Steady Circadian Rhythms Are Music to Bipolar Patients' Ears
Erik L. Goldman, New York Bureau
[Clinical Psychiatry News 27(9):18, 1999. © 1999 International Medical News Group.]
PITTSBURGH -- As in a jazz band, rhythm is everything when it comes to management of bipolar disorder.
Helping patients establish stable circadian and social rhythms is emerging as a major treatment goal, one that can markedly improve these patients' quality of life, according to Ellen Frank, Ph.D., director of the Depression and Manic Depression Prevention Program at the Western Psychiatric Institute in Pittsburgh.
She and her colleagues have developed a comprehensive psychosocial intervention they call Interpersonal and Social Rhythm Therapy (IPSRT). As an adjunct to pharmacotherapy, they believe it can address some of the factors driving persistent symptoms and recurrent depressive or manic episodes despite "adequate" drug treatment.
"We have no fantasy that bipolar disorder can be treated with any sort of psychotherapy alone. But this is really good for stabilization, for control of circadian rhythm dysfunction -- which is common in these patients," Dr. Frank said at a conference on bipolar disorder sponsored by the Western Psychiatric Institute and Clinic.
Psychosocial stresses and diurnal rhythm disruptions promote neurotransmitter dysregulation, and this in turn fosters behavioral disturbances and symptom exacerbation. In other words, chaotic biorhythms and unpredictable stresses make life worse for bipolar patients. They tend to do best when their daily lives are highly routinized.
IPSRT hinges on identifying the daily activity patterns that are most chaotic and stabilizing them as much as possible.
"Try to get the patient sleeping, waking, and eating at regular times. They don't necessarily need to be strictly tied to the light-dark cycle -- remember that many of these patients are phase-delayed 'late-night' people. That's all right, so long as they are regular in their sleep and waking times and not completely out of synch with day and night," Dr. Frank said at the conference, also sponsored by the University of Pittsburgh.
The goal is to stabilize as many daily rhythms as possible. This includes meal times, work, and leisure activities. The specific routines should be individualized based on patient preferences, inclinations, family, and work obligations. The point is not to impose a predefined schedule but to gradually introduce greater routine and rhythmicity to daily life.
IPSRT also contains a patient education component.
Bipolar patients need to understand the genetic and biochemical predispositions underlying their disorder and that these organic factors are exacerbated or attenuated by social and environmental factors, Dr. Frank said.
In this light, they must be vigilant about impending life changes that have potential to disrupt daily rhythms -- changes such as marriage or separation, birth of a child, school graduation, or change of job or residence.
Major changes can be detrimental in bipolar disorder, but if the patient is prepared and you work together to develop strategies to preserve some routines and quickly establish others, the risk can be minimized.
The social rhythm aspect of Dr. Frank's approach involves identifying who the important people in a patient's life are, those who create stress, and those who provide support.
It is equally important to recognize interpersonal problem areas and to work with the patient to develop strategies to minimize their negative impact.
Dr. Frank has found grief counseling models very helpful, especially in newly diagnosed bipolar patients.
Many patients divide their lives into "before" and "after" diagnosis. They don't see themselves as who they were.
Part of this approach is to encourage them to grieve for their old "healthy" self while at the same time showing them that bipolar disorder is not something that has to hinder their lives and dreams and accomplishments.
IPSRT approach involves biweekly psychotherapy visits for the first 12 weeks, followed by monthly visits for as long as it is deemed necessary.
Dr. Frank and her colleagues are currently conducting a long-term follow-up study comparing the IPSRT intervention with an intensive clinical management paradigm that does not address circadian and social rhythms.
Patients in both cohorts are receiving standard pharmacotherapy as well.
Data from the first 91 patients, followed up for 1 year, suggest that while both groups were more or less equivalent in terms of frank manic or depressive episodes during the follow-up period, IPSRT patients tended to remain euthymic for longer periods of time. IPSRT may have its biggest impact in reducing subsyndromal depression.
"The issue is not so much how long they are not episodic but what states are they in and what is the daily symptom burden during these subsyndromal stable periods," said Dr. Frank.
She stressed that the current data are preliminary; it remains to be seen whether IPSRT translates into a demonstrable reduction of recurrences or reduces the degree of functional impairment in daily life.