Friday, April 22, 2011

On the Road Again With NAMI Walks

In honor of Earth Day, this is the second annual Blog Post Recycling Day.  I think it is the second annual Blog Post Recycling Day.  Somebody declared one last year, and I recycled then, but I haven't actually seen anything about it this year.  Maybe because my Facebook friend who posts that kind of stuff is in church today?

Anyway, it's timely -- just one week from Johnson County, Iowa's NAMI Walk.  So my recycled blog from a month ago comes with one more plea to contribute to the organization that has contributed so much to me, making my contribution to you, dear readers, possible.

Please, please, please, click on the button to

To find out why, read:


Friday, March 25, 2011

On The Road Again -- NAMIWalks 2011

It's that time of year again.  Across the country people with mental illness, our friends, family, care providers, even law enforcement officials are pulling on our walking shoes to raise money for NAMI -- National Alliance on Mental Illness.  Last year soldiers in Iraq pulled on their hiking boots and their 40 lb. packs and ran while NAMI San Diego walked.

So what is this all about?  Here, my friends, is my testimony.

A couple years ago, I wrote a post on holiday gift giving for your favorite normal.  I asked my spouse, What would be a good present for the family member of somebody with a mental illness?

She didn't even look up from her computer.  Without missing a beat, she said, A cure.

A cure.  I know that mental illness is a family illness.  The whole family lives with it.  But her words caught me.  What she wanted was for both of us, a cure.

It's something she can't give me.  I can't give her.  My doctor can't.  You can't give it to the person you love.

We can, however, learn to manage symptoms.  We can claim the very best lives we can live.  We can live in recovery. 

Peer To Peer Program

I learned about recovery from NAMI, from their Peer to Peer program.  P2P is a ten-week course taught by people with a mental illness for people with mental illness about what we do after the doctor hands us a diagnosis and a prescription.

P2P teaches us how to live.  It is why I bust my butt for this walk.  It's not a cure.  But it's a lot.

That first class, I heard that I am not alone.  The very first note I took said, More unites us (our experiences) than divides us (our diagnoses.)

Next P2P showed me the immense dignity of those who live with mental illness.  It made me proud to know and be known by and be in community with others who live with mental illness.

It supplied tools like dialectical thinking, mindfulness, relapse prevention planning, techniques for emotional regulation and getting a good night's sleep, strategies for staying safe and coping with hospitalization.

P2P gave me something to do when medication didn't give me a cure.

And it opened for me a path into my future.  It reminded me that I am an advocate.  That is who I am.  I still have an identity, after all

So I bust my butt for this walk.  It is how I give back.

NAMI Walks

Now, the first time I did a NAMI walk, to tell the truth, I was scared.  Would it be grim?  A protest and a wailing against what is not possible, what we have lost and what we have to face?

If you have walked for NAMI, you are laughing here.  You know a NAMI Walk is so -- not grim.  It's a party!  With balloons and babies and dogs, music, belly dancers, football players, great food.  In Johnson County, Iowa, the Old Capitol City Roller Girls lead off the walk.  In San Diego, you are likely to hear a didgeridoo.

Bottom line, a NAMI walk is a gift.  It's a public demonstration to our families, friends, politicians, our neighbors, coworkers, the people in our places of worship, the viewing public -- a public demonstration that we are here for each other.  We take a break from all that wailing.  And throw a whale of a party.

At the same time, we raise funds for the programs that help us help ourselves and one another, the things that nobody else will pay for, for people who have fallen off the bottom of the budget.  NAMI does the stuff that makes a difference the day after the doctor hands us a diagnosis and a prescription.

Team Prozac Monologues debuted last year, with results that were not too shabby.  We raised $2640.  Mazie's sponsors contributed $250 toward that total.  Helen is walking in her stead this year.  Sponsors can contribute in Mazie's memory here.

Why I Walk

Me, I am walking for everybody who used to be on a three month wait list for an intake interiew at the local community mental health center; but this year that became a six month wait list at the center the next county over.  I am walking for everybody who used to  be on a four year wait list for sheltered housing; but this year the shelter shut down.

I am walking for those who are not crazy enough to pull out a gun and get the sheriff to buy their meds; they're just crazy enough to sleep in the alley behind the homeless shelter after they have stayed their ninety-day limit.

I am walking for family members who go to work wondering what is happening at home with their loved ones, now that the day program is closed.

