Group Interpersonal and Social Rhythm Therapy for Bipolar Depression

Bipolar depression presents treatment challenges. Even with pharmacological stabilization of bipolar symptoms, up to 60% of individuals experience recurrence of bipolar depression within two years (Miklowitz, 2008). Adverse effects of lithium, anticonvulsants, and antipsychotics contribute to illness burden, comorbidity, and treatment non adherence (Malhi, Adams & Berk, 2009). Treatment of bipolar depression with antidepressants has not been substantiated by randomized controlled trials despite historical use of antidepressants in management of bipolar depression (Frye, 2011). These pharmacological challenges underscore consideration of effective psychological interventions in clinical treatment for bipolar depression. The effectiveness of interpersonal and social rhythm therapy (IPSRT) in lengthening the time between episodes of bipolar symptoms has been demonstrated by a two year randomized controlled trial (Frank et al., 2005). IPSRT addresses medication adherence, interpersonal stressors, and establishment of daily routines (Frank, 2005). It is postulated that changes in daily routines burden the biochemical systems which regulate sleep, energy, and mood, thereby increasing the risk for bipolar episodes in vulnerable individuals. Interpersonal stressors, such as grief, role transitions, and relationship conflicts have potential to disrupt circadian and social rhythms and adversely impact mood. By establishing daily routines for sleep, wake, meals, and purposeful activity and addressing interpersonal problems, IPSRT intervenes to “stabilize patients’ social rhythms… improve current mood and functioning and to teach patients skills that will enable them to protect themselves against the development of new affective episodes” (Frank, 2007, p. 465). IPSRT was specifically developed to address the circadian rhythm vulnerabilities associated with bipolar disorders (Frank, 2005). Salvatore et al. (2008) found that during acute episodes of mania or mixed illness states, patients with bipolar disorder had more daytime napping, lower total daytime activity, and a two hour phase advance when compared with healthy controls. When in remission, patients demonstrated more nighttime sleep, less daytime sleep and more total sleep compared to their acute episodes of mania or mixed illness states. Patients in remission, however, continued to differ from healthy controls in overall higher total sleep time, less daytime activity, and an approximate two hour phase advance of circadian motor activity, indicating that abnormalities of circadian rhythms persisted in patients with bipolar disorder, even while well. In a prospective study utilizing the Social Rhythm Metric tool, Shen, Alloy, Abramson, and Sylvia (2008), found that less social rhythm regularity predicted a shorter time to onset of major depressive, hypomanic, and manic episodes in individuals with bipolar spectrum disorders, even after controlling for family history of bipolar disorder and initial symptoms. Shen et al. (2008) reinforces findings of Frank et al. (2005) that when patients received IPSRT, the length of their wellness increased. The literature supports the effectiveness of individual IPSRT, but little has been published regarding group IPSRT. Limited literature exists for educational, multifamily, and cognitive-behavioral groups for bipolar disorder. Although not psychotherapy, positive outcomes have been reported for educational groups (Colom et al., 2003; Colom et al., 2009). A five year follow up of 120 individuals with bipolar disorder who were randomized to group education (education on illness, treatment adherence, prodromal symptoms, recurrence, and lifestyle regularity) or non-structured support group found that the patients in the educational group had longer time to illness recurrence, fewer recurrences, and had a lower median number of hospitalized days (Colom et al., 2009). Multifamily psychotherapy group for individuals with bipolar I disorder resulted in fewer hospitalizations compared to individuals receiving individual family therapy or medication management alone. Solomon, Keitner, Ryan, Kelley, and Miller (2008) randomized 53 patients to multifamily group (six sessions with multiple patients and their family members), individual family therapy (6–12 sessions with one patient and the patient’s family, with number of sessions determined by family needs), or medication management without psychotherapy (weekly sessions for the first month with decreasing frequency as symptoms improved). Patients were assessed monthly over 28 months. Fewer hospitalizations occurred for patients in the multifamily group (5%) compared to patients receiving individual family therapy (31%) or medication alone (38%). Two randomized controlled studies compared cognitive behavioral group therapy and medication to medication treatment alone in individuals with bipolar I or II disorder. Gonzalez-Isasi et al. (2010) randomized twenty patients to 13 weekly sessions of cognitive behavioral group therapy (n=10) or medication alone (n=10). The cognitive behavioral group therapy topics included illness education, identification of early warning signs, social skills training, conflict resolution, cognitive restructuring, self-esteem building, and activity planning. Improvement for the cognitive behavioral therapy group, measured by the Global Assessment of Functioning, was significant 12 months after treatment, but not immediately after treatment or six months after treatment. Da Costa et al. (2011) randomized 41 individuals to 14 weekly sessions of cognitive behavioral group therapy (n = 27) or medication alone (n = 14). The cognitive therapy included education on bipolar disorder and cognitive behavioral skills based on the treatment manual “Cognitive-Behavioral Therapy for Bipolar Disorder” (Basco & Rush, 2005). A significant decrease in symptoms of mania, depression, and anxiety were reported immediately after treatment in the cognitive behavioral group therapy. No long term data were reported. A randomized trial comparing a group program for bipolar disorder to treatment as usual reported improved outcomes for the group program. Castle et al. (2010) randomized 84 individuals with bipolar disorder type I, II, or not otherwise specified to a 12-week program with three booster sessions (n = 42) or to a control group (n = 42). Participants were followed for nine months after treatment. The control group consisted of treatment as usual and 12 weekly telephone calls. The program topics included bipolar disorder education, stress monitoring, relapse prevention, goal setting, medication management, and skill establishment. Participants in the 12-week program had significantly lower rates of relapse and spent less time ill during the 9-month follow-up period. The literature supports education and psychotherapy in the comprehensive treatment of bipolar disorder. Although not specific to groups, a meta-analysis of randomized trials of adjunctive therapy for bipolar disorder (included individual and group education, systematic care, cognitive-behavioral therapy, family-focused therapy, and IPSRT), concluded that psychosocial treatments are cost-effective when symptom recurrence, daily functioning, and hospitalization are considered (Miklowitz, & Scott 2009). Positive outcomes for IPSRT group modalities have been reported at the medical center where IPSRT was developed. Swartz et al. (2009) reported a significant decline in depressive scores (p < 0.001) for outpatient IPSRT groups (12–16 sessions) and increased utilization of the gym for patients in the daily inpatient IPSRT group (average hospital stay of 11 days). The Bipolar Intensive Outpatient group program (three times weekly with three hour group sessions and variable lengths of participation) demonstrated improved scores on the Quick Inventory of Depressive Symptomatology-Self-Rated at 60 days (Swartz et al., 2011). Positive outcomes of IPSRT and group interventions led to the design of an outpatient IPSRT group (IPSRT-G) for bipolar depression for this study. This feasibility study was conducted to evaluate effectiveness of the 2-week IPSRT-G format as an adjunct to medication for individuals with bipolar depression and to determine satisfaction with the IPSRT-G treatment. This format was chosen secondary to the identified need for an intensive, time-limited outpatient program for individuals with bipolar depression who might benefit from IPSRT, but might not be able to participate in weekly psychotherapy. Tertiary care patients discharged from inpatient psychiatric units or referred by the outpatient mood consultation clinic could receive IPSRT treatment. A 2-week IPSRT-G provides access to treatment for individuals who might not have IPSRT treatment readily available in their home areas.