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Interpersonal and social rhythm therapy: An intervention addressing rhythm

dysregulation in bipolar disorder

Article  in  Dialogues in Clinical Neuroscience · February 2007

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Clinical research
Interpersonal and social rhythm therapy:
an intervention addressing rhythm
dysregulation in bipolar disorder
Ellen Frank, PhD; Holly A. Swartz, MD; Elaine Boland, BA

I n the original edition of their landmark text on

manic-depressive illness, Goodwin and Jamison asserted
that “instability is fundamental to bipolar disorder.”
(p 594).1 Indeed, one of the most prominent features of
the disorder is its propensity to recur.2,3 Our own work4,5
has placed particular emphasis on the connection between
specific kinds of instability and the recurrence of illness
episodes. We have argued that psychosocial stressors (as
well as otherwise innocuous life events that nonetheless
retain the capacity to alter the patterning of daily life)
may have destabilizing effects on the body’s natural
Bipolar disorder is characterized by frequent recurrences, rhythms. We believe that life events which may appear
often related to noncompliance with drug treatment, harmless (or even beneficial) from a psychological per-
stressful life events, and disruptions in social rhythms. spective may still be linked with considerable changes in
Interpersonal and social rhythm therapy (IPSRT) was daily routines. These disruptions can, in turn, place sub-
designed to directly address these problem areas. This stantial stress on the body’s capacity to maintain stable
article discusses the circadian basis of IPSRT and the biological rhythms (particularly sleep-wake, energy, alert-
importance of stable daily routines in the maintenance ness, and appetite rhythms) that are usually synchronized
of the euthymic state, as well as the two large controlled in the absence of an affective episode. In most individu-
trials which empirically support this intervention. The als, such rhythms will restabilize shortly after the destabi-
authors discuss the advantages of IPSRT as an acute lizing event. However, in individuals who are vulnerable
intervention, as well as a prophylactic treatment for both to mood disorders, a period of pathological entrainment
bipolar I and II disorder. Using a case example, the of circadian rhythms—otherwise labeled as an episode of
authors describe how IPSRT is implemented in a clinical depression or mania—may ensue.
setting, detailing the therapeutic methods and processes In addition to frequent recurrence, bipolar illness is char-
involved. acterized by absence of full recovery between episodes,6,7
© 2007, LLS SAS Dialogues Clin Neurosci. 2007;9:325-332.
as well as by suboptimal interepisode functioning.7 Treating
bipolar disorder, then, presents challenges not only in
terms of resolving acute episodes, but also in preventing
Keywords: interpersonal and social rhythm therapy; bipolar disorder; circadian
symptomatic recurrence and assuring complete recovery
rhythm; psychotherapy between episodes in terms of both symptom remission and
restoration of functioning. For example, a woman with
Author affiliations: University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania, USA bipolar disorder who works two highly stressful and time-
consuming jobs might find that decreasing her workload
Address for correspondence: Ellen Frank, PhD, Western Psychiatric Institute and
Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213, USA considerably leads to a marked reduction in her depres-
(e-mail: franke@upmc.edu) sive symptoms.Alternatively, it is also possible that her less