I am walking for the resident on call in the ER who has to send home the merely suicidal, while the flaming psychotic waits for 36 hours in the hallway for the next available bed.  And for the newly diagnosed and dazed person who just got released with not enough meds to make it through the weekend, to make room for the flaming psychotic.

I am walking for the young people I know whose brains are even now being damaged in a war that we got into for oil.

I am walking in gratitude for law enforcement personnel who are trying to figure out how to do this new job, and need new training, to take care of those who have been discarded so that the very richest people in the world can get a tax cut.  I am walking in prayer for those who get caught up in somebody's suicide by cop.

This would be the place to note that the co-chairs of Johnson County's NAMI Walk this year are Janet Lyness, County Attorney, and Lonnie Pulkrabek, County Sheriff.  Props to them and to the competition between their two teams!

I did say that the Walk would be a party.  So even while I am angry that so much suffering comes not from the illness, but from the neglect, I will nevertheless celebrate those who do what they can do.  (That sentence would be an example of dialectical thinking, by the way -- see above, the curriculum of Peer to Peer.)

I am walking in wonder and amazement at the strength of the human spirit.  I am walking in deep appreciation for those who have helped me personally, for peer teachers, support group members, care providers, friends and family.

I will be walking with tears in my eyes, that my son and daughter-in-law will travel from Madison to Iowa City to walk beside me.

I am walking on April 30, 2011 in Iowa City, Iowa for all these reasons.  And I am walking also for you, dear reader.  I ask you to support me in this walk.  Click here to make your tax deductible, safe and quick contribution to NAMIWalks Johnson County.

Closing Shot

There are many versions of this song on Youtube.  I chose this one, despite the credits that run over it, because the ragged bunch of friends who sing it, some not sure of the words, illustrate the point.  We are a ragged bunch.  And pretty wonderful because of it.

The Scream by Edvard Munch in public domain
photo of Team Prozac Monologues by Judy Brickhaus
photo of homeless vet by Matthew Woitunski and used under the Creative Commons licencse
photo of New York City police officer by See-ming Lee, copyrighted and used by permission

Monday, April 18, 2011

Treating Bipolar Disorder Part III -- The Interpersonal Therapy Part

Lately I have been reviewing Treating Bipolar Disorder by Ellen Frank -- the recommendation of a friend who is researching hypomania.  Part I described the basis of Interpersonal Social Rhythms Therapy (IPSRT) in circadian rhythms that control the many physiological symptoms of mood disorders.  Part II outlined the Social Zeitgeber Theory and described the early stages of the therapy process, history taking and stabilizing social rhythms.  Today I pick up with the later stages, interpersonal therapy and maintenance.

Interpersonal Social Rhythms Therapy came to Ellen Frank in an epiphany on her birthday, July 14, 1990.  Personally, I like that.  I especially like that it was the day that she participated in a conference for people with bipolar, and listened to them.

Frank and her colleagues were already using interpersonal therapy for people with recurrent unipolar depression.  Their theory was that certain life events, particularly losses could result in lost social zeitgebers, (timekeepers), with subsequent disruption of circadian rhythms, leading to eventual relapse into another episode of depression.

IPSRT took up from there as an adaptation specifically for people with bipolar disorder, integrating the work on issues (as in, you've got issues) with greater focus on behavioral changes to achieve and maintain daily rhythms, time of rising, time of first human contact, work, main meal, etc.  The purpose of IPSRT is to help people achieve stability and then to avoid relapses into either depression or mania/hypomania. 

Why Do People Relapse?

IPSRT builds on Goodwin and Jamison's work in their classic Manic-Depressive Illness, which argues that instability is the fundamental dysfunction in manic depressive illness.  Goodwin and Jamison identify three interrelated reasons why relapse occurs for those who have been successfully treated with medication (lithium): noncompliance with medication regime; disruptions in social rhythms; and stressful life events.  IPSRT addresses all three. 

How Interpersonal Therapy Helps

The friend who brought Frank's work to my attention wonders if the interpersonal part of this mash-up (IP+SRT) is integral to the results, or if they do IP just because that is what they were already doing.  I wondered that, too.

Frank answers most succinctly in a 1994 article for the journal, The Behavior Therapist.  (And I thank her for sending me a copy.)  There she identifies the interpersonal work specifically with the third reason for relapse, stressful life events:

By addressing interpersonal problem areas in the patient's life, IP/SRT attempts to reduce the number and severity of interpersonally-based stressors the patient experiences.  We believe that reduction of interpersonal stress was important for three reasons.  First, stressful life events can have a direct effect on circadian integrity through increased autonomic arousal.  Second, many life events lead to marked changes in routine which, in turn, affect circadian rhythms.  Finally, the psychological meaning of such events frequently has the capacity to affect mood directly.

