Interpersonal and social rhythm therapy

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Interpersonal and social rhythm therapy (IPSRT) is an intervention for people with bipolar disorder (BD). Its primary focus is stabilizing the circadian rhythm disruptions that are common among people with bipolar disorder [1] [2] [3] (BD). IPSRT draws upon principles from interpersonal psychotherapy, an evidence-based treatment for depression [4] and emphasizes the importance of daily routine (rhythm). [5]

Contents

IPSRT was developed by Ellen Frank, PhD at the University of Pittsburgh who published a book on her theories: Treating Bipolar Disorder, a Clinician's Guide to Interpersonal and Social Rhythm Therapy. [6] Her research on IPSRT [7] [8] has shown that, in combination with medication, solving interpersonal problems and maintaining regular daily rhythms of sleeping, waking, eating, and exercise can increase quality of life, reduce mood symptoms, and help prevent relapse in people with BD.

Social Zeitgeber Hypothesis

Zeitgebers (“time givers”) are environmental cues that synchronize biological rhythms to the 24-hour light/dark cycle. As the sun is a physical zeitgeber, social factors are considered social zeitgebers. These include personal relationships, social demands, or life tasks that entrain circadian rhythms. [9] Disruptions in circadian rhythms can lead to somatic and cognitive symptoms, as seen in jet lag or during daylight saving time. Individuals diagnosed with, or at risk for, mood disorders may be especially sensitive to these disruptions and thus, vulnerable to episodes of depression or mania when circadian rhythm disruptions occur. [10] [11] [12] [13]

Changes in daily routines place stress on the body's maintenance of sleep-wake cycles, appetite, energy, and alertness, [8] all of which are affected during mood episodes. For example, depressive symptoms include disturbed sleep patterns (sleeping too much or difficulty falling asleep), changes in appetite, fatigue, and slowed movement or agitation. Manic symptoms include decreased need for sleep, excessive energy, and increase in goal-directed activity. When the body's rhythms becomes desynchronized, it can result in episodes of depression and mania. [14] [15]

Aims of Treatment

Goals of IPSRT are to stabilize social rhythms (e.g., eating meals with other people) while improving the quality of interpersonal relationships and satisfaction with social roles. [8] Stabilizing social rhythms helps to protect against disruptions of biological rhythms; individuals are more likely to maintain a rhythm when other people are involved to hold them accountable.

Interpersonal work can involve addressing unresolved grief experiences including grief for the lost healthy self, negotiating a transition in a major life role, and resolving a role dispute with a significant other. These experiences can be disruptive to social rhythms and thus, serve as targets of treatment to prevent the onset and recurrence of mood episodes seen in bipolar disorder.

Phases of Treatment

IPSRT typically proceeds in four phases: [6] [8]

  1. The initial phase involves a review of the patient's mental health history in order to elucidate patterns in the associations between social routine disruptions, interpersonal problems and affective episodes. Psychoeducation about BD and the importance of stable routines to mood maintenance is provided. Additionally, The Interpersonal Inventory is used to assess the quality of the patient's interpersonal relationships. One of four interpersonal problem areas is chosen to focus on:
    1. Grief (e.g. loss of loved one, loss of healthy self)
    2. Role transitions (e.g. married-to-divorced, parenthood)
    3. Role disputes (e.g. conflict with spouse or parents)
    4. Interpersonal deficits (e.g. persistent social isolation) The Social Rhythm Metric (SRM) is used to assess the regularity of social routines. Target and actual time of the following activities are tracked on a daily basis: got out of bed; first contact with another person; started work, school, or housework; ate dinner; and went into bed. The intensity of involvement with other people is also rated: 0 = alone, 1 = others present, 2 = others actively involved, and 3 = others very stimulating. Finally, mood is rated on a scale of -5 to +5 at the end of each day.
  2. The intermediate phase focuses on bringing regularity to social rhythms and intervening in the interpersonal problem area of interest.
    1. Social Rhythm Metric is heavily used to assess amount of activity being engaged in and the impact of activity on mood. The regularity (or irregularity) of activities is examined, and the patient and therapist collaboratively plan how to stabilize the daily routine by making incremental behavioral modifications until a regular target time at which these activities are done is achieved.
    2. Sources of interpersonal distress are explored, and individuals in the patient's life who destabilize routine, along with those who are supportive, are identified. Frequency and intensity of social interactions, as well as other social rhythms (e.g. time at which returning home from school/work and then interacting with family), are discussed.
  3. The maintenance phase aims to reinforce the techniques learned earlier in treatment in order to maintain social rhythms and positive interpersonal relationships.
    1. Discussion of early warning signs of episodes are reviewed.
    2. Symptomatic and functional change is monitored at each session by asking the patient to rate their mood and note any shifts in routine using the SRM.
  4. The final phase involves termination in which sessions are gradually reduced in frequency.

