Monday, April 4, 2011

Treating Bipolar Disorder Part I -- Interpersonal Social Rhythms Therapy

Medication And Mental Illness

Medication for mental illness is just like medication for anything else.  It works better when you don't ask it to do all the work itself.

In the case of bipolar, once lithium and the chemical imbalance theory came along, the thinking was that medication was the only thing that worked.  Therapy by itself certainly didn't.  I wonder if therapists, worn out by their bipolar patients, were simply relieved to believe that medication was the only thing that worked.  I wonder if therapists today, worn out by their recurrent depression patients, are secretly relieved to terminate when the diagnosis changes to bipolar, because medication is the only thing that works.

Frankly, there is a lot of wishful thinking out there in pharmacotherapy land.  If only our brains were a chemical stew and the illnesses of the brain could be treated by adjusting the recipe.  If only.

But people with mental illness, especially people with bipolar, can't afford the wishful thinking behind the better living through chemistry fantasy.  Sometimes the medications do work.  But not as well nor as often as your doctor would like to think.

I have a friend who is a psychiatrist.  He challenges his colleagues who keep trying to solve this noncompliance issue, to get their patients to comply.  He reminds them, if the medication (antidepressants, in this example) worked for 40% of those who took it in the trial, and the placebo worked for 30%, that means only three out of ten people benefit from the medication itself.  So what's the big deal about seven who quit?

He says they just look at him funny.

Treating Bipolar Disorder by Ellen Frank

This same friend, God bless him, loaned me a book about a psychotherapy designed specifically for bipolar disorder titled, appropriately enough, Treating Bipolar Disorder.  The author Ellen Frank, professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at Western Psychiatric Institute and Clinic, and her colleagues invented Interpersonal Social Rhythms Therapy (IPSRT), a kind of mash-up between talk therapy and regulating circadian rhythms.  It gets my next few posts.

In A Nutshell... 

IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

In other words, the therapy focuses first on getting your daily activities on a regular schedule.  That will support your body's internal schedule and reduce the manias, hypomanias and depressions of bipolar.  Then the therapy turns to the classic issues of talk therapy, particularly those that interfere with a regular schedule, like grief and conflict.  The long term goal is to anticipate and manage whatever would throw your routine off track, so that new episodes are not triggered, or are identified and interrupted quickly.

IPSRT was designed for bipolar I, but can also be used for bipolar II.  For the latter, the therapist is not so concerned to get you to take your meds.  Which is good, because while there are always people for whom an ineffective med is effective, mostly the meds for bipolar II depend on the placebo effect.  Now that the placebo effect has worn off for me, I am delighted to learn the following:

Medication Is Not The Only Thing That Works -- STEP-BD

IPSRT is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

The other psychotherapies studied were family focused therapy and cognitive behavioral therapy.  None showed an advantage over the others.  Each was better than medication alone.

Circadian Rhythms -- Your Interior Clock

IPSRT is unique in its attention to circadian rhythms, the biochemical, physiological and behavioral processes that are driven by the twenty-four hour cycle of the day.  There are lots of these rhythms.  If your schedule is relatively regular, your body prompts you to wake up, feel hungry, have peaks and lows of energy and get sleepy at about the same time of day every day.

These are not simply habits.  Your body signals each of these by releasing hormones like cortisol and neurotransmitters like melatonin on a cycle.  Your body temperature rises and falls on a cycle.  Your digestive juices flow on a cycle.  Your kidneys even empty into your bladder on a cycle.

These cycles are called a circadian rhythms.  They are interrelated and are regulated by an interior clock.

Circadian rhythms are why people get so grumpy by the time change every year, all that springing forward and falling backward, why changing work shifts interferes with sleep, and why travel across time zones causes jet lag.  Our clocks don't like to be messed with.

Some people don't mind the time change.  They fall asleep whenever anybody tells them to go to bed.  The day after a transcontinental flight, they are as perky as ever.  They can reset their interior clocks on demand.  These people do not have bipolar disorder.

The clocks of those who do have bipolar disorder are less flexible.  And those who do not expect their medication to do all the work, who work on recovery, pay attention to their cycles, learn from each other -- these people know this.  We respect our circadian rhythms, because when you mess with our clocks, they mess with us.

Insomnia And Mood Disturbance: Chicken And Egg

When I told my former pschiatrist that the antidepressant-induced insomnia was making my depression worse, she countered that insomnia is a symptom of depression, and would go away as the antidepressant took effect.  That was the end of the discussion.  But there has been considerable research on circadian disregulation and mood disorders, some of it supporting my side of this chicken and egg argument.

Prozac Monologues has made recent forays into the possibility of treating depression by treating sleep disorders directly, sleep cycles being a foundational circadian rhythm.  Treating Bipolar Disorder reviews the basic research behind the miscellaneous studies I mentioned, endearing the book to my heart.  It made me feel very smart.