The interpersonal issues on which they focused for treating unipolar depression included unresolved grief, social role transitions, interpersonal role disputes and interpersonal deficits.  Grief for the formerly healthy self was added in their modification for for bipolar disorder.

Where To Begin

The therapist and client contract together on which issue to address in therapy, usually the one that most clearly contributed to the most recent relapse.  A tour through each issue can illustrate how closely integrated the theory and therapy indeed are.  Some of what follows is from Frank.  Some is my own take on the matter.

Unresolved Grief -- Even normal grief makes people with bipolar disorder vulnerable to a mood episode.  A death in the family brings with it all kinds of stresses.  Pick your own favorite family craziness.  Plus travel, finances, interacting with unfamiliar professionals, unresolved spiritual issues... There is a reason why funeral home directors speak in that gentle voice.  They know how close to the edge you are, and don't want to set you off.  It's called funeral parlor mania.  Add to stress the disruption of schedules, temporary for some and long term for those whose daily lives were most closely linked with the deceased.  In the chaos of events and emotions, self care, including medication can be neglected or forgotten.  Stressful life events, disruptions in social rhythms, noncompliance with medication regime -- there you have the Goodwin/Jamison relapse trifecta.

If the person with bipolar has not worked through a past grief, like, went off the deep end during the original event, he/she can return to the chaos at an anniversary or when confronted with some trigger.  Reload, repeat, relapse.

Grief For The Lost Healthy Self -- It's a real whack upside the head to be diagnosed with a serious mental illness that will be with you for the rest of your life.  Frank says it helps to acknowledge what has been lost, like meaningful work, accomplishment, recognition -- my glorious career with its circadian rhythm wrecking lifestyle.  Framing the issue in terms of grief helps people move on to acceptance of a new sense of self.  Self-expectations, concepts of healthy and ideal have to be redefined to include good judgment about self care.

I have to take her word on this.  Among the stages of grief, I have moved past stunned, and am stuck on royally pissed.  I can see that more realistic expectations could reduce stress, and that acceptance could morph into motivation to search for and stick with the program that works, including limits on those late night sessions that solve the problems of the world.  But I suspect a large part of Frank's agenda, wanting me to get to acceptance, includes acceptance of medications I don't want to take.  And I go back to royally pissed.  Notice, we have stress, schedule and meds again, all addressed in one stop shopping for resolving grief for the lost healthy self.

Interpersonal Disputes -- Perhaps because a central feature of both hypomania and depression is irritability, and because a characteristic of the "bipolar temperament" is a certain tendency toward an attitude of entitlement, interpersonal disputes tend to be common in this patient population.

Well.  The bipolar temperament and attitude of entitlement will take a whole post to unravel.  Later.

Irritability -- yes, we know that story.  Irritability is not only a symptom, it is also a side effect of medication.  How blessed is the patient whose doctor and/or therapist will explore the second possibility and not take it personally; for that bipolar II patient might get to a correct diagnosis sooner and suffer fewer years of antidepressant trials.

But one does need to save ones attitude of entitlement for the doctor's office.  When we inflict our symptomology on family, friends, coworkers, bosses, we end up in interpersonal disputes.  Therapy can teach reasonable expectations and alternate means of communicating distress.  Again, the goal is to lower stress, preventing its increased autonomic arousal and potential for circadian disruption, loss of sleep or appetite, or even being kicked out the door.  Nothing like getting fired or divorced to disrupt your rhythm and move you to your next interpersonal therapy issue:

Role Transitions -- Whether positive, negative or neutral, marriage, divorce, new parenthood, birth of child or kids leaving home, new job or retirement, new house, new town, change is difficult for people with bipolar.  We just have a hard time with change, whether it hits our relationships, social rhythms or self image.

Which is a bite, because bipolar is all about change.  The therapist's focus will be on management of symptoms, helping the client to plan transitions, possibly set limits on expectations that come with the new role or even rethink choices to decrease stress and overstimulation.

Interpersonal Deficits -- Are you chronically dissatisfied, burned all your bridges or afraid that you have in previous manic episodes?  Interpersonal deficits is one of those global issues, more difficult to tease out and to treat.  Frank recommends that it get postponed until later in treatment, and has less to say about it.  I suspect this issue includes the slush category for when therapy just gets stuck.  Interventions include a more general approach to the conflict issue, addressing patterns of interpersonal conflict, building new interests and relationships to replace those that have been lost, and exploring whether broken relationships might indeed be reconciled.

