IPSRT provides a biopsychosocial model for bipolar disorder and recognizes that the illness cannot be fully treated

with medication alone, although it is

biologically based. It postulates that stressful events, disruptions in circadian rhythms and personal relationships, and conflicts arising out of difficulty
in social adjustment often lead to relapses.
The idea was developed by Ellen Frank,

GOAL
How does it help bpad patients:

Interpersonal and social rhythm therapy (IPSRT) was designed to directly address the major pathways to recurrence in
bipolar disorder, namely medication nonadherence, stressful life events, and disruptions in social rhythms.

i)Instability Is Fundamental to Bipolar Disorder

ii)We believe that many apparently benign (from a traditional psychological standpoint) life events that are associated
with changes in daily routines place considerable stress on the bodys attempt to maintain the synchronized sleep
wake, appetite, energy, and alertness rhythms that are the hallmark of the euthymic state.

iii)In modern society where light is freely available 24 hr a day, social factors such as the timing of work, the timing of
meals, and even the timing of specific television programs can have an important influence on circadian rhythms. We
assert that changes in such social time cues lead to brief disruptions in circadian rhythms for all of us

Social zeitgebers are personal relationships, social demands or tasks, or routinized activities that are theorized to impact the timing of biological
rhythms . Examples of social zeitgebers include awakening in the morning, eating meals, exercising, and other activities within typical daily
routines.
social zeitgebers can best be conceptualized as behaviors that modify the expression of biological rhythms by altering exposure to light. They may
also directly affect the expression of various circadian rhythms.

Researchers also found that life events associated with disruptions in social rhythms (e.g., overseas travel, being fired from a full-time job, marital
separation) were better predictors of manic episodes than severe life events in general in a sample of patients with bipolar disorder( such
significant social events effect the mood directly as well in addition to disrupting the schedule which further increases chances of relapse.
major life stressors, such as losing ones job or getting divorced, not only have the capacity to affect mood directly but
also lead to marked changes in social rhythms.)
(Malkoff-Schwartz S, Frank E, Anderson B, Sherrill JT, Siegel L, Patterson D, Kupfer DJ Arch Gen Psychiatry. 1998 Aug; 55(8):702-7.)

iv) individuals who are vulnerable to mood disorders have a more difficult time adapting to such changes and, in a
sense, get stuck in the somatic and cognitive state associated with disrupted circadian rhythms and then go on to
experience that state as fully syndromal episodes of depression or mania

v)The specific goals of IPSRT are to stabilize patients social rhythms or routines while improving the quality of their
interpersonal relationships and satisfaction with social roles

Interpersonal and Social Rhythm Therapy:

A Means of Improving Depression and
Preventing Relapse in Bipolar Disorder
_
Ellen Frank
University of Pittsburgh School of Medicine

IPSRT is a four-phase treatment. Whether the patient is first seen in an acute episode
or in remission, the initial phase of treatment begins with a focused history-taking that
emphasizes the extent to which disruptions in social routines and interpersonal problems
have been associated with affective episodes, and is intended to develop the rationale for
the treatment. In this initial phase, the therapist also provides the patient (and his or her
family, when indicated) with education about his or her mood disorder, taking into consideration
what the patient already has or has not learned about bipolar illness. The therapist
then assesses the quality of the patients interpersonal relationships through a process
known as the Interpersonal Inventory and assesses the regularity of the patients social
routines by asking him or her to complete an instrument called the Social Rhythm Metric

Finally, the therapist and patient collaboratively select an interpersonal focus, from
among the four IPT problem areas (i.e., grief, role transitions, role disputes, interpersonal
deficits), that will become the initial focus of therapy. This initial phase typically lasts
three to five sessions, depending on the length and complexity of the patients affective
history and interpersonal relationships as well as the amount of psychoeducation required.
Having concluded the initial phase of treatment, the therapist moves on to the intermediate
phase of therapy. Here, the focus is on regularizing the patients social rhythms
and intervening in the selected interpersonal problem area. Typically, IPSRT is conducted
weekly in the initial and intermediate phases, but other schedules may be appropriate if
the patient is either very symptomatic, in which case more frequent visits may be needed,
or fully remitted and in treatment primarily to improve current functioning and prevent
future episodes.
The continuation, or maintenance, phase of IPSRT is one in which the therapist
works to establish patients confidence in their ability to use the techniques learned earlier
in the treatment. These include maintaining regular social rhythms, even in the face
of challenges such as vacations, job changes, and unexpected life disruptions, and maintaining
or further improving their interpersonal relationships.
As the treatment moves from the intermediate to the continuation or maintenance
phase, the frequency of visits is typically reduced from weekly to bimonthly, and eventually
to monthly.
The final phase of IPSRT involves work toward termination of therapy or further
reduction in the frequency of visits.

