Mrinalini Mahajan

M Phil CP trainee
Ist year
* Introduction
* Theory behind IPSRT:
* IPT framework
* Social Rhythms theories
* IPSRT Formulation
* Assessment
* Phases of Therapy
* Research evidence
* Interpersonal and social rhythm therapy (IPSRT) was designed to directly address
the pathways to recurrence in bipolar disorder, namely medication non-
adherence, stressful life events, and disruptions in social rhythms.

* The relationship between psychosocial stressors (and, equally important, non-

“stressful” alterations in the patterning of daily life) and changes in biological
rhythms is emphasized.

* Circadian rhythm researchers refer to the exogenous environmental factors that set
the circadian clock as zeitgebers or “time givers” (Aschoff, 1981). The sun is a
natural zeitgeber. Social factors such as the timing of work, meals, and even
specific television programs can have an important influence on circadian
rhythms.

* The changes in social time cues lead to brief disruptions in circadian rhythms and
are experienced as transient somatic and cognitive symptoms. E.g. jetlag
* Individuals who are vulnerable to mood disorders have a more difficult time
adapting to such changes and may get stuck in the somatic and cognitive state
associated with disrupted circadian rhythms. They may then go on to experience that
state as fully syndromal episodes of depression or mania.

* Loss of social zeitgebers (i.e., time givers) and/or the presence of significant
zeitstörers (i.e., rhythm disrupters) are important in triggering affective episodes in
vulnerable individuals. Thus, principles of social rhythm stabilization are an
important part of the treatment of bipolar disorder.

* Specific goals of IPSRT are to stabilize patients’ social rhythms or routines, improve
the quality of their interpersonal relationships and their satisfaction with social roles.

* Forpatients with bipolar I disorder, affective symptoms can be managed through

pharmacotherapy and efforts to regularize their social rhythms. For patients with
bipolar II disorder, IPSRT may be offered either as a stand-alone intervention or
along with pharmacotherapy depending upon the severity of the mood symptoms.
* IPSRT addresses each of the potential pathways previously mentioned to new
episodes of illness.
* By providing medication-adherence training

* In addition, it gives a forum in which patients can explore their feelings about the
disorder, grieve for what we have called “the lost healthy self,” and come to
terms with how the disorder has altered their lives. Thus it reduces denial and
increases acceptance of the lifelong nature of the disorder and its never-to-be
underestimated propensity to recur.

* By addressing interpersonal and social role problems in the patient’s life,

IPSRT attempts to reduce the number and severity of patients’ interpersonally or
socially based stressors. By paying careful attention to the regularity of daily
routines (both the timing of events and the amount of stimulation they produce)
and the extent to which both positive and negative life events may influence these
daily routines, IPSRT increases the stability of social rhythms in patients’ lives and
their vigilance with respect to maintaining that stability.
* The reduction of interpersonal stress in individuals with bipolar disorder is
considered as being important to their wellness for several reasons:

* Stressful life events can have a direct effect on circadian integrity through
increased autonomic arousal, leading to reductions in sleep and appetite.

* Many stressful (and not so stressful) life events lead to marked changes in
daily routines. E.g. change in school timings of the child.

* Major life stressors, such as losing one’s job or getting divorced, not only
have the capacity to affect mood directly but also lead to marked changes in
social rhythms.
* Interpersonal psychotherapy (IPT) focuses on improving the quality and number of
interpersonal relationships in the patient’s life and on helping the patient to
negotiate difficult transitions in social roles. IPT defines four key problems areas:
unresolved grief, social role transitions, interpersonal role disputes (usually with
a spouse, parent, or child), and more generalized interpersonal deficits (chronic
isolation or chronic dissatisfaction with most or all interpersonal relationships).

* It should be noted, however, that in the process of improving the quality and number
of social relationships or negotiating a role transition, IPT also serves to regulate
daily and weekly social interaction. It serves to reestablish social zeitgebers.
* Until the late 1970s the vast majority of circadian rhythm research in humans
concentrated on social cues, assuming that light–dark cycles played only a very minor
role in setting human circadian rhythms in an urban society (Wever, 1988). Although
since the 1980s there has been much more interest in the role of physical zeitgebers, it
is still clear that social zeitgebers can be enormously potent as synchronizers of
human circadian rhythms.

* The disruption of these social “regulators” is thought to have considerable effects on

biological rhythms.
* The initial phase of treatment begins with a focused history-taking. This emphasizes
the extent to which disruptions in social routines and interpersonal problems have
been associated with affective episodes, and is intended to develop the rationale for
the treatment. At this time, psycho-education about the mood disorder is provided to
the patient (and his or her family, when indicated).

* The quality of the patient’s interpersonal relationships is assessed through the

Interpersonal Inventory. The regularity of the patient’s social routines is assessed by
the Social Rhythm Metric (Monk, Flaherty, Frank, Hoskinson, & Kupfer, 1990).

* Finally,an interpersonal focus is selected collaboratively by the therapist and

patient, from among the four IPT problem areas (i.e., grief, role transitions, role
disputes, interpersonal deficits). This will become the initial focus of therapy. The
focus should definitely be on grief for the lost healthy self.