Copyright © 2007 LLS SAS. All rights reserved

325 www.dialogues-cns.org
Clinical research
Selected abbreviations and acronyms However, we propose that those individuals who are sus-
CBT cognitive behavior therapy ceptible to mood disorders find this sort of adjustment
CC collaborative care much more challenging. In essence, they find themselves
FFT family-focused therapy trapped in a sustained, disrupted cognitive and somatic
ICM intensive clinical management state attributed to their perturbed circadian system. As
II interpersonal inventory an extension of this initial desynchronization, these indi-
IPSRT interpersonal and social rhythm therapy viduals may then go on to experience fully syndromal
SRM Social Rhythm Metric manic or depressive episodes. Indeed, since first articu-
STEP-BD Systematic Treatment Enhancement Program lating this social zeitgeber hypothesis of mood disorders,
for Bipolar Disorder we established that life events with the capacity to alter
daily routines are in fact associated with the onset of both
demanding schedule may lead to chronic understimulation depressive and manic episodes, with particular emphasis
and lack of routine. Coupled with the strain of diminished on the latter.9,10
economic resources and lowered self-esteem due to the It is still unclear how, and to what extent, the body’s circa-
loss of a key social role, this change in employment status dian system becomes disrupted in patients with mood dis-
might set the stage for a lengthy period of depression and orders. Studies of seasonal affective disorder have pointed
functional impairment.Thus, in considering various “social towards day length and/or exposure to light as possible
engineering” interventions for patients with bipolar dis- factors in the development and treatment of the illness.11
order, it becomes paramount for clinicians to remain atten- However, studies of nonseasonal depression have failed to
tive to the dual tasks of ameliorating current affective corroborate the idea that light is the key synchronizing
episodes and preventing new ones, while also encouraging force in these individuals’ disorders.12
their patients to strive to live fully rewarding lives. Given that the loss of social zeitgebers and/or the presence
of life events with the capacity to disrupt daily routines are,
The role of circadian rhythms in fact, implicated in the generation of new affective
episodes in biologically susceptible individuals, then it
The external environmental cues that set the body’s cir- would follow that effective treatment of bipolar disorder
cadian “clock” are referred to as zeitgebers or “time- should center on principles of social rhythm stabilization,
givers” by those who study circadian rhythms.8 These particularly as a preventative measure. Other empirically
external cues, in turn, entrain a cascade of neurohormonal validated treatments for mood disorders already support
events, such as diurnal patterns of cortisol and melatonin this concept. Cognitive therapy,13 with its focus on mastery
secretion, which are key components of circadian physi- and pleasure scheduling, and interpersonal psychother-
ology. The principal, and arguably most influential, zeit- apy,14 which emphasizes the resolution of role disputes and
geber is the rising and setting of the sun. However, our the easing of role transitions, both play substantial roles in
modern society is no longer governed by the availability establishing social routines, albeit via indirect means.
of natural light, as artificial light sources are readily avail-
able 24 hours a day. By extension, social factors such as Interpersonal and social rhythm therapy
the timing of meals, work schedules, the schedules of
other family members, and even, to some extent, the tim- Our research group has had a long-standing interest in the
ing of television programs can all have a substantial influ- association between mood disorders and the circadian sys-
ence on an individual’s social rhythms and, in turn, on tem. As a result, we developed a therapeutic intervention
their circadian rhythms. It is our belief that all of us are for bipolar disorder that sought to prevent the recurrence
susceptible to the disruptive effects of changes in any of of new affective episodes through indirect regulation of
these important social time cues, and that these changes the endogenous circadian system.15 The idea behind this
manifest themselves to varying degrees of temporary cog- approach, which we called interpersonal and social rhythm
nitive or somatic distress. Take jet lag, for example. Many therapy (IPSRT), was that if we could somehow increase
of us have experienced the fatigue and malaise associated the regularity of patients’ daily routines (specifically, their
with the adjustment to a new time zone, but for most of often erratic sleep/wake cycles, meal times, and times of
us, these feelings generally dissipate quite rapidly. rest versus activity) we could thereby help strengthen their

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Interpersonal and social rhythm therapy - Frank et al Dialogues in Clinical Neuroscience - Vol 9 . No. 3 . 2007