IPSRT as a Modular Treatment

In some respects, IPSRT can be thought of as a series of modulesan education module,

a social rhythm regularization module, and several interpersonal problem modulesthat
can be employed and re-employed throughout a course of treatment

Sometimes, the interpersonal problem area most closely linked to the onset of the
patients episode (e.g., a marital role dispute) is too threatening as an initial focus of
treatment. The therapist who insists upon focusing on such a problem runs the risk of
early termination. In that case, it is best to begin therapy with an alternate focus that is
acceptable to the patient.

After taking a clinical history, Louisas IPSRT therapist could see that a number of
things would need to change for Louisa to recover from this depression. First, she would
need to reduce her time in bed. Second, she would need to set a regular sleep/wake
schedule that she could stick to even on the weekends. Third, she would need to become
more active outside of work. Finally, she would need to either find a way to meet most of
her roommates expectations or find another place to live.

Course of Treatment
Session 1: psychoeducating about the disorder & its symptoms-explaining the current difficulties faced by the person & caregiver
Setting up some goals in collaboration

Starting slow-eg waking up 15min early as opposed to 1 hr early and trying that for 3 days

Setting up bargains-

During that next session, Louisas therapist described what depression and depressive
symptoms were. She asked Stacey how Louisas depression was affecting her, and then
explained that many of the things Louisa was doing that were so annoying to Stacey were
a direct result of depression, not a function of being lazy or of wanting to be a miserable
roommate. The therapist also explained how important it was that Louisa limit the amount
of time she was spending in bed as a first step to getting over her depression. She then
asked the two young women for suggestions on how they might work on this problem
together. Louisa admitted that to get dressed properly, clean up after herself, and grab
something to eat before she left for work, she needed to be up at 6:30 a.m., an hour earlier
than she was typically getting up these days. Louisas therapist suggested that she begin
by trying to get out of bed just 15 min earlier each day for 3 days, and if that went all
right, she should then try to be out of bed at 7:00. She then struck a bargain with Stacey:
As long as Louisa was meeting her wake-up time goals, would Stacey be willing to bite
her tongue about the bathroom and kitchen for just 2 weeks? The therapists bargain with
Louisa was that if she absolutely had to nap when she got home from work, she would set
her alarm and not sleep more than 45 min. She suggested that the girls establish a routine
of having dinner together, sitting down with their kitchen table set with silverware and
napkins, at a specific time agreed upon each night . . . even if it was only to eat yet
another bowl of soup. Finally, she suggested that Louisa find another, less stimulating
way of getting back to sleep if she woke up in the middle of the night . . . and one that
would be less disturbing to Stacey.

IPSRT fuses three distinct strategies,

interpersonal psychotherapy,

psychoeducation,

and social rhythm therapy, to accomplish these goals. The therapist moves seamlessly among the strategies, according to the particular

needs of the patient at the time

Social Rhythm Metric

The backbone of Social Rhythm Therapy is the Social Rhythm Metric (SRM). The SRM is a pencil and paper assessment that patients

complete each week to record the time at which they complete each of 5 daily activities: out of bed, first contact with another person, start

regular daily activity (school, work, etc.), dinner, and in bed. An app version of the SRM is in development.