Perpetual dissatisfaction does keep that autonomic arousal system aroused and prevents the stability/rhythms that good relationships offer.  Social isolation might decrease stress.  That would be why some of us do it.  But again, it costs us the stability and the stress buffer that positive relationships offer. 

Why The Mash-Up

So interpersonal issues cause stress.  They have the potential to screw up your circadian rhythms.  They mess with your mood.  And they can interfere with the program.

The major reason for interpersonal therapy is to support the program, meds and schedule, and to intervene in whatever would mess with the program.

Living Healthy With A Chronic Disease

I was concerned about a young friend whose marital conflicts are reported with several Facebook updates every day.  I just don't get people who fight with their spouses on Facebook.  Anyway.  The emotional whip-lash between perfect and doom got so extreme that one day I picked up the phone and told her I was worried for her.  Actually, scared.  I don't let suicidal language pass by.  I reminded her of her previous diagnosis of bipolar.  Oh no, that was years ago.  I haven't taken medication for a long time.  It didn't help anyway.

Sigh.  The girl doesn't have health insurance.  Where she lives, she doesn't have access to psychiatrists nor community mental health nor support groups.  All she has is Facebook messages from friends who are not qualified to say what her diagnosis is.  I am not qualified to say what her diagnosis is, nor how it should be treated.  And my amateur armchair diagnosis goes to a different section of the DSM anyway.

But if it's bipolar, it won't go away.  That the meds stopped working has nothing to do with it.  That's what meds do.  They stop working.  They never were able to prevent relapse, only postpone it.

It is not helpful when doctors tell us that if we don't take our meds for the rest of our life, we will get sick again.  They imply a promise that the meds won't keep.  We probably will get sick again.  The meds help.  They do not cure.  When we relapse, we quit taking them, because they didn't live up to the sales job.

If you have bipolar, you have to take care of it every day, or it will get the best of you.  Every day for the rest of your life.

Now if you do that, you can have a life.  It may or may not be the life you planned on.  But it can be a good life.  And a hellava lot better than if you don't take care of it.

Meds alone do not solve the problem.  This is what Ellen Frank heard over and over on July 14, 1990, when she listened more than she talked at a conference for people with bipolar.  And she decided to find something that would do better.

Those who have been at this for a long time say that #1 is lifestyle.  #2 is support.  #3 is meds.  IPSRT is about helping you learn a lifestyle that will maximize the success of treatment.  And NIMH agrees.  People who take meds do better if they also do IPSRT than if they do just meds alone.

Maintenance Treatment For Bipolar Disorder 

The last part of IPSRT is sticking with it.  

Once you've got a workable program, have a better handle on what would interfere with the program and know how to adapt to changing circumstances, appointments become less frequent, every two weeks, once a month, once a quarter, whenever something major comes up.

Things do come up.  Not all of them are events.  The fundamental dysfunction in manic depressive illness is instability.  You go up, you come down.  You do your best to create and maintain what stability you can.  Then you monitor your moods, your energy level, your sleep, the volume of your voice, the rapidity of your thoughts, the number of projects you take on, looking for evidence that things are slipping.

The IPSRT therapist and client learn to recognize the warning signs of an impending episode, and then to respond.  Interventions might include ratcheting up or down the level of stimulation one is experiencing.  Maybe you need to get out of the house more.  Maybe you need less time with your chronically hypomanic buddy.  Maybe the book you are reading at night is too stimulating, and a different author will solve your sleep issue.  Or maybe you could use a few nights of "rescue" medication for sleep to nip that incipient hypomania in the bud.  Maybe your regular meds need adjusting.

The earlier the intervention, the more successful.  It's all about the right balance, knowing how far you can move off center and how to get back. 

Hope For Living With Bipolar Disorder

If your meds don't work well enough or if they don't work at all, there are more tools in the tool box.  I love this book.