otherwise vulnerable circadian systems. mood symptoms lies in the regulation of social rhythms.
IPSRT directly incorporates social rhythm theories into For individuals with bipolar disorder who are being treated
the framework of interpersonal psychotherapy, initially with mood-stabilizing medications, recurrence vulnerabil-
developed by Klerman and colleagues for the treatment ity appears to occur via three main pathways: (i) nonad-
of unipolar depression.14 Specifically, IPSRT is geared herence to medication; (ii) presence of a stressful life event;
toward stabilizing patients’ routines while simultaneously and (iii) disruptions in social rhythms. IPSRT was designed
improving the quality of their interpersonal relationships with each of these potential vulnerability factors in mind,
and their performance of key social roles. Through this making it a targeted approach to treating this frequently
approach, IPSRT aims to improve patients’ current mood recurring illness. Patients are provided with guidance and
and level of functioning and to provide them with the training on how to maintain a consistent medication sched-
skills necessary to shield them from new affective ule, an opportunity to discuss how they feel about the dis-
episodes. Although IPSRT was originally developed for order itself and express their grief and/or anger over what
individuals with bipolar I disorder, it now appears that we have frequently referred to as the “lost healthy self,”
IPSRT can be utilized in the treatment of both bipolar I and a chance to come to grips with the often debilitating
and II disorders. For patients with bipolar I disorder, acute effect the illness has had on their lives. As a result, IPSRT
affective symptoms are managed primarily through phar- often helps patients accept the life-long nature of their ill-
macological means, with IPSRT used mainly as an adjunc- ness, reduces the denial commonly associated with the dis-
tive treatment to help regularize routines and improve order, and thus facilitates medication adherence.
social relations and role performance. However, it now The behavioral component of IPSRT focuses on evaluat-
appears that IPSRT can be used as monotherapy for ing the degree to which the timing of a patient’s routines
patients with bipolar II disorder of moderate symptom varies throughout any given week. To do this, we utilize a
severity (Swartz HA et al, unpublished data), or can be self-report charting instrument called the Social Rhythm
combined effectively with pharmacotherapy when such Metric (SRM),17 which allows the patient to keep track of
treatment is indicated.16 Regardless of the subtype of when he or she goes to bed, gets out of bed, eats, goes to
bipolar illness, we would argue that one key to managing work, makes social contacts, etc. Table I shows an adapted

ID: Adapted SRM-5 Initials:

Directions:
• Record the ideal (or target) time you would like to do these daily activities
• Record the time you actually did the activity each day
• Record the people involved in the activity: 0 = Alone; 1 = Others present; 2 = Others actively involved; 3 = Others very stimulating

Day and Date:

People

People

People

People

People

People

Activity Target Time Time Time Time Time Time

time

Out of bed

First contact with other person

Start work/school/ Volunteer/

family care

Dinner

To bed

Rate ENERGY LEVEL each day from -5 to +5

- 5 = very slowed, fatigued / + 5 = very energetic, active

Table I. Adapted SRM-5.

