Introduction
Interpersonal and social rhythm therapy in the treatment of bipolar disorder can assist patients in reducing the stressors leading to acute episodes. The ideal treatment for bipolar disorder includes treatment of an episode of mood disturbance, a period of stabilization of symptoms and finally discharge to primary care services. However, evidence suggests the importance of psychotherapy for effective treatment. Interpersonal and social rhythm therapy is one such psychotherapy combining interpersonal interactions with social relationships and demands or tasks involved in biological rhythms.
Objective
To compare the clinical effectiveness of interpersonal and social rhythm therapy with treatment as usual in bipolar disorder.
Patients and Methods
A randomized clinical trial comprising 88 patients with bipolar I or bipolar II disorder. The patients were divided into two groups:
- Group A (n=43): Interpersonal and social rhythm therapy along with medication
- Group B (n=45): Treatment-as-usual (general practice medical care)
Study Duration
18 months
Outcomes
Primary Outcome measures
- Severity of Depression and Mania
Secondary Outcome measures
- Social Functioning
- Quality of Life
Result
- In both the groups, the majority of the patients were female and had bipolar I disorder.
- It was observed that, at baseline, 28% of the interpersonal and social rhythm therapy along with medication participants were taking lithium, 44% were taking another mood stabilizer, 49% were taking antipsychotics and 51% were taking antidepressants.
- In the treatment-as-usual group, 33% were taking lithium, 36% were taking another mood stabilizer, 56% were taking antipsychotics and 56% were taking antidepressants.
- Around 42% of the participants undergoing interpersonal and social rhythm therapy along with medication and 40% participants taking the treatment-as-usual had a mood episode.
- Even in a repeated intention to treat analysis, no significant statistical differences in rates of mood episodes between the two groups were observed.
- During the per protocol analysis, 40% patients relapsed in the interpersonal and social rhythm therapy along with the medication group as compared to 31% in the treatment-as-usual group (OR=0.76, 95% CI=0.31 — 1.86, p=0.55).
- Majority of the mood episodes for both the groups happened during the first 20 weeks of the study.
- No significant differences between the two groups were observed for the Longitudinal Interval Follow-up Evaluation (LIFE) scores for the incidence of any mood episode (U=962.5, p=0.60), depression (U=896.0, p=0.95), or mania (U=1,002.0, p=0.39).
- Statistically notable differences were observed in the Social Adjustment Scale (SAS) scores for both the groups.
- Greater improvement in the following subscales of the SAS was seen in the interpersonal and social rhythm therapy along with medication group: friction (t=2.58,df=69,p=0.01,effect size=0.67); social and leisure activities (t=2.0, df=69, p=0.05, effect size =0.68); parental (t=2.23, df=20, p=0.04, effect size=0.88); and interpersonal behavior (t=2.532, df=69, p=0.02, effect size=0.54).
- Only 14% participants from the interpersonal and social rhythm therapy along with the medication group required remission to a mental health service as opposed to 40% of those belonging to the treatment-as-usual group. (OR=3.83, CI=1.32–11.12, p=0.01)
- The percentage of participants taking lithium and other mood stabilizers was the same as the percentage at baseline, 28% (N=12) and 44% (N=19), respectively in interpersonal and social rhythm therapy along with the medication group.
- A dip in antipsychotic use (49%, N=20) and an increase in antidepressant use (67%, N=29) was also observed.
- In the treatment-as-usual group, it was found that the use of medications had decreased for all the medications compared to the baseline wherein 30% (N=13) were taking lithium, 31% (N=14) were taking another mood stabilizer, 38% (N=17) were taking antipsychotics and 40% (N=18) were taking antidepressants at the end of the study.
- Higher use of antidepressants was observed amongst the interpersonal and social rhythm therapy along with the medication group as compared to the treatment-as-usual group at the end of the study (OR=0.34,CI=0.13 — 0.87, p=0.02).
Conclusion
The combination of interpersonal and social rhythm therapy along with medication did not distinctly improve mood relapse but it played a key role in improving patient functioning.