Learning Objectives

After reading this article, you should be able to.. .

1. Understand the importance of Interpersonal and Social Rhythm Therapy (IPSRT) as an adjunctive treatment for bipolar disorder.
2.    Identify the four phases of IPSRT and their respective goals.
3.    Apply IPSRT principles in developing personalized relapse prevention plans for patients with bipolar disorder.

While medications play a primary role in the treatment of bipolar disorder, psychotherapy is critical for recovery as well. One of the more effective approaches is Interpersonal and Social Rhythm Therapy (IPSRT). This technique seeks to empower your patients with bipolar disorder to take control of their lives by helping them establish stable routines and build stronger interpersonal relationships. IPSRT is based on the theory that variability in daily activity disrupts circadian rhythm, predisposing patients to relapse. Using IPSRT, you will work with your client to buffer the effect of disruptive life events by using behavioral techniques to stabilize daily routine.

Numerous studies have shown that IPSRT, in combination with medication, leads to significant improvements in patients' mood stability, functioning, and overall quality of life (Swartz HA, et al., Am J Psychiatry, 2012;169(3):223-231). Furthermore, research indicates that IPSRT can help reduce the risk of relapse and hospitalization, making it a valuable adjunct to pharmacological treatments (Miklowitz DJ, et al., JAMA Psychiatry, 2014;71(9):957-965). In this article, we'll delve deeper into the mechanics of IPSRT and its four phases, equipping you with practical tools and strategies to help your patients with bipolar disorder.

The four phases of IPSRT

1.    The Foundation Phase (3-5 sessions):

In this initial phase, you will lay the groundwork for treatment. Take a detailed history to establish a correct diagnosis, and identify factors contributing to mood episodes (Swartz HA, Psychiatric Annals, 2014;44(11):535-540). For instance, a detailed history may reveal that your patient’s first manic symptoms occurred in college after three days of minimal sleep while preparing for midterm exams. Or perhaps the end of a relationship led to a change in eating habits and daily activity patterns, subsequently followed by a depressive episode.

During the foundation phase, guide your patient through completing an interpersonal inventory, gathering information about important current and past relationships. Work with your patient to identify a problematic area of interpersonal functioning, such as unresolved grief, role transition, role disputes, or pervasive interpersonal deficits. The goal is to recognize connections between interpersonal stressors and mood symptoms, fostering a greater understanding of how these issues contribute to bipolar disorder (Frank E, JAMA Psychiatry 2016;73(6):574-581).

Finally, your client will complete a Social Rhythm Metric (SRM), recording details about daily routine, including time awake, start of work or school, mealtimes, and time to bed. The SRM was developed by researcher Timothy J. Monk, PhD, and others (Monk TH et al, J Nerv Mental Dis 1990;178(2):120–126). You can find an updated sample SRM here. The SRM helps identify patterns in the patient's life that may contribute to mood instability and provides a foundation for the development of strategies to establish a more stable daily routine.

2.    Building Stability (10-12 weekly sessions):

In the second phase of IPSRT, shift your focus to using the SRM to establish a regular daily routine and work towards resolving the identified interpersonal problem. Help your patient find solutions to address these issues and lessen variations in their schedules (Frank E, JAMA Psychiatry 2016;73(6):574-581). This phase encourages patients to develop healthy habits and routines that promote stability in their lives.

During this phase, provide guidance on sleep hygiene, nutrition, exercise, and other aspects of daily routine that can impact mood and overall well-being. Encourage your patient to make incremental changes in their daily routines, providing support and feedback throughout the process.

For instance, you and your patient may identify that the amount of sleep she gets varies widely since starting a job as an ultrasound technician that requires her to answer calls and go into the emergency room in the middle of the night (ie, a role transition). Her SRM reveals that limited sleep for more than one night in a row leads to dysphoria and neurovegetative symptoms. Here, you help the patient to accept that her current job situation is increasing the risk that there will be a recurrence of a full-blown mood episode. You then help the patient find solutions to address this interpersonal problem and lessen the variation in her daily schedule (eg, requesting no overnight obligations from her employer, or finding a position in an office-based setting with regular hours).

3.    Strengthening Confidence (up to 2 years or longer):

The third phase of IPSRT focuses on increasing your patient's confidence in using the skills they've learned to stabilize daily routines and maintain regularity despite the inevitable occurrence of stressors. As your patient becomes more adept at managing their routines and relationships, gradually space out sessions from weekly to biweekly to monthly (Miklowitz DJ, Am J Psychiatry 2014;171(4):400-410).

During this phase, continue to provide support and guidance as your patient works to integrate the skills and strategies learned in the previous phases into their everyday lives. Help your patient develop a personalized relapse prevention plan, identifying early warning signs of mood episodes and outlining steps to take if symptoms re-emerge.

4.    Wrapping Up (3-5 monthly sessions):

Termination is the final phase of IPSRT, where you reinforce learned skills and identify areas for further improvement. Although IPSRT may come to an end, medication treatment often continues, with the termination process encouraging ongoing follow-ups with psychiatric providers (Swartz HA, Psychiatric Annals 2014;44(11):535-540).

In this phase, you and your patient will review the progress made throughout the course of treatment, celebrating successes, and identifying any lingering challenges. Help your patient solidify the skills and strategies they've learned, ensuring they feel confident in their ability to manage their bipolar disorder independently.

During the termination phase, discuss any remaining concerns or issues, addressing potential obstacles to maintaining gains made in therapy, and establish a long-term plan for maintaining stability. This may include connecting your patient with additional resources or support systems, such as support groups or individual therapy as needed.
Encourage your patients to reflect on their personal growth and newfound sense of empowerment. The focus is on reinforcing the idea that, although bipolar disorder may be a lifelong condition, it is manageable with the appropriate skills and support.

CARLAT TAKE:

There is mounting evidence that, when added to pharmacotherapy, psychosocial interventions (eg, IPSRT, cognitive behavior therapy, supportive psychotherapy, and family therapy) benefit patients by improving functioning in between episodes and by reducing the risk of relapse. Patients with bipolar disorder often describe feeling a lack of control over their mood and behavior. IPSRT, as an adjunct to medication, helps empower patients by helping them control aspects of their lives that can have an effect on the course of the bipolar disorder.