So after a break next week, I will finish up with a little nitpicking and my overall recommendations regarding Treating Bipolar Disorder, by Ellen Frank.

photo of book cover from
flair from facebook
photo of jenga blocks by Jason7825, used under the GNU Free Documentation License
photo of roller coaster by WillMcC, used under the GNU Free Documentation License
photo of dirty dishes by Mysid and in the public domain

Thursday, April 7, 2011

Treating Bipolar Disorder Part II -- The Social Zeitgeber Theory in Action

So you have bipolar.  You know you have bipolar.  You are way past the denial stage.  You are into the pulling out your hair, screaming with frustration stage.  Or maybe moved on to despair stage.  Because:
  1. The medication sucks.
  2. You keep getting sick again anyway.
But contrary to what everybody has been telling you, medication is not the only thing that works.  It may be essential to your recovery and continued functioning.  But you can do better if you do more.  From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention?  Today we continue with Ellen Frank's Treating Bipolar Disorder, in which she describes this therapy of her invention.

What Happens In IPSRT

After diagnosis with bipolar I or II (primarily designed for bipolar I), IPSRT proceeds roughly in four stages:
  • history-taking with education about bipolar and orientation to the treatment
  • evaluating and then stabilizing social rhythms
  • addressing interpersonal problem areas appropriate to the individual
  • monitoring progress and termination

An Integrative Theoretical Model: Social Zeitgeber Theory

Therapy generally begins with history-taking, going over the client's life story with focus on factors related to the therapist's theoretical orientation.  The intake interview for IPSRT is guided by its own theory of how people with bipolar get off kilter.

Off Kilter.  Like:

Here is the flow chart for Social Zeitgeber Theory, with my comments in italics:

Well, first you start with your life.  Then, more life happens.

Life Events Affecting Interpersonal Relationships
and Social Roles

Like, you get laid off from work.

Change in Social Prompts (Social Zeitgebers)

So you don't have anywhere to go in the morning.

Change in Stability of Social Rhythms

So, whatever.  You party wherever, sleep whenever.

In these early stages, you may have a variety of mitigating factors, reducing the disruptive impact of whatever life event just started this slide.  Frank lists social supports, coping, gender and temperament as potential protection.  Maybe you have a dog who will insist on her 6 AM run, no matter what you have in mind.

 Good dog.

Change in Stability of Biological Rhythms

Lacking a dog to keep your social life sane and your out of bed hour regular, the hormones governing sleep don't know when to come online.

Change in Somatic Symptoms

Uh-oh.  Here comes the insomnia again.

Again, Frank lists mitigating factors.  You may have a genetic background that makes you more or less vulnerable to these disruptions.  Or you may have previous treatment experience, so that you recognize when you are in trouble and change your ways before you go off the rails.  If something doesn't turn this train around, then...

Mania or Depression = Pathological Entrainment of Biological Rhythms

In other words, mania and depression happen when your lack of normal becomes your normal.

Been here before, have we?

IPSRT Theory Integrates Social, Psychological and Biological Explanations Of Mood Episodes

Notice, life events, emotional and behavioral responses to these events, and subsequent physical symptoms are all included in the development of a mood episode -- the whole person, not just the final so-called chemical imbalance.  The target of medication is the bottom of the line.  But any of these stages is an appropriate point of intervention and prevention.

This is really good news for people whose medication isn't up to doing the whole job.

History Taking

Lots of case studies make the book readable and illustrate points along the way.  Frank tells the stories of individuals who functioned well until a disruption in social patterns triggered a depression or a mania.

An IPSRT therapist helps the client create a time line tracking the current and past episodes of depression, mania and hypomania with attention to what preceded the onset, or started the descent into the train wreck outlined above, particularly disruptions in social rhythms.  This history-taking begins the educational process and makes the case for the behavioral changes the therapist will recommend.

As I read, episodes from my own life came to mind.  I used to be a legislator in a national church convention that happens every three years -- extremely stimulating events.  I was on 14-16 hours a day, 11-12 days in a row.  I would be living in strange surroundings, eating restaurant food at irregular hours, on a work schedule invented by the devil.  I always "rose" to the occasion, was energetic, productive, persuasive, effective, charming... hypomanic.  Some of my readers can give an Amen to that statement.  What they didn't know was that I went home from two weeks of brilliance to begin another several months of depression.  The classic bipolar II cycle before it progressed to rapid cycling.

This life review did indeed make the case for me.  There is no IPSRT therapist in my area.  So I moved on to stage two on my own.

Evaluating And Stabilizing Social Rhythms

The challenge begins here.  Having come to suspect that irregular habits contribute to mood disturbances, now we establish just how irregular the client's habits are.

Frank and colleagues developed a chart, the Social Rhythm Metric to track the times that seventeen different events occur each day, getting up, first contact with another person, time to work or school, meals, and so on.  Seventeen.  What time does each happen today.  Every day.  For three weeks.  To start.  If I know my friends with bipolar, we would bail right here.