Interpersonal Strategies

Once the interpersonal problem area of focus is chosen, the following strategies may be used: [16]

  1. Grief – This refers to symptoms resulting from incomplete mourning or unresolved feelings about the death of an important person. This can also refer to grief for the loss of a healthy self (i.e., the person before the illness or the person one could have become, if not for BD). Strategies include encouraging expression of painful feelings about lost hopes, ruined relationships, interrupted careers, and passed opportunities. This is followed by encouragement to develop new relationships, establish new, more realistic goals, and focus on future opportunities.
  2. Interpersonal role disputes – This refers to any close relationship in which there are nonreciprocal expectations, such as in marital conflict and arguments with parental figures. Strategies include learning how to be more patient, tolerant, and accepting of limitations in self and others. [6] This, in turn, can lead to fewer critical and argumentative instincts.
  3. Role transition – This refers to any major life role change, such as new employment, graduation, retirement, marriage, divorce, and giving birth. This can also refer to the loss of previously pleasurable hypomania. Strategies can include noting the negative consequences of hypomania and encouraging the identification of rewarding life goals as suitable alternatives.
  4. Interpersonal deficits – This refers to a long-standing history of impoverished or contentious social relationships, leading to an overall feeling of dissatisfaction. Strategies include identifying the common thread in the multiple disputes across one's life and possibly working to restore “burnt bridges”. [6]

Social Rhythm Strategies

Individuals with BD benefit from a higher level of stability in their sleep and daily routines than those with no history of affective illness. [6] It is important to identify situations in which routines can be thrown off balance, whether by excessive activity and overstimulation or lack of activity and under-stimulation. Once destabilizing triggers are identified, reasonable goals for change are established. Specific strategies include:

  1. Encouraging proper sleep hygiene to introduce regularity to sleep-wake cycle
    1. Establish a regular wake and sleep time
    2. Avoid caffeine or other stimulants
    3. Use the bed only for sleep and sex, not for watching TV, doing homework, reading etc.
    4. Align sunlight exposure with wake time to help set circadian clock
  2. Maintaining regular meal times throughout the day
    1. Plan ahead by meal prepping the day before
    2. Include snack times if needed to encourage consistent eating habits
  3. Encouraging medication adherence and establishing a regular schedule
    1. Use alarms on phone as reminders for when to take pills
    2. Use daily pillboxes to keep track of which pills to take at certain times
  4. Monitoring frequency and intensity of social interactions using Social Rhythm Metric
    1. Note time at which interactions happen and adjust accordingly to establish regularity
  5. Minimizing overstimulation of social interactions
    1. Avoid frequent parties or events
    2. Use recovery days as needed
  6. Addressing under-stimulation with behavioral activation
    1. Engage in activities that are pleasurable and that give one a sense of mastery
    2. Focus on small, manageable goals that can lead to engagement in other activities (e.g., start jogging to get in shape prior to joining a basketball team)
  7. Identifying interpersonal sources of stabilizing and destabilizing influence
    1. Spend time with those who are supportive and stabilizing
    2. Reduce time with those who are disruptive

Evidence of IPSRT Efficacy

In a randomized controlled trial, those who received IPSRT during the acute treatment phase went longer without a new affective episode (depression or mania) than those who received intensive clinical management. Participants in the IPSRT group also had higher regularity of social rhythms at the end of acute treatment, which was associated with reduced likelihood of relapse during maintenance phase. [7] Additionally, those who received IPSRT showed more rapid improvement in occupational functioning than those assigned to intensive clinical management. However, at the end of two years of maintenance treatment, there were no differences between treatment groups. [17]

