KELLIE NEWSOME: If all your patients with bipolar disorder are cured on mood stabilizers, you can skip this podcast. But if not, you’re going to learn some behavioral steps that will move them closer to recovery.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.
CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.
KELLIE NEWSOME: I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
Today we reach the end of the practice-changing updates from the International Bipolar Conference. Here’s a recap of the past episodes:
1. Screen for bipolar disorder with a tool that looks at signs and symptoms of the illness, like the Rapid Mood Screener or the Bipolarity Index.
2. Use more lithium.
3. Move lurasidone up in your treatment algorithms now that it’s generic, and keep Robert Post’s three L’s on the tip of your tongue for bipolar depression: Lithium, lamotrigine, and lurasidone.
4. Avoid valproate in women of childbearing age.
5. When things go wrong in treatment – even if it’s because your patient stops taking their meds – assume it is your fault. You haven’t found the meds they want to take.
6. Rate the symptoms at every visit, and find a way to visually track them to find those cyclical patterns that are the heart of bipolar illness.
7. Make it your goal to improve functioning, not just symptom reduction.
8. Use light therapy for bipolar depression.
9. Use dark therapy for active mania, mixed states, insomnia, and to prevent future episodes.
And for today #10: Social Rhythm Therapy
CHRIS AIKEN: “Chance favors the prepared mind,” wrote Louis Pasteur, originator of the germ theory. For Dr. Ellen Frank, that chance struck on her 46 th birthday, July 14, 1990, in a restroom at a conference for patients with bipolar disorder.
Dr. Frank knew little about bipolar disorder when she went to the conference. She had spent the previous decade researching the effects of social stressors on depression as part of a team that developed Interpersonal Psychotherapy (IPT), the first psychotherapy to prove itself as a worthy alternative to cognitive behavioral therapy. IPT posits that depression is caused by major changes in our social relationships – those changes may be good – like going to college – or bad – like losing a job. Either way, they are changes that disrupt our connections to other people, things like a major conflict with a close friend, grief, moving to a new city. IPT therapists use practical, intuitive techniques to help patients problem-solve these transitions, ultimately changing the things they can and adjusting to the ones they can’t.
KELLIE NEWSOME: Dr. Frank was invited to speak on this groundbreaking approach to depression. Just before her talk, she stepped into the restroom, where she overheard the conference organizers talking about the emergency safety system for attendees. The system was working well – already 3 attendees had been hospitalized for breakthrough episodes. Many more felt close to the edge. Even though they looked forward to this conference all year, they felt overstimulated by the intense discussions, thrown off balance by the jet lag. That’s when it came to her. Maybe bipolar was caused by changes in social relationships but of a different sort. In depression, it was all about our connections and our role in relationships – changing roles like fatherhood, retirement, or losing a friend. In bipolar, it was about the timing. She flew back to the University of Pittsburgh and spent the next decade developing a psychotherapy that would fuse the circadian biology of bipolar disorder with the social understanding of depression. Fifteen years later, the first controlled trial of this IPSRT therapy came out in JAMA Psych, a large trial that tested it against a pretty effective comparator –intensive clinical management. IPSRT therapy didn’t work at first. It didn’t treat the acute episodes of mania and depression that patients entered the study in. But over time it kept people out of mood episodes better than intensive clinical management alone.
CHRIS AIKEN: Those of you who’ve been keeping up with bipolar research may recognize this story – we saw the same thing with lamotrigine (Lamictal). That mood stabilizer did not work in the short term, but the manufacturer made a bold gamble – launching 2 large studies that would test it out over 2 years. Much like the IPSRT study, and like IPSRT social rhythm therapy, lamotrigine delayed the time to relapse in those large studies of bipolar disorder. Here’s what else IPSRT (interpersonal social rhythm therapy) can do, based on randomized controlled trials large and small:
1. It hastens the speed of recovery in bipolar depression.
2. It improves functioning in work and relationships.
3. It reduces inflammation in bipolar II depression.
That last one deserves some explanation. It comes from a remarkable study that was done by Holly Swartz and colleagues at the University of Pittsburgh a few years ago. They tested IPSRT in 92 patients with bipolar II depression. Half got IPSRT with quetiapine, so medication and therapy, and the other half got IPSRT, the therapy, alone. After 5 weeks, both groups had similar outcomes, suggesting that IPSRT alone might work as well as quetiapine – I say suggesting because there was no placebo group here – so it could be that everyone would have gotten better with time no matter what their treatment. But not everything was exactly the same for these groups. When the researchers looked closer they found some differences that are very relevant to practice, if limited by their secondary, “data fishing” nature.