327
Clinical research
version of the SRM-5. After reviewing the SRM with Four phases of IPSRT
the patient, we then strive to help him or her make the
timing of such routines more regular, ideally varying by IPSRT is implemented in a series of four phases.
no more than an hour. This often needs to be done quite Regardless of the patient’s clinical state at the beginning
gradually, especially when specific routines vary by of treatment (either in an acute episode or remission) the
many hours over the course of a week. When this is the first phase of treatment is always a focused history-tak-
case, we might choose to focus on just one routine, such ing. During this phase, the clinician seeks to establish the
a when the patient gets out of bed, attempting, by suc- correct diagnosis and then to assess the linkage between
cessive approximation, to approach an out-of-bed time acute episodes and interpersonal issues and social rou-
that does not vary by more than an hour from day to tines in the patient’s history, thus developing the foun-
day. Once reasonably regular routines are established, dation for treatment. In addition to taking a detailed his-
we review with the patient possible triggers to rhythm tory, the clinician also takes the time to provide the
disruption that may surface in the near future (ie, house patient and involved family members with education
guests or vacations) and work on strategies for main- about the nature of bipolar mood disorder, being partic-
taining the greatest amount of regularity despite the ularly careful to take into consideration what he or she
presence of these possible disruptions. Thus, IPSRT may already know about the illness.
attempts not only to increase the stability of these Also part of this initial phase of treatment is an infor-
rhythms, but also to increase the patient’s awareness of mation-gathering process that we refer to as the
how easily these rhythms can be disrupted and how to Interpersonal Inventory (II). Through this semistructured
manage in the face of such potential disruptions. interview, the therapist assesses the nature and quality of
This behavioral approach to rhythm regularity is then the patient’s current and past interpersonal relationships.
interwoven with work on the four main problem areas Once these evaluations have been made, the clinician
targeted by Klerman and colleagues’ interpersonal psy- then proceeds to appraising the regularity of the patient’s
chotherapy: unresolved grief, role transitions, role dis- social routines by using the SRM. The initial phase con-
putes, and interpersonal deficits.14 By addressing these cludes with the selection of an interpersonal problem
interpersonal and social role issues with the patient, it area (unresolved grief, role transition, role disputes, or
is our hope that the number and severity of such stres- more pervasive interpersonal deficits), upon which the
sors will decrease, thus making it easier to maintain the patient and the clinician both agree. The combination of
routine regularity stressed in the behavioral component the history-taking and the II should allow the clinician
of the treatment while at the same time enhancing self- and patient to reach a consensus about which of these
esteem and social support. Indeed, there are several four problem areas is most closely linked to the onset of
reasons why the reduction of interpersonal and social the most recent mood episode. This focus then, becomes
role stress is vital to achieving wellness in individuals the initial jumping-off point for the interpersonal part of
with bipolar disorder. First of all, stressful events have the therapy. Depending upon the severity and duration
the capacity to impact the circadian system via of the patient’s past psychiatric history, as well as the
increases in autonomic arousal that can, in turn, alter complexity of the patient’s current interpersonal rela-
sleep-wake cycles, timing (and amount) of food con- tionships and level of insight into his or her own illness,
sumption, and normal circadian patterns of release of this initial phase of treatment can last anywhere from
other hormones.. Second, regardless of the level of three to five sessions.
stress incurred, events of any size or severity can lead Once the first phase of treatment is completed, the clin-
to significant changes in daily routines. Even a seem- ician moves on to the second or intermediate phase of
ingly benign event, such as a child joining a sports team therapy. The focus of this phase of the intervention
and needing to be at school an hour earlier for practice, involves helping the patient establish more regular daily
can be difficult for someone struggling with bipolar dis- social routines and resolve the interpersonal problem
order. Third, major life stressors such as moving house area specified in the initial phase of treatment. During
or getting a divorce can not only have a negative psy- this phase of IPSRT it is most common to conduct
chological impact on the individual, but may also dis- weekly sessions. However, depending upon the patient’s
rupt social rhythms. clinical status, more or less frequent sessions may be

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Interpersonal and social rhythm therapy - Frank et al Dialogues in Clinical Neuroscience - Vol 9 . No. 3 . 2007