IPSRT was studied as one of three intensive psychosocial treatments in the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder [18] (STEP-BD). STEP-BD was a long-term outpatient study investigating the benefits of psychotherapies in conjunction with pharmacotherapy in treating episodes of depression and mania, as well as preventing relapse in people with bipolar disorder. [19] Patients were 1.58 times more likely to be well in any study month if they received intensive psychotherapy (cognitive-behavioral therapy, family focused therapy, or IPSRT) than if they received collaborative care in addition to pharmacotherapy. [18] They also had significantly higher year-end recovery rates and shorter times to recovery.

In a trial conducted by a separate research group, 100 participants aged 15–36 years with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified were randomized to IPSRT (n = 49) or specialist supportive care (n = 51). Both groups experienced improvement in depressive symptoms, social functioning, and manic symptoms, but there were no significant differences between the groups. [20]

Adolescents

IPSRT was adapted to be delivered to adolescents with BD [21] (IPSRT-A). In an open trial (N=12), feasibility and acceptability of IPSRT-A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent-rated satisfaction scores were high. IPSRT-A participants experienced significant decreases in manic, depressive, and general psychiatric symptoms over the 20 weeks of treatment. Participants’ global functioning increased significantly as well.

In an open trial aimed at prevention, adolescents (N=13) who were identified as high risk for bipolar disorder, due to having a first-degree relative with BD, received IPSRT. [22] Significant changes in sleep/circadian patterns (i.e. less weekend sleeping in and oversleeping) were observed. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BD illness severity.

Group Therapy

IPSRT was adapted for a group therapy setting; [23] administered over 16 sessions, in a semi-structured format. Patients (N=22) made interpersonal goals, reflected on how they managed their illness, and empathized with fellow group members. Patients were encouraged to react to each other from their own experience, express their feelings about what was said, and to give constructive feedback. Patients spent significantly less time depressed in the year following treatment than they did in the year prior to treatment.

In another small trial, patients with BD who experiencing a depressive episode (N = 9) received six IPSRT-G sessions across two weeks. Topics of discussion in group included defining interpersonal focus area, defining target times for daily routines, discussing grief and medication adherence, addressing interpersonal disputes and role transitions, and reviewing IPSRT strategies and relapse prevention. Depressive symptoms improved significantly at the end of the treatment; improvements were maintained 10 weeks following treatment end. [24]

Related Research Articles

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention. Also, the depressive episodes will be approximately 2 weeks long.

<span class="mw-page-title-main">Major depressive disorder</span> Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.

<span class="mw-page-title-main">Sleep disorder</span> Medical disorder of a persons sleep patterns

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Sleep disorders are frequent and can have serious consequences on patients' health and quality of life. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Mood disorder</span> Mental disorder affecting the mood of an individual, over a long period of time

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

<span class="mw-page-title-main">Seasonal affective disorder</span> Medical condition

Seasonal affective disorder (SAD) is a mood disorder subset in which people who typically have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year. It is commonly, but not always, associated with the reductions or increases in total daily sunlight hours that occur during the summer or winter.

<span class="mw-page-title-main">Delayed sleep phase disorder</span> Chronic mismatch between a persons normal daily rhythm, compared to other people and societal norms

Delayed sleep phase disorder (DSPD), more often known as delayed sleep phase syndrome and also as delayed sleep–wake phase disorder, is the delaying of a person's circadian rhythm compared to those of societal norms. The disorder affects the timing of biological rhythms including sleep, peak period of alertness, core body temperature, and hormonal cycles.

<span class="mw-page-title-main">Mood swing</span> Extreme or rapid change in mood

A mood swing is an extreme or sudden change of mood. Such changes can play a positive part in promoting problem solving and in producing flexible forward planning, or be disruptive. When mood swings are severe, they may be categorized as part of a mental illness, such as bipolar disorder, where erratic and disruptive mood swings are a defining feature.