But seriously, when you are the lab rat in the chemistry experiment, trying to find the medication that works, it is first frustrating and eventually flat out scary when the doctor rejects the reported results of the experiment because it conflicts with her theory.

So how extraordinary to find a treatment that was developed when a doctor listened!

The IPSRT Story

Treating Bipolar Disorder begins with a story, how Dr. Frank invented IPSRT in one flash at the end of a fly in/fly out day at a convention for the National Depressive and Manic-Depressive Association (now called the Depression and Bipolar Support Alliance, DBSA).  It was for her an unusual exposure to people who actually live with bipolar.  Contrary to her understanding that bipolar disorder was a problem solved, she heard the real stories of people living with stigma, underemployment and doctors who discouraged them from participating in activities that meant something to them.  She discovered the planners of the convention had anticipated that people would have problems from overstimulation, and had prepared for it with an emergency hospitalization protocol.  She found people hungry for more attention to and information about the psychosocial dimensions of the illness.

As the door to the limousine closed... I knew with absolute certainty that I needed to dedicate the next decade of my life to doing better by these patients and their family members.  No sooner were the words formed in my head than I knew exactly what to do: Combine IPT [interpersonal therapy] with a social rhythm regulation treatment.

As Dr. Frank describes it, My colleagues and I had argued in papers... that the major mood disorders (major depression and bipolar disorder) reflected, among other things, a disruption in circadian rhythms, a disturbance in the body's clock.

Zeitgebers/Timekeepers

Think about how many of the symptoms of these two disorders are functions that have a regular 24-hour rhythm: sleep (and waking), hunger, energy, ability to concentrate, even mood itself.  Furthermore, we said that external social factors, like the time we need to be at work, the time the family normally has dinner, the time a favorite TV show ends, help to set the body's clock.  When social factors function in this way, they become social zeitgebers.

Zeitstorers/Time Disturbers

We had also argued that changes or interferences in social routines, which we termed zeitstorers (or time disturbers), could disrupt the body's clock and destroy the body's naturally synchronized rhythms.  We concluded that, in those who were vulnerable to mood disorders, it was the loss of social zeitgebers or the appearance of zeitstorers that led to new illness episodes (depression or mania).

IPSRT Is Born

During that flash in the limo, I knew that it would be relatively easy to borrow some of the scheduling and monitoring techniques of cognitive therapy and refashion them for the purpose of helping patients to establish and maintain regular social rhythms.  I also realized that such efforts would fit very naturally with at least three of the four interpersonal problem areas that form the foundation of the interpersonal work in IPT for unipolar depression...

Next week: what happens in IPSRT.

photo of weightlifter in public domain from the Bundesarchiv
flair from facebook
book cover from Amazon.com
photo of clockworks by HNH and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license

2 comments:

  1. I always find it interesting to read your blog and see my own thoughts and conclusions in print. I wasn't content with the "medication works" approach to my Bipolar because quite frankly it didn't work for me. In fact it was making me worse, much worse. So I began my own determined research (coupled with decades of experience) to determine the underlying cause of my Bipolar mood fluctuations. And lo and behold, I stumbled upon information about circadian rhythms and knew this was an important piece of the Bipolar puzzle that I could use to manage my mood fluctuations.
    It works spectacularly well for me. When I stick to regular routines I do well. When I don't the mood symptoms creep back in.
    Thanks for another interesting and insightful blog post.

    ReplyDelete
  2. Thanks, catlady. It encourages me to be in touch with people who take responsibility to study, learn, experiment and work on our own recovery. And I am glad to read your testimony that this approach can work over the long haul

    I do feel ambivalence about the medication issue. So let me make a few clarifying comments.

    First, I am not a doctor, I am not a doctor, I am not a doctor. I am part of a community of people with mental illness who are learning from each other. Each of us is responsible for our own decisions. I am not giving anybody permission to be irresponsible, because...

    Second, medication does indeed work for a lot of people. A lot of people go absolutely bonkers when they stop taking their meds. They may need to talk with their doctors about adjusting their meds. But a lot of people should keep taking them.

    Third, medication is one tool in the tool box. We have a big job to do, to build a life that works with mental illness. We need to use every tool that we can. I use "rescue" meds on an as needed basis, and would take something every day if I was fortunate to get a benefit from it. I am delighted to learn about circadian rhythms, and how I can use them to enhance my recovery. One more tool in the box.

    Fourth, I will discuss Frank's approach to medication in a future post. For the time being, she hopes that her clients are taking meds. The NIMH research I cited was conducted with people all of whom were on meds.

    Thank you for your comment. As these conversations continue, I believe that our treatments will improve, and we all will be the healthier for it.

    ReplyDelete