more appropriate. In the two large trials of IPSRT con- lem areas must be more concentrated. Despite the short-
ducted to date,18,16 this phase has typically required 10 to ened overall duration of treatment in this case, it is still
12 sessions; however, in a small open study of bipolar dis- advisable that treatment frequency be reduced near the
order complicated by full-criterion borderline personal- end, so as to still allow for at least three to four bimonthly
ity disorder, a much longer intermediate phase—of the sessions to accomplish the necessary termination steps.
order of 9 to 10 months—was required to achieve mood
stability.19 Case example
The next phase of treatment, continuation or mainte-
nance IPSRT, focuses on building up patients’ confidence The following is a detailed example of how IPSRT is uti-
in their capability to use the skills learned in the acute lized in the treatment of a patient with bipolar I disorder.
phase of treatment to maintain their current euthymic
mood, level of functioning, and social rhythm regularity. Presenting problem
The objective is for the patient to be able to maintain
regular social rhythms despite the probable occurrence Anne is a 35-year-old separated woman who began
of stressors such as job changes, vacations, and other IPSRT while in the throes of a particularly severe depres-
unexpected life events. Additionally, the patient is sion that had had its onset 4 months previously. Anne had
encouraged to continue to improve the quality of his or been working as a waitress at a local restaurant, with a
her interpersonal relationships and keep the level of schedule that varied widely: she never had a consistent
interpersonal distress at a minimum. Techniques that are day off, and she was frequently scheduled for lunchtime
commonly used for accomplishing these interpersonal shifts one day followed by evening shifts the next. She
goals include communication analysis, which allows the had recently moved out the home she shared with her
therapist and patient to identify problem areas in com- estranged husband and she was having great difficulty
munication to help the patient interact more effectively making ends meet, with the rental fees of her new apart-
with significant others; role-play, which allows the patient ment and the need to buy a car of her own.
a safe environment in which to practice expressing emo- As Anne’s depression worsened, she found herself strug-
tions and self-assertion; and decision analysis, which helps gling with disrupted sleep and a lack of motivation which
patients to reflect on the potential risks and benefits of began to negatively impact her work. She began showing
alternate choices and options with regard to a specific up late for her shifts, and the fatigue stemming from her
problem. More detailed explanations of IPT techniques erratic sleep schedule caused her to make several mis-
and strategies can be found in the manual for interper- takes with her customers. Soon she was in serious jeop-
sonal psychotherapy.14 Treatment frequency generally ardy of losing her job, the prospect of which sparked
decreases from weekly, to biweekly, and eventually to intense financial anxiety.
monthly sessions as the patient moves from acute to
maintenance therapy. Case formulation and course of treatment
When termination of treatment is deemed appropriate
(or is otherwise necessitated by outside factors such as The therapist’s detailed history-taking revealed the fol-
financial constraints or logistical challenges) the clini- lowing information. While Anne had a rather protracted
cian and patient will begin work on the final phase of history of brief but severe manias, this appeared to be
treatment which focuses on impending termination. This one of very few depressions Anne had experienced in her
can typically be accomplished within three to five life. Additionally, Anne had married young (at age 20)
monthly sessions. If it is not considered clinically appro- and had, for all intents and purposes, moved directly from
priate to stop treatment completely, this final phase can her parents’ home into the home she shared with her
also be utilized to further decrease the frequency of ses- husband. She had never actually lived alone, and was
sions to little more than occasional booster sessions finding her new circumstances as frightening as they were
when necessary. difficult.
IPSRT can also be successfully implemented simply as a Anne’s therapist could see that there were several fac-
short-term treatment, in which case the initial phase is tors that would need to be addressed in order to help
more condensed and the work on the interpersonal prob- Anne out of her depression. First, Anne’s schedule was

