EMPIRICAL SUPPORT FOR IPSRT
Growing evidence suggests that IPSRT has a prophylactic effect as an adjunct to longterm maintenance pharmacotherapy. A randomized clinical trial compared IPSRT with an intensive clinical management control condition as both an acute and maintenance treatment for patients with bipolar I disorder (Frank et al., 2005). After accounting for significant covariates of outcome, we found that receiving IPSRT in the acute treatment phase of the trial was associated with significantly longer time to recurrence during the maintenance phase of the trial. At the end of the acute treatment phase, patients assigned to IPSRT demonstrated significantly higher social rhythm regularity than those in the control condition. Consistent with the social zeitgeber hypothesis, the length of the illness-free period during the maintenance phase of the trial was significantly related to how much patients increased the regularity of their social rhythms during acute treatment, indicating that increased regularity of social routines mediated longer survival without a new affective episode. A post-hoc analysis examined the effect of IPSRT and control clinical management on rates of suicide attempts among individuals with bipolar I disorder who were followed for an average of 1.4 years (Rucci, Frank, Kostelnik, et al., 2002). Both IPSRT and clinical management were associated with lowered suicide attempt risk. The low number of suicide attempts precluded comparing the efficacy of IPSRT to clinical management. A small pilot study of patients at particularly high risk of relapse or recurrence integrated the central tenets of FFT and IPSRT (Miklowitz et al., 2003) and found that patients given this combined therapy along with medication showed longer time to relapse than was observed in matched controls given clinical management. Consistent with previous FFT and IPSRT studies, however, the combined treatment improved depressive more than manic symptoms. Finally, in the large, multicenter STEP-BD study, participants receiving IPSRT demonstrated shorter time to and greater likelihood of recovery from bipolar depression than participants assigned to the control psychosocial intervention (Miklowitz et al., 2007).
Each of the empirically validated psychosocial treatments for bipolar disorder attempts to stabilize social and sleep/wake routines. In FFT (Miklowitz & Goldstein, 1997), the clinician emphasizes the importance of regular and sufficient sleep and of establishing regular household routines. Likewise, most versions of cognitive therapy for bipolar disorder (including Basco & Rush , Lam et al. , and Scott et al. ) include psychoeducation about the importance of regular sleep/wake and rest/activity rhythms.
We present the case of Adam, a patient with bipolar disorder treated with acute and maintenance IPSRT over several years. Adam’s case describes the four phases of IPSRT: initial, intermediate, maintenance, and final treatment phases.