Key IPSRT Concepts:

Social Rhythm Therapy (SRT)

Interpersonal Psychotherapy (IPT)

Social Rhythm Therapy :

Underscore link between regular routines & moods

Foster regular daily routines
Use Social Rhythm Metric to monitor routines
Interpersonal Psychotherapy
Emphasizes link between mood and life events
Focuses on interpersonal problem areas
grief2, disputes, role transitions

Social Rhythm Therapy

Theoretical Rationale
Social Zeitgeber Theory of Mood Episodes
Life Events -->
Change in Social Prompts -->
Change in Stability of Social Rhythms -->
Change in Stability of Biological Rhythms -->
Change in Somatic Symptoms

Change in Social Prompts:

The loss of beloved spouse

The loss of not-so-beloved dog
Change in office, no change in job
Change in office AND promotion

IPSRT: Initial Sessions

Assessment and history
Education about bipolar disorder
Rationale for IPSRT
Interpersonal Inventory
Identify interpersonal problem area and formulation
Initiate Social Rhythm Metric

IPSRT: Intermediate Phase

Stabilizing social rhythms
Intervening in the interpersonal problem areas

Sleep and IPSRT

Bedtime routine
 What to do if you have to get up in the night

IPSRT Theory of Psychopathology:

Grief for the lost healthy self

Grief/Bereavement
Role transitions
Disputes
Deficits, Sensitivities, Fearful Attachment*

Grief for the lost Healthy Self

Goals
Mourn
Foster mourning for what the patient might have been/accomplished without bipolar disorder
Compensation
Some original life goals are still attainable
Accept life-long nature of illness and adapt to
management.

Role Transition
Goals
Mourn
Foster mourning loss of role
(recognize, describe, communicate)
Encourage acceptance of change that has altered
interactions, roles, and sources of well-being

Disputes
Goals
Increase awareness of nonreciprocal expectations
Identify stage of dispute: renegotiation, impasse, or irreconcilable differences
Clarify relationship needs: currencies
Negotiate differences in expectations and needs

Interpersonal Inventory
Some Key General Questions
Who are the important people in your life?
 How would you describe your social support system?
Whom do you go to for support?
To whom do you provide support?

Interpersonal Inventory
Some Key Specific Questions
How often do you see this person?
What do you like/dislike about this relationship?
Has anything changed in this relationship?
How would you like the relationship to be different?
What roles do you assume in this relationship?
What kind of support do you get?
What kind of support do you provide?
What are your disagreements or arguments like?

1)psycheducating the pt and his family

2) starting with the management of social cycles

3)Addressing the interpersonal domain-role lost, mourning the same roles to be reneogitiated, regneogitating
dynamics with family members

Doubt: timing for using ipsrt? During symptoms? Preventive mostly or after the symptoms subside?

What all it treats?

Cyclothymia, bpad I, ii, psychosis-no

The conception of IPSRT

Interpersonal and social rhythm therapy (IPSRT) was developed with the late adolescent and adult patient with bipolar I disorder in
mind.
r
Combine IPT with a social rhythm regulation treatment.

The treatment we developed built on the essential components of IPT: taking a history
of the patients illness, educating the patient about the disorder, managing the
mood symptoms, learning about the interpersonal realm of the patients life and its relationship
to his or her mood disorder, and intervening to improve existing interpersonal
problems and prevent new ones.

major
mood disorders (major depression and bipolar disorder) reflected, among other things,
a disruption in circadian rhythms, a disturbance in the bodys clock. 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.

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 bodys clock. When social factors function in this way, they become social zeitgebers.
We had also argued that changes or interferences in social routines, which we termed
zeitstrers (or time disturbers), could disrupt the bodys clock and destroy the bodys
naturally synchronized rhythms. We concluded that, in those who were vulnerable to
mood disorders, it was the loss of social zeitgebers (timekeepers) or the appearance of
zeitstrers (disrupters) that led to new illness episodes (depression or mania).

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: resolving an unresolved grief experience, negotiating a transition
in a major life role, and resolving a role dispute with a significant other.