Wake therapy is a specific application of intentional sleep deprivation. It encompasses many sleep-restricting paradigms that aim to address mood disorders with a form of non-pharmacological therapy.

A zeitgeber is any external or environmental cue that entrains or synchronizes an organism's biological rhythms, usually naturally occurring and serving to entrain to the Earth's 24-hour light/dark and 12-month cycles.

The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

In medicine, a prodrome is an early sign or symptom that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. It is derived from the Greek word prodromos, meaning "running before". Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Sundowning, or sundown syndrome, is a neurological phenomenon associated with increased confusion and restlessness in people with delirium or some form of dementia. It is most commonly associated with Alzheimer's disease but also found in those with other forms of dementia. The term "sundowning" was coined by nurse Lois K. Evans in 1987 due to the timing of the person's increased confusion beginning in the late afternoon and early evening. For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long term adverse outcomes. Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia and seems to subside with the progression of the person's dementia. People are generally able to understand that this behavioral pattern is abnormal. Research shows that 20–45% of people with Alzheimer's will experience some variation of sundowning confusion. However, despite lack of an official diagnosis of sundown syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there is currently a wide range of reported prevalence.

Bipolar disorder not otherwise specified (BD-NOS) is a diagnosis for bipolar disorder (BD) when it does not fall within the other established sub-types. Bipolar disorder NOS is sometimes referred to as subthreshold bipolar disorder.

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

Chronotherapy, also called chronotherapeutics or chronotherapeutic drug delivery, refers to the coordination of therapeutic treatments with an individual's circadian or other rhythmic cycles. This may be done to maximize effectiveness of a specific treatment, minimize possible side effects, or both.

Ellen Frank is a psychologist and Distinguished Professor Emeritus of Psychiatry and Distinguished Professor of Psychology at the University of Pittsburgh. She is known in the field of Psychotherapy as one of the developers of Interpersonal and Social Rhythm Therapy, which aims to treat bipolar disorder by correcting disruptions in the circadian rhythm while promoting increased regularity of daily social routines. Frank is the co-founder and Chief Scientific Officer of HealthRhythms, a company that uses mobile technology to monitor the health and mental health of clients, facilitate the detection of changes in their status, and better manage mental health conditions.

Sleep is known to play an important role in the etiology and maintenance of bipolar disorder. Patients with bipolar disorder often have a less stable and more variable circadian activity. Circadian activity disruption can be apparent even if the person concerned is not currently ill.

In chronobiology, photoentrainment refers to the process by which an organism's biological clock, or circadian rhythm, synchronizes to daily cycles of light and dark in the environment. The mechanisms of photoentrainment differ from organism to organism. Photoentrainment plays a major role in maintaining proper timing of physiological processes and coordinating behavior within the natural environment. Studying organisms’ different photoentrainment mechanisms sheds light on how organisms may adapt to anthropogenic changes to the environment.

