Social rhythm therapy reduces bipolar episodes.

VIENNA -- A psychosocial intervention aimed at instilling greater regularity of daily routines in patients with bipolar disorder effectively protects against recurrences of both mania and depression, Ellen Frank, Ph.D., said at the annual congress of the European College of Neuropsychopharmacology.

Moreover, this intervention, which Dr. Frank and her colleagues developed and call interpersonal and social rhythm therapy (IPSRT), recently has been shown in a large multicenter randomized trial to speed recovery from acute episodes of bipolar depression.

"I think of this therapy as the wisdom of our grandmothers being evidenced for us," explained Dr. Frank, professor of psychiatry and psychology at the University of Pittsburgh. "We're learning from studies the importance of what all our grandmothers told us: It's good to go to bed at a regular time; it's good to get enough sleep; it's good to have meals at a regular time."

Nearly 20 years ago, she and her colleagues described what they termed the "social zeitgeber" hypothesis of mood disorders. They argued that stressful life events that disrupted an individual's normal routines could skew circadian biorhythms and initiate a cascade, resulting in onset of an episode of a mood disorder. They further posited that interventions that restore regularity to a patient's daily routines would reorder circadian rhythms and protect against mood symptoms.

"It's not simply that mood disorders are reflected in disruptions in circadian function and sleep but that these disruptions may actually lead to the expression of mood symptoms," Dr. Frank said.

The first compelling evidence of IPSRT's clinical efficacy came from a single-center randomized trial in Pittsburgh involving 175 acutely ill patients with bipolar disorder on appropriate drug therapy. During 2 years of follow-up, those assigned to manual-based IPSRT in the acute treatment phase went significantly longer without a new affective episode than did controls who received a more general psychosocial intervention the investigators called intensive clinical management (Arch. Gen. Psychiatry 2005;62:996-1004).

Confirmation of IPSRT's efficacy came in the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study reported earlier this year.

In STEP-BD, 293 outpatients with bipolar disorder and depression who were on protocol-mandated pharmacotherapy were randomized. One group participated in one of three intensive psychotherapies--cognitive-behavioral therapy, IPSRT, or family-focused therapy--weekly and biweekly for 9 months. The other outpatients were part of a control arm that received a brief psychoeducational intervention. The year-end recovery rate was 64% in those who got intensive psychotherapy, significantly greater than the 52% rate in controls. Recovery rates were similar in all three intensive psychotherapy groups (Arch. Gen. Psychiatry 2007;64:419-26).

In a separate analysis, the STEP-BP investigators reported that patients who received any of the three intensive psychotherapies also had significantly better total functioning, relationship functioning, and life satisfaction scores (Am. J. Psychiatry 2007;164:1340-7).

Dr. Frank said based on her clinical experience--she has been following some patients for 10-12 years--people with bipolar disorder are vulnerable to disruptions in their social zeitgebers throughout life.

Ongoing studies strongly suggest that IPSRT also is effective in unipolar depression and other disorders involving sleep disruption, she said.

"Psychosocial therapies should now be regarded as routine in the management of bipolar disorder," said Dr. Michael Berk, professor of psychiatry at the University of Melbourne and vice chairman of the International Society for Bipolar Disorders.

Both STEP-BD and the Pittsburgh randomized trial of IPSRT were funded by the National Institute of Mental Health.

BY BRUCE JANCIN

Denver Bureau