Jills IPSRT therapist began by taking a history of her bipolar illness, going all the
way back to her seasonal mood changes in high school. Together they created a
timeline in which her episodes, her treatments, and any life circumstances that seemed
to be associated with the onset of symptoms were represented, along with her work
and marital status. Her therapist pointed out how important challenges to her circadian
system and changes in her hormonal state seemed to be connected to the onsets of her
episodes. He also pointed out how much better she seemed to function when she was
in a regular routine. He queried her about the various medications she had taken over
the course of her illness, trying to understand what had worked best for her. He then
completed what we call the interpersonal inventory, an informal review of all the relationships
that were currently important to Jill and all the relationships that had been
important to her in the past.

he discussed the IPSRT problem areas with Jill and together they agreed that
first she needed to grieve for her lost healthy self and former life as a functioning professional
and wife. They talked about the fact that she really had not fully made the
transition to being single or to being a single parent and decided that this would be a
later focus of their work. First, though, they needed to concentrate on getting Jill and
her boys into some sort of regular routine. Fortunately, Jills therapist didnt need to do
much to convince her that she would feel better if she were on a regular schedule. That
was something she knew already. He gave her the Social Rhythm Metric to complete
before their next session.

(mourning the loss of previous capacities at the very beginning might not be a good idea, but can be included midway. This is turn in
collaboration with acknowledging the new circumstances, the capacities they demands and seeing what kind of skills and roles the
patient needs to adopt in order to cope better with his/her current circumstances)

Once she was on a modestly regular schedule, he began

to help her grieve for the young professor of such high promise and for all that she
had hoped to become. He gently helped her to see how her once supportive parents
had subsequently failed her by mostly denying her illness.

He tried to
understand what kind of life Jill wanted now and how much of what she wanted she
might be capable of having. Very, very gradually over the ensuing months Jill came to
accept her illness as a challenge she might be able to master and her life as a single
mother as one that might offer satisfactions.

At each step along the

way, they helped him to grieve for what he was losing and congratulated him on what
he was accomplishing.

Briefly, the essential feature of bipolar I disorder is the

lifetime experience of an episode of mania. Episodes of depression are usually present
in the history as well, but are not a requirement for the official DSM-IV diagnosis. In
contrast, the diagnosis of bipolar II disorder requires that the individual have a history
of both hypomanic and depressive episodes.

Formal diagnostic considerations aside,IPSRT is almost certainly appropriate for any patient with clearly defined and
impairing
episodes of high and low mood (as opposed to fleeting shifts in mood) that are accompanied
by the cognitive and neurovegetative changes associated with mania/
hypomania and depression.

this is an intervention that requires considerable

effort and, particularly, effort at change on the patients part. Thus, IPSRT is intended
for individuals whose clinical condition is such that major psychotic symptoms have receded or are absent.

In IPT and
IPSRT the interpersonal problem areas to be addressed are always conceptualized
within the context of the subjects own values with respect to interpersonal roles and
relationships. Likewise, the social routines aspect of the treatment makes no particular
judgment as to when specific daily routines should occur, but simply emphasizes the
importance of regularity of routines in the lives of those who suffer from manic
depressive illness. If breakfast is not taken until after morning prayers are said, or the
large meal is eaten at midday, or there is a period of sleep following the midday meal
as essential parts of a cultural routine, the treatment is easily able to accommodate
these cultural preferences. Thus, in theory at least, IPSRT should be adaptable to a multiplicity
of ethnic groups and subcultures.

An essential foundation for IPSRT is familiarity with Klerman and colleagues interpersonal
psychotherapy (IPT) for unipolar disorder (Klerman et al., 1984;Weissman,
Markowitz, & Klerman, 2000).

IPT

Interpersonal Psychotherapy (IPT) is based on the observation that major depressionregardless of symptom patterns,
severity, presumed biological or genetic vulnerability, or the patients personality traits usually occurs in an
interpersonal context, often an interpersonal loss or dispute. By clarifying, refocusing, and renegotiating the
interpersonal context associated with the onset of the depression, the depressed patients symptomatic recovery may
be accelerated and the social morbidity reduced. Meyer viewed psychiatric disorders as an expression of the patients
attempt to adapt to the environment.

Within the framework of IPT, major depression is seen as involving three components:

1. Symptom formation, which includes the depressive affect and vegetative signs and symptoms, such as sleep and
appetite disturbance, loss of interest and pleasure;

2. Social functioning, which includes social interactions with other persons, particularly in the family, derived from
learning based on childhood experiences, concurrent social reinforcement, and/ or current problems in personal
mastery of social situations;

3. Personality, which includes more enduring traits and behaviors, such as the handling of anger and guilt, and overall
self-esteem. These constitute the persons unique reactions and patterns of functioning and may contribute to a
predisposition to depression, although this is not clear