References

  1. ↑ Crowe, M.; Beaglehole, B.; Inder, M. (2015-10-12). "Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice". Journal of Psychiatric and Mental Health Nursing. 23 (1): 3–11. doi:10.1111/jpm.12271. ISSN   1351-0126. PMID   26459928.
  2. ↑ Miziou, Stella; Tsitsipa, Eirini; Moysidou, Stefania; Karavelas, Vangelis; Dimelis, Dimos; Polyzoidou, Vagia; Fountoulakis, Konstantinos N (2015-07-07). "Psychosocial treatment and interventions for bipolar disorder: a systematic review". Annals of General Psychiatry. 14 (1): 19. doi: 10.1186/s12991-015-0057-z . ISSN   1744-859X. PMC   4493813 . PMID   26155299.
  3. ↑ Scott, Jan; Gutierrez, Maria Jose (2004). "The current status of psychological treatments in bipolar disorders: a systematic review of relapse prevention". Bipolar Disorders. 6 (6): 498–503. doi:10.1111/j.1399-5618.2004.00153.x. ISSN   1398-5647. PMID   15541065.
  4. ↑ "Interpersonal and Social Rhythm Therapy (IPSRT) for Bipolar Disorder | Society of Clinical Psychology". www.div12.org. 19 August 2014. Retrieved 2019-12-09.
  5. ↑ Ehlers, Cindy L.; Frank, Ellen; Kupfer, David J. (1988-10-01). "Social Zeitgebers and Biological Rhythms: A Unified Approach to Understanding the Etiology of Depression". Archives of General Psychiatry. 45 (10): 948–52. doi:10.1001/archpsyc.1988.01800340076012. ISSN   0003-990X. PMID   3048226.
  6. 1 2 3 4 5 Frank, Ellen (2005). Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy. New York, NY: Guilford Press.
  7. 1 2 Frank, Ellen; Kupfer, David J.; Thase, Michael E.; Mallinger, Alan G.; Swartz, Holly A.; Fagiolini, Andrea M.; Grochocinski, Victoria; Houck, Patricia; Scott, John; Thompson, Wesley; Monk, Timothy (2005-09-01). "Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder". Archives of General Psychiatry. 62 (9): 996–1004. doi:10.1001/archpsyc.62.9.996. ISSN   0003-990X. PMID   16143731.
  8. 1 2 3 4 Frank, Ellen (2007). "Interpersonal and social rhythm therapy: A means of improving depression and preventing relapse in bipolar disorder". Journal of Clinical Psychology. 63 (5): 463–473. doi:10.1002/jclp.20371. PMID   17417811.
  9. ↑ Nusslock, Robin; Abramson, Lyn; Harmon-Jones, Eddie; Alloy, Lauren; Coan, James (2009). "Psychosocial Interventions for Bipolar Disorder: Perspective From the Behavioral Approach System (BAS) Dysregulation Theory". Clinical Psychology: Science and Practice. 16 (4): 449–469. doi:10.1111/j.1468-2850.2009.01184.x. ISSN   0969-5893. PMC   2790718 . PMID   20161456.
  10. ↑ Alloy, Lauren B.; Ng, Tommy H.; Titone, Madison K.; Boland, Elaine M. (2017-03-20). "Circadian Rhythm Dysregulation in Bipolar Spectrum Disorders". Current Psychiatry Reports. 19 (4): 21. doi:10.1007/s11920-017-0772-z. ISSN   1523-3812. PMC   6661150 . PMID   28321642.
  11. ↑ Melo, Matias C.A.; Abreu, Rafael L.C.; Linhares Neto, Vicente B.; de Bruin, Pedro F.C.; de Bruin, Veralice M.S. (2017). "Chronotype and circadian rhythm in bipolar disorder: A systematic review". Sleep Medicine Reviews. 34: 46–58. doi:10.1016/j.smrv.2016.06.007. ISSN   1087-0792. PMID   27524206.
  12. ↑ Nováková, Marta; Praško, Ján; Látalová, Klára; Sládek, Martin; Sumová, Alena (2014-10-31). "The circadian system of patients with bipolar disorder differs in episodes of mania and depression". Bipolar Disorders. 17 (3): 303–314. doi:10.1111/bdi.12270. ISSN   1398-5647. PMID   25359533. S2CID   30090427.
  13. ↑ Salvatore, Paola; Ghidini, Stefano; Zita, Gianmaria; Panfilis, Chiara De; Lambertino, Samuele; Maggini, Carlo; Baldessarini, Ross J (2008). "Circadian activity rhythm abnormalities in ill and recovered bipolar I disorder patients". Bipolar Disorders. 10 (2): 256–265. doi:10.1111/j.1399-5618.2007.00505.x. hdl: 11381/2414168 . ISSN   1398-5647. PMID   18271904.
