6 denied Axis I disorder. Pre-treatment actigraphy data support significant sleep disruptions in this high-risk sample. Specifically, we observed high rates of short sleep, frequent awakenings, and low sleep efficiency. Feasibility data indicate high satisfaction with the treatment approach, yet participants only attended 50% of scheduled sessions (M=6.3, range=2-10). Over half of missed sessions were associated with parental illness severity (e.g., parent hospitalized). Although limited conclusions can be drawn from this small sample, it appears that adolescents had fewer nights of short sleep (75% pre-treatment to 25% post-treatment), improved sleep efficiency, and decreased weekday-weekend bedtime variability following IPSRT. Conclusions: The IPSRT treatment focus on stabilizing sleep and social rhythms and interpersonal relationships may be beneficial for adolescents at risk for bipolar disorder.

Interpersonal and Social Rhythm Therapy for Adolescents with Bipolar Disorder: Treatment Development and Results From an Open Trial

Stefanie Hlastala, PhD

In adolescents and adults, bipolar disorder (BD) is associated with significant morbidity, mortality, and impairment in psychosocial and occupational functioning. Interpersonal and Social Rhythm Therapy (IPSRT) is an empirically supported adjunctive psychotherapy for adults with BD which has been shown to help delay relapse, speed recovery, and increase occupational and psychosocial functioning in adults with BD. Because of the documented efficacy in adults and the developmental relevance of the targets of IPSRT to adolescents, we have adapted IPSRT to meet the developmental needs of adolescents with bipolar spectrum disorders. Method: The current study described the adolescent-specific adaptations made to IPSRT (i.e., IPSRT-A) and reported the results from an open trial of IPSRT-A with 12 adolescents with a bipolar spectrum disorder. Twelve adolescents (mean age 16.5 1.3 years) diagnosed with a bipolar spectrum disorder participated in 16-18 sessions of adjunctive IPSRT-A over

20 weeks. Manic, depressive, and general symptoms and global functioning were measured at baseline, monthly during treatment, and at post-treatment. Adolescent satisfaction with treatment was also measured. Results: Feasibility and acceptability of IPSRT-A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent-rated satisfaction scores were high. IPSRT-A participants experienced significant decreases in manic, depressive and general psychiatric symptoms over the 20 weeks of treatment. Participants’ global functioning increased significantly as well. Conclusions: IPSRT-A appears to be a promising adjunctive treatment for adolescents with bipolar disorder. A current randomized controlled trial is underway to examine effects of adjunctive IPSRT-A on psychiatric symptoms and psychosocial functioning. Preliminary findings from this trial will also be discussed.

IPSRT for Bipolar Disorder in the Perinatal Period

Suzanne Luty, PhD, MBBS

Purpose: IPT for depression is efficacious for women in the perinatal period (pregnancy and 1 yr postpartum) but IPSRT has not been evaluated. Up to 75% of women with BD develop symptoms/episodes of mania or depression postpartum, and the risk of postpartum psychosis (PP) is markedly increased. Good management is crucial to preserve maternal well being and the mother infant relationship, but since there are many concerns about prescribing medication because of teratogenic risks and exposing infants to medication in breast milk, psychotherapy may be a useful alternative/adjunct. Unstable sleep patterns and routines in the perinatal period are thought to play a role in the development of symptoms. An emphasis on stabilizing circadian rhythms and addressing functioning are integral components of IPSRT and this may be useful for both preventing and treating mood episodes hence improve outcomes for mother and infant. Content: To describe the adaptation of IPSRT in the perinatal period and present data from a subgroup of patients who received IPSRT in a psychotherapy research study. Methodology: 100 patients enrolled in the psychotherapy for bipolar disorder study received IPSRT or Specialist Care plus medication over 18 months. All sessions were audiotaped for integrity, and measures of manic and depressive symptoms recorded at each session. Baseline measures included prior number and type of episode, hospitalizations, diagnoses, medication and age of onset. Follow up measures included measures of episodes, symptoms, medication use and hospitalization. Data was extracted on the subgroup of 13 patients who were within one year postpartum or became pregnant during therapy and for whom the focus of IPSRT was adapted accordingly. Results: The group had significantly lower than expected symptoms, episodes (including PP), medication use and hospitalizations. Importance: IPSRT can improve outcomes for mother and infant during the high risk perinatal period.

Group Interpersonal and Social Rhythm (IPSRT) Therapy Across the Continuum of Care in Routine Practice Settings

Ellen Frank, PhD

Introduction: Empirically validated psychotherapies such as IPSRT—despite showing benefit in randomized controlled trials—rarely transition to typical practice settings where they are likely to have broader impact. To make IPSRT available to more patients, researchers and clinicians collaborated to develop group models of IPSRT for individuals receiving treatment across multiple levels of care within a single hospital system. Methods: IPSRT was adapted for delivery as daily inpatient (IP) groups, thrice-weekly intensive outpatient (IOP) groups, and weekly outpatient (OP) groups. IP groups focus primarily on developing skills required to promote social rhythm regularity and are highly structured/didactic. OP groups consist of 12 weekly closed sessions followed by open and open-ended weekly maintenance groups. Group content focuses on illness history timeline, interpersonal communication strategies, psychoeducation about BP, and maintenance of regular social rhythms. IOP groups are intermediate in content and structure to outpatient and inpatient groups. In all groups, members complete the Social Rhythm Metric to monitor and modulate social rhythms to promote biologic rhythm stability. Results: On the IP unit, rates of participation in all IP groups increased significantly during the 6 months following initiation of IPSRT compared to 6 months prior to IPSRT [t(388)=4.08; p=0.0001]. In the OP groups, among those who entered the group with elevated depression scores on the Quick Inventory of Depressive Symptoms (QIDS) (n=8), there was a statistically significant decline in mean scores over time [F(1,7)=14.84, p=0.006]. Similarly, analyses of data from individuals participating in the intensive outpatient (IOP) groups (n=55), using a mixed effect model,indicated a significant decline in QIDS scores (p=.0045). Conclusions: Group IPSRT is a feasible and promising approach to care in routine practice settings.

References

1. Frank, E. (2005). Treating bipolar disorder: A clinician’s guide to interpersonal and social rhythm therapy. New York, NY: Guilford Press.

2. Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., et al. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62(9), 996-1004.

3. Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Wisniewski, S. R., Kogan, J. N., et al. (2007). Psychosocial treatments for bipolar depression: A 1-Year randomized trial from the Systematic Treatment Enhancement Program. Archives of General Psychiatry, 64, 419-427.

Adapted from materials found on the American Psychiatric Association Annual Meeting website.