1. No surprise, the quetiapine group had more side effects – and a lot more.
2. Also not a surprise, the quetiapine group improved faster – therapy takes time, but again after 5 weeks they all improved the same.
3. Inflammatory markers went up in the quetiapine group, but they went down in the social rhythm therapy group. Remember, both groups got this psychotherapy, so this means either quetiapine is pro-inflammatory, or social rhythm therapy alone is anti-inflammatory, or both.
4. Patients who got their preferred treatment, that is if they preferred medication and got medication or preferred to do psychotherapy alone and got that, were 4.5 times more likely to respond.
So, in the end, the best way to choose a treatment is to present the patient with a menu of reasonable options and let them choose.
KELLIE NEWSOME: Let’s get into how you do IPSRT. The therapy consists of two parts. First, the interpersonal part helps patients adjust to the new understanding of themselves that a bipolar diagnosis brings. This isn’t about forcing them to conform to the medical worldview. The IPSRT therapist follows the patient’s cues, using their language and incorporating their own understanding into this work. Just like Dr. Frank did in IPT for depression, the therapist focuses on how this diagnosis affects their relationships. Will they be open about it at work, with friends, with lovers? How do they explain it? How do people view them differently? The second part is the social rhythm regulation, and it’s much more behavioral. Some programs carve this part out as “Social Rhythm Therapy” or SRT, and research is underway on new approaches that attach SRT to therapies for other psychiatric disorders that have impaired circadian rhythms – like PTSD, borderline personality disorder, schizophrenia spectrum disorders, addictions, and major depression.
CHRIS AIKEN: In Social Rhythm Therapy, the therapist helps patients find key activities that give them a sense of time – rituals that set the biological clock. Dr. Frank calls these zeitgebers, it's a German word that means "Time Giver". The goal is to guide the patient to do these zeitgebers at the same time each day – give or take half an hour. As they do this, they track their mood and the time they did these zeitgebers every day. The therapist uses this “social rhythm chart” to look for patterns, like if their mood improved, you look back to the week before. Were they doing any activities at a more regular time? And if their mood got worse, was there a major change in the timing in the prior week, as it would have been for all the frazzled attendees at the conference where Dr. Frank got this idea.
KELLIE NEWSOME: Dr. Aiken describes the therapy in more detail in his Depression and Bipolar Workbook, and he’s made the client handout for IPSRT free online – go to moodtreatmentcenter.com/ipsrt. It includes a social rhythm chart as well as practical tips for managing major circadian disruptors like jet lag, fights with your bed partner, and holidays. The goal of IPSRT is to help the patient find their own zeitgebers. When they become aware of them through their own experience, they are more likely to value them and stick with the routines. But, the goal is not rigid adherence. They shouldn’t have to fight for their right to party – everybody needs to stay out late with a good friend now and then. Respecting the patient’s freedom of choice is part of the treatment. But if you’re doing IPSRT on the quick, you can make a difference by suggesting some common zeitgebers; the most important is exposure to light in the morning and darkness at night. Rewind to our September podcasts on light and dark therapy for tips on this one, and here’s another: The Dawn Simulator.
CHRIS AIKEN: Dawn Simulators create a virtual sunrise in the bedroom, gradually lifting people from deep sleep to full awakening. They help healthy people feel more alert during the day. In one study, they found that medical students spontaneously reduce their caffeine use when they were randomized to a dawn simulator. And in a handful of clinical trials, dawn simulators treated winter depression (seasonal depression). We often recommend these devices for patients with bipolar depression or those who just have trouble waking up. They are a lot easier to use than a lightbox because they work while the patient is asleep. You can learn more about which devices to use and more tips on how to use them at moodtreatmentcenter.com/dawnsimulator, and there is no 'T' in the beginning of 'simulator' it's S-I-M-U-L-A-T-O-R.
Two of the top zeitgebers that I focus on in IPSRT are getting light in the morning, whether it's through the sun or through a dawn simulator, and getting out of bed at regular times. That's much more important to focus on than the time that you fall asleep because it's more in the patient's control. Dr. Frank found something similar in her own research. She looked for the daily events or zeitgebers that were most associated with mood stability, and surprisingly, the time that people fall asleep was not one of them. Instead, it was the time that patients got out of bed that mattered most. And when they measured that time, it's the time they actually get out of bed and stand up. If you work with people with mood disorders, you will find this is otherwise hard to measure because they are often getting in and out of bed in the morning. After that one, the most critical zeitgebers in that study were:
1. The time that they start goal-directed activity, like work, chores, or school.
2. The time that they first had meaningful interactions with other people, like talking with their spouse over breakfast, driving their kids to school, or a team meeting at work.