329
Clinical research
far too erratic. In order for Anne to be able to regulate current situation. Anne’s therapist knew from the II that
her daily routines, there had to be a routine established Anne maintained a good relationship with her parents
to begin with. Second, it appeared to the clinician that and had at least two female friends from high school with
Anne’s primary interpersonal problem was the role tran- whom she remained close; however, she rarely saw either
sition from being a married woman to a single one and her parents or these girlfriends because she felt too
the challenges of self-sufficiency that came along with it. depressed to leave her apartment other than to drag her-
The particularly stressful life event of her marital sepa- self to work. She encouraged Anne to visit her parents on
ration was also the impetus for her current disordered one of her days off and to make some arrangements to
state of affairs, so work focused on ameliorating her see one of her friends on the other day. Anne noted a link
interpersonal stress would be fundamental to achieving between getting herself to her parents' house and
stable social rhythms. improvement in her mood. She also found that after
Once Anne’s therapist had completed the history-taking doing something with her friends, she felt better as well.
and interpersonal inventory, she and Anne moved into Her therapist then drew the connection between her
the intermediate phase of treatment.Anne’s therapist first increased socializing and her improved mood.
began problem-solving with Anne about how to make her As Anne continued to work on regularizing her daily
schedule more consistent at work. After discussing the routines and improving her satisfaction with her inter-
nature of Anne’s relationship with her supervisor (good personal relationships, she felt her depressive symptoms
until she had started missing work), her therapist sug- begin to dissipate. Anne’s therapist remained cognizant
gested she talk with her supervisor about requesting set of Anne’s history of mania, and kept a careful eye out for
shifts on a weekly basis. While Anne knew that, because any signs that Anne’s mood disorder was not actually
of the nature of the restaurant business, it would be nearly remitting, but rather was cycling into an episode of
impossible for her to have the same days off each week, mania. She stressed that it was important for Anne to not
she agreed that her boss might be somewhat receptive to become too overstimulated (especially considering the
the idea of at least making her shifts take place during the often hectic nature of her job), in the hopes of prevent-
same times each day, especially if it meant this would help ing a manic recurrence.
her to be a more reliable employee. With Anne’s history Anne remained in the acute phase of treatment for
of mania, her therapist suggested that she avoid the late- approximately 22 weeks, and then moved into the main-
night shifts if at all possible. tenance phase of treatment. After three biweekly ses-
Anne’s supervisor was in fact amenable to her requests, sions, Anne and her therapist moved to monthly sessions
and upon successfully obtaining a more stable work where they focused on maintaining Anne’s routine reg-
schedule, Anne and her therapist then went to work on ularity and strove to stay ahead of any potential pitfalls
regulating her sleep schedule. Using the SRM as a guide, to her progress, particularly the stress of impending
Anne and her therapist agreed on set times when Anne divorce proceedings.
would go to bed at night and get up in the morning, aim-
ing to have these times vary by no more than an hour, Efficacy of IPSRT
even on her days off. Anne’s therapist offered her edu-
cation on sleep hygiene, and explained how getting bet- IPSRT has been supported empirically through two large
ter sleep would not only help her mood, but would also studies involving the therapy in combination with phar-
make her less clumsy and forgetful at work, thereby alle- macotherapeutic interventions in the treatment of bipo-
viating some of her work-related stress and worry. lar disorder. The first of these studies18 involved 175
While this behavioral work was being done to help reg- patients with bipolar I disorder who presented for treat-
ulate Anne’s social rhythms, her therapist was simulta- ment while in the midst of a depressive, manic, or mixed
neously working with her on her role transition to being episode. In this two-phase study, these individuals were
a single woman and dealing with the stress and loneliness randomly allocated to four acute and maintenance treat-
she felt as a result of her marital separation. Her thera- ment sequences: acute and maintenance IPSRT
pist stressed the importance of creating a solid support (IPSRT/IPSRT), acute and maintenance intensive clini-
network to help her through this difficult time, encour- cal management (ICM/ICM), acute IPSRT and mainte-
aging Anne to find ways to express her feelings about her nance ICM (IPSRT/ICM), or acute ICM and mainte-