  14. ↑ Malkoff-Schwartz, Susan; Frank, Ellen; Anderson, Barbara; Sherrill, Joel T.; Siegel, Lori; Patterson, Declan; Kupfer, David J. (1998-08-01). "Stressful Life Events and Social Rhythm Disruption in the Onset of Manic and Depressive Bipolar Episodes". Archives of General Psychiatry. 55 (8): 702–707. doi:10.1001/archpsyc.55.8.702. ISSN   0003-990X. PMID   9707380.
  15. ↑ Malkoff-Schwartz, S.; Frank, E.; Anderson, B. P.; Hlastala, S. A.; Luther, J. F.; Sherrill, J. T.; Houck, P. R.; Kupfer, D. J. (2000). "Social rhythm disruption and stressful life events in the onset of bipolar and unipolar episodes". Psychological Medicine. 30 (5): 1005–1016. doi:10.1017/s0033291799002706. ISSN   0033-2917. PMID   12027038. S2CID   27389598.
  16. ↑ Frank, Ellen; Swartz, Holly A; Kupfer, David J (2000). "Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder". Biological Psychiatry. 48 (6): 593–604. doi:10.1016/s0006-3223(00)00969-0. ISSN   0006-3223. PMID   11018230. S2CID   7926489.
  17. ↑ Frank, Ellen; Soreca, Isabella; Swartz, Holly A.; Fagiolini, Andrea M.; Mallinger, Alan G.; Thase, Michael E.; Grochocinski, Victoria J.; Houck, Patricia R.; Kupfer, David J. (2008). "The Role of Interpersonal and Social Rhythm Therapy in Improving Occupational Functioning in Patients With Bipolar I Disorder". American Journal of Psychiatry. 165 (12): 1559–1565. doi:10.1176/appi.ajp.2008.07121953. ISSN   0002-953X. PMC   3308335 . PMID   18829872.
  18. 1 2 Miklowitz, David J.; Otto, Michael W.; Frank, Ellen; Reilly-Harrington, Noreen A.; Wisniewski, Stephen R.; Kogan, Jane N.; Nierenberg, Andrew A.; Calabrese, Joseph R.; Marangell, Lauren B.; Gyulai, Laszlo; Araga, Mako (2007-04-01). "Psychosocial Treatments for Bipolar Depression". Archives of General Psychiatry. 64 (4): 419–426. doi: 10.1001/archpsyc.64.4.419 . ISSN   0003-990X. PMC   3579612 . PMID   17404119.
  19. ↑ "NIMH » Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)". www.nimh.nih.gov. Retrieved 2019-12-09.
  20. ↑ Inder, Maree L; Crowe, Marie T; Luty, Suzanne E; Carter, Janet D; Moor, Stephanie; Frampton, Christopher M; Joyce, Peter R (2015). "Randomized, controlled trial of Interpersonal and Social Rhythm Therapy for young people with bipolar disorder". Bipolar Disorders. 17 (2): 128–138. doi:10.1111/bdi.12273. PMID   25346391. S2CID   25099759.
  21. ↑ Hlastala, Stefanie A.; Kotler, Julie S.; McClellan, Jon M.; McCauley, Elizabeth A. (2010). "Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial". Depression and Anxiety. 27 (5): 457–464. doi:10.1002/da.20668. PMC   4318681 . PMID   20186968.
  22. ↑ Goldstein, Tina R.; Fersch-Podrat, Rachael; Axelson, David A.; Gilbert, Alison; Hlastala, Stefanie A.; Birmaher, Boris; Frank, Ellen (2014). "Early intervention for adolescents at high risk for the development of bipolar disorder: Pilot study of Interpersonal and Social Rhythm Therapy (IPSRT)". Psychotherapy. 51 (1): 180–189. doi:10.1037/a0034396. ISSN   1939-1536. PMID   24377402.
  23. ↑ Bouwkamp, Christian G.; de Kruiff, Marije E.; van Troost, Thea M.; Snippe, Dina; Blom, Marc J.; de Winter, Remco F. P.; Judith Haffmans, P. M. (2013). "Interpersonal and Social Rhythm Group Therapy for Patients with Bipolar Disorder". International Journal of Group Psychotherapy. 63 (1): 97–115. doi:10.1521/ijgp.2013.63.1.97. ISSN   0020-7284. PMID   23252817. S2CID   21388078.
  24. ↑ Hoberg, Astrid A.; Ponto, Julie; Nelson, Pamela J.; Frye, Mark A. (2013-01-18). "Group Interpersonal and Social Rhythm Therapy for Bipolar Depression". Perspectives in Psychiatric Care. 49 (4): 226–234. doi:10.1111/ppc.12008. ISSN   0031-5990. PMC   4156105 . PMID   25187443.
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