* This initial phase typically lasts three to five sessions, depending on the length and
complexity of the patient’s affective history and interpersonal relationships as well as
the amount of psycho-education required.
* Ask the patient to describe the nature of * Ask the patient to describe what he or she
the crisis. thinks will happen.
* Let the patient talk. * Discuss what the factors are that may
* Limit your interventions. Just letting the make the crisis worse.
patient talk or cry may be enough to calm * Reevaluate whether it is safe to treat the
him or her down. patient on an outpatient basis.
* Listen, show interest. This may be * Discuss what the factors are that may
enough to establish a relationship. improve the current situation.
* Evaluate whether it is safe to treat the * Provide the patient with an emergency
patient on an outpatient basis. plan in case the situation becomes much
* Discuss the factors that may have worse.
contributed to the crisis. * Describe the goals of the treatment that
* Ask the patient to describe what is you plan to provide, and give the patient
happening right now with respect to the an idea of how the sessions will be
crisis. organized.
* Discuss what the factors are that are * Arrange for another visit with the patient
continuing to contribute to the crisis. within 3–5 days.
* Following the conclusion of the initial phase of treatment, the therapist moves on to
the intermediate phase of therapy.

* The focus is on regularizing the patient’s social rhythms and intervening in the
selected interpersonal problem area. It also involves discussion of early warning
signs for impending episodes.

* Measuring symptomatic and functional change in treatment is important.

Monitoring and enhancing treatment adherence as well as adherence to working on
the interpersonal problem area is encouraged.

* Typically,IPSRT is conducted weekly in the initial and intermediate phases, but

other schedules may be appropriate if the patient is either very symptomatic, in which
case more frequent visits may be needed, or fully remitted and in treatment primarily
to improve current functioning and prevent future episodes.
* Once the plan for regulating social rhythms has been initiated, the information is
reviewed to determine (or at least speculate about) what in this particular patient’s life
leads to increased or decreased sleep, increased or decreased social stimulation. In
addition to inputs from the outside (physical and social zeitgebers) that may affect the
patient’s biological rhythms, it is important to identify situations where
overstimulation as a result of internal cognitive, intellectual, or emotional arousal or
as a result of excessive social interaction is possible.

* Behavioral activation to maintain the balance between activity-inactivity is crucial.

* Rescue protocols may also involve specific and even signed agreements between the
patient and family members or significant others as to what each will do (in addition
to the use of rescue medication) when the patient’s mood appears to be escalating or
slipping, but the patient is unwilling or unable to do anything about it.

* Careful review of medications, side-effects, consumption of alcohol and other illicit

drugs, as well as exercise and nutrition consultation is provided.
* The continuation, or maintenance, phase of IPSRT is one in which the therapist
works to establish patients’ confidence in their ability to use the techniques learned
earlier in the treatment. These include maintaining regular social rhythms, even in the
face of challenges such as vacations, job changes, and unexpected life disruptions,
and maintaining or further improving their interpersonal relationships.

* Asthe treatment moves from the intermediate to the continuation or maintenance

phase, the frequency of visits is typically reduced from weekly to bimonthly, and
eventually to monthly.
* Thefinal phase of IPSRT involves work toward termination of therapy or further
reduction in the frequency of visits.

* When termination is seen as an appropriate goal or is necessitated by financial

concerns or relocation, this is usually accomplished over the course of three to five
monthly visits. Alternatively, the final phase may involve a further reduction in the
frequency of visits, such as occasional check-ups or booster sessions.

* When the contract is for short-term treatment only, the initial phase of treatment may
need to be somewhat compressed and focus intently on social rhythm regulation.

* Even when IPSRT is provided as a short-term treatment, it is probably advisable to

reduce the frequency of the sessions toward the end, allowing for three to four
bimonthly sessions during which the termination work is accomplished.
* 175 individuals in an acute episode of bipolar I disorder were randomly assigned to
one of four acute and maintenance treatments: acute and maintenance IPSRT
(IPSRT/IPSRT), acute and maintenance intensive clinical management or ICM
(ICM/ICM), acute IPSRT followed by maintenance ICM (IPSRT/ICM), or acute ICM
followed by maintenance IPSRT (ICM/IPSRT).

* No difference between the treatment strategies in time to stabilization of the acute

episode was observed, possibly because of the strong influence of acute
pharmacotherapy on time to remission.
* However, after controlling for significant covariates of survival time (i.e., marital
status, anxiety disorder diagnosis, and medical comorbidity), it was found that those
individuals who were assigned to IPSRT in the acute treatment phase survived longer
without a new affective episode, irrespective of maintenance treatment assignment.
Patients in the IPSRT group had achieved higher regularity of social rhythms at the
end of acute treatment than did their counterparts receiving ICM. Furthermore, the
ability to increase regularity of daily routines during acute treatment was significantly
related to reduced likelihood of recurrence during the maintenance phase.
* IPSRT also was studied as one of three intensive psychosocial treatments in the
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). This
multisite investigation examined the benefits of four disorder-specific
psychotherapies in conjunction with pharmacotherapy on time to recovery and the
likelihood of remaining well following an episode of bipolar depression.

* A total of 293 individuals with bipolar I or II disorder were randomly assigned to an

intensive psychotherapy (n=163) or collaborative care (CC; n=130), a brief
psychoeducational intervention. Intensive psychotherapy was given weekly and
biweekly for up to 30 sessions over 9 months, according to protocols for family-
focused therapy, IPSRT, or cognitive-behavioral therapy. CC consisted of three
sessions over 6 weeks.
* After a period of 12 months patients who received intensive psychotherapy had
significantly higher year-end recovery rates (64 vs. 52%, respectively) and shorter
times to recovery than did patients in CC control condition Patients in intensive
psychotherapy were 1.58 times more likely to be clinically well during any study
month than were those in CC.