3. The time they eat dinner.
Those zeitgebers were most critical on average and it's a good list to start with, though as you work with people, you're going to want to find many more that make a difference for particular patients, like the time they exercise, walk the dog, meditate or pray. You want for them to do those activities at the same time each day, give or take 15 minutes-if you are a circadian purist-but patients will still get good results with a looser approach, say give or take 30 minutes, its a spectrum the closer they are too regular times the better.
KELLIE NEWSOME: That’s how we did things when I lived in Hawaii. We called it island time.
CHRIS AIKEN: Yes, the brain ruins on Island time here.
KELLIE NEWSOME: Let’s track back to that second one – the time they first have meaningful interaction with other people. We are social creatures, and part of the theory behind IPSRT is that people play a very important role in setting our biological clocks. That clock is run by hormones – like melatonin that rises in the evening (if it’s dark) and cortisol that peaks and then falls in the morning (unless you’re depressed or stressed out then cortisone is off track and runs high all day long). Well, being around people changes our hormones to – whether it’s the flush of love on a first date, the pump of adrenaline in a fight, or the soothing oxytocin from those you’re closest to. Dr. Frank hypothesized that these biological effects alter the biological clock, and you’ll find a grain of truth in your patient's experience of the holidays. During the holidays social interactions are much more intense, and their timing is off from the usual. The result, sleep gets off kilter and mood gets unstable. Many patients with bipolar disorder dislike the holidays. They don’t get along with their family, or they are too depressed to keep up with the activity, but the disruption to their schedule may be just as relevant.
CHRIS AIKEN: In Social Rhythm Therapy, patients don't just log what time of day they do these activities, but how involved other people were while they were doing them – were they alone? Were they with others but not very involved, like buying a coffee from a barista? Or were others actively involved – like talking with family over breakfast – or were they so involved as to be over-stimulating – like a fight or a lively party? The idea is to regulate not just the timing of the activities, but also the intensity of other people's involvement. Whether or not social relationships are necessary to set the biological clock is debatable, but what’s not debatable is that weaving relationships into the social rhythm work has a side effect that is good for depression; it builds support and helps people get connected.
KELLIE NEWSOME: Social rhythm therapy is very behavioral, which makes it apt as an-add on to a 30-minute medication visit, along with other lifestyle techniques that were touted at the conference: Healthy diet and exercise. Neither has strong evidence yet in bipolar disorder, but they do in regular depression, and one particular type of diet is actively being investigated: The Ketogenic Diet.
CHRIS AIKEN: Most lifestyle approaches suffer from a serious lack of funding, but not The Ketogenic Diet. The Baszucki, who made several billion on popular video game Roblox, has funded major trials of the ketogenic approach for bipolar disorder after their son experienced a medication-free recovery from what was a treatment-resistant Bipolar I condition with the ketogenic diet. So far it is backed by a few case reports and a lot of theory – we don't know exactly how it might work or even if it does work, but it is hypothesized to treat bipolar disorder through neuroprotection, possibly mitochondrial stabilization, or improving insulin resistance, or it may reduce oxidative stress or even modulate neurochemicals like GABA and Glutamate. I am open to anything that has good evidence to help bipolar disorder, but I bring up the ketogenic diet not to endorse it, as the studies are pending, but just to make you aware of it, as the idea has taken hold through social media and publicity from groups like Metabolic Mind. And one thing to know about this low-carb diet is that it is not without risks. It is difficult for patients to stay on it, it can cause kidney stones, it might cause nutritional or mineral deficiencies, and it has been associated with an increased risk of cardiovascular disease.
KELLIE NEWSOME: We’ll end with one more intervention for bipolar disorder that means a lot to patients: Stigma. Andrea Vassilev pulled together research on self-stigma to develop a practical group therapy, Overcoming Self-Stigma in Bipolar Disorder. The 8-session program is designed to be led by experts with lived experience – in other words, patients – and the guidebook is available free – email email@example.com
KELLIE NEWSOME: Earn CME for this episode from the link in the show notes, and get $30 off your first year’s subscription to the full journal with the promo code PODCAST. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay this way, free of commercial support.
CHRIS AIKEN: And a special thanks to the clinicians at Hackensack Meridian Jersey Shore University Medical Center, who previewed an early version of this podcast last month as a grand round at their psychiatry training program.