330
Interpersonal and social rhythm therapy - Frank et al Dialogues in Clinical Neuroscience - Vol 9 . No. 3 . 2007

nance IPSRT (ICM/IPSRT). Patients were seen weekly n=130), a brief psychoeducational intervention. Intensive
during the acute phase and then progressed to biweekly psychotherapy was given weekly and then biweekly for
and finally monthly sessions during the maintenance up to 30 sessions over 9 months, according to the manu-
phase. Therapy lasted approximately 55 minutes, while als for family-focused therapy (FFT), IPSRT, or cogni-
ICM sessions, which focused primarily on psychoeduca- tive-behavioral therapy (CBT). CC consisted of three
tion about bipolar disorder and addressing any issues face-to-face sessions over 6 weeks and the provision of a
with medication side effects, were roughly 25 minutes in workbook and videotape outlining the essential elements
duration. The maintenance phase lasted for 2 years. of each of the three intensive treatments. The primary
Initial analyses revealed no differences among conditions outcomes of interest were time to recovery from depres-
in terms of time to stabilization, likely due to the strong sion and the proportions of patients classified as well dur-
pharmacological impact on time to remission. After con- ing each of 12 study months.
trolling for significant covariates of survival time (mari- Patients assigned to intensive psychotherapy had signif-
tal status, significant medical comorbidities, and comor- icantly higher year-end recovery rates (64% vs 52%) and
bid anxiety disorders) we found that individuals who shorter times to recovery than did patients in CC control
received acute IPSRT survived longer without a new conditions (hazard ratio =1.47; 95% CI =1.08-2.00).
episode, regardless of the nature of their maintenance Patients in intensive psychotherapy were 1.58 times (95%
treatment (P=0.01). Patients who received acute IPSRT CI =1.17–2.13) more likely to be clinically well during
achieved significantly higher regularity of social rhythms any study month than those in CC. Post-hoc comparisons
than those individuals assigned to acute ICM (P≤0.001) of the individual intensive therapies to CC indicated sig-
and the degree of protection that IPSRT subjects nificant benefit of IPSRT with respect to time to remis-
received from the therapy was correlated with the extent sion. There was also an advantage of intensive psy-
of increase in their social routines (P≤0.05). From this chotherapy in terms of improved relational functioning.16
study, we concluded that IPSRT was an effective adjunct
to the pharmacological treatment of bipolar disorder, pri- Summary
marily in the preventative capacity.
IPSRT was also studied as one of three intensive psy- A small, but consistent, body of data now suggests that
chosocial treatments in the Systematic Treatment an intervention designed to regularize patients’ social
Enhancement Program for Bipolar Disorder (STEP- rhythms, and presumably thereby their circadian
BD).16 This multisite investigation involved 15 different rhythms, has significant positive effects on the course of
academic centers in the United States and examined four bipolar disorder. In our original maintenance trial, that
disorder-specific psychosocial approaches to the treat- effect was observed for the impact of acute treatment on
ment of bipolar disorder in conjunction with protocol- long-term survival without a new mood episode, while in
driven pharmacotherapy on time to recovery and the the STEP-BD trial acute IPSRT had a positive effect on
likelihood of remaining well following an episode of time to remission of bipolar depression. Additional stud-
bipolar depression. A total of 293 individuals with bipo- ies are under way to explore IPSRT as treatments for
lar I or II disorder were randomly allocated to intensive bipolar disorder in adolescents and as monotherapy for
psychotherapy (n=163) or collaborative care (CC, bipolar II disorder. ❏

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Terapia del ritmo social e interpersonal: una Traitement du rythme social et interperson-
intervención orientada a la falta de regula- nel : une méthode destinée à la dysrégula-
ción del ritmo en el trastorno bipolar tion du rythme dans les troubles bipolaires

El trastorno bipolar se caracteriza por frecuentes Les troubles bipolaires sont caractérisés par des réci-
recurrencias, a menudo relacionadas con la falta de dives fréquentes, souvent liées à une mauvaise
cumplimiento de la terapia farmacológica, sucesos observance du traitement, à des événements de vie
vitales estresantes y desorganización en los ritmos stressants et à des modifications des rythmes
sociales. La terapia del ritmo social e interpersonal sociaux. La thérapie interpersonelle et des rythmes
(TRSI) fue diseñada para orientarse directamente sociaux (TIPRS) a été conçue pour s’attaquer direc-
hacia estas áreas problema. Este artículo discute las tement à ces types de problèmes. Les questions des
bases circadianas de la TRSI y la importancia de ruti- rythmes circadiens dans la TIPRS et l’importance
nas diarias estables para la mantención del estado d'habitudes quotidiennes stables dans le maintien
eutímico, como también dos extensos ensayos con- d’un état euthymique sont examinées dans cet
trolados que sustentan empíricamente esta inter- article, comme dans les deux grandes études contrô-
vención. Los autores discuten las ventajas de la TRSI lées qui soutiennent empiriquement cette méthode.
tanto en la intervención aguda como en el trata- Les auteurs discutent des avantages de la TIPRS soit
miento profiláctico para el trastorno bipolar I y II. en phase aiguë soit en prévention des troubles
Utilizando un caso como ejemplo, los autores des- bipolaires de type I et II. La description d'un cas
criben la manera de implementar la TRSI en una illustre la mise en pratique de la TIPRS dans un cadre
situación clínica, detallando los procesos y los méto- clinique, en détaillant la méthode thérapeutique et
dos terapéuticos involucrados. les processus impliqués.

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