Then there is a formula to determine the average time of occurrence for each activity, the deviation each day, and the total of all the deviations.  It's more complicated than that.  But I decided to pass on the flow chart.  The client doesn't have to do the math; the therapist does.  I imagine this is where the potential therapist bails.

Never mind.  They figured out which five activities give you the most bang for your buck.  The book recommends the five item version for clients who are not well enough to do track all seventeen.  I hope sometime since the book was published, Frank has changed her interpretation of the resistance to the longer instrument.  Maybe it's not the clients who are too sick to do it.  Maybe it's just an unwieldy instrument.

So I started to track five items.  The shorter instrument also asks how stimulating the activity was on a 0-4 scale.  By the third day, I was in tears and had managed to record no more than two activities each day.  Toward the end of the book, Frank acknowledges that people who have been sick a long time may have cognitive deficits and be able to handle only one or two items.

That's me, cognitive deficits.

Choose A Place To Start

Nevertheless, I moved on to a decision -- get up at more or less the same time every morning.

Of course, getting out of bed anchors other social rhythms, what time I greet my wife, what time I eat breakfast.  At the other end, I have to structure my evening so that I sleep better and long  enough to wake up at the appointed hour.

There are other self care activities/rhythms anchored by getting out of bed.  If I am out of bed before I drink my first cup of coffee, I do my stretches, I say my prayers -- habits that went by the wayside when my out of bed time was disrupted a couple years ago. 

There is significant meaning attached to doing these self care activities that are anchored by getting out of bed -- which affects my mood.

Pretty soon I've got some positive movement in social, psychological and biological realms, my whole person.  My normal baseline, from which I veer violently up and down, is mild depression.  Lately, that seems to have lifted ever so slightly.  We'll see.

See, I didn't need to track five items.

That's Fine For You But My Life Isn't That Regular...

I never said that IPSRT is easy.  But it might help.

In fact, it seems pretty difficult to me.  And Frank acknowledges that.  Treating Bipolar Disorder is written for clinicians.  Her advice to clinicians is to expect resistance, to normalize resistance, and to review, whenever needed, the multiple motivations for the difficult changes that are required.
  • What did the time line indicate?  Is there a connection between loss of social rhythms and onset of episodes?  (If not, then this is not the therapy for you.)  But if there is...
  • What has this illness cost you already?  What will it cost you in the future if you cannot manage your symptoms better?
  • What issues (therapy-type issues) prevent you from making these changes?

We continue with issues, the IP part of IPSRT, next.

flair from facebook
photo of Train wreck at Montparnasse Station, 1895 in public domain

Monday, April 4, 2011

Treating Bipolar Disorder Part I -- Interpersonal Social Rhythms Therapy

Medication And Mental Illness

Medication for mental illness is just like medication for anything else.  It works better when you don't ask it to do all the work itself.

In the case of bipolar, once lithium and the chemical imbalance theory came along, the thinking was that medication was the only thing that worked.  Therapy by itself certainly didn't.  I wonder if therapists, worn out by their bipolar patients, were simply relieved to believe that medication was the only thing that worked.  I wonder if therapists today, worn out by their recurrent depression patients, are secretly relieved to terminate when the diagnosis changes to bipolar, because medication is the only thing that works.

Frankly, there is a lot of wishful thinking out there in pharmacotherapy land.  If only our brains were a chemical stew and the illnesses of the brain could be treated by adjusting the recipe.  If only.

But people with mental illness, especially people with bipolar, can't afford the wishful thinking behind the better living through chemistry fantasy.  Sometimes the medications do work.  But not as well nor as often as your doctor would like to think.

I have a friend who is a psychiatrist.  He challenges his colleagues who keep trying to solve this noncompliance issue, to get their patients to comply.  He reminds them, if the medication (antidepressants, in this example) worked for 40% of those who took it in the trial, and the placebo worked for 30%, that means only three out of ten people benefit from the medication itself.  So what's the big deal about seven who quit?

He says they just look at him funny.

Treating Bipolar Disorder by Ellen Frank

This same friend, God bless him, loaned me a book about a psychotherapy designed specifically for bipolar disorder titled, appropriately enough, Treating Bipolar Disorder.  The author Ellen Frank, professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at Western Psychiatric Institute and Clinic, and her colleagues invented Interpersonal Social Rhythms Therapy (IPSRT), a kind of mash-up between talk therapy and regulating circadian rhythms.  It gets my next few posts.

In A Nutshell... 

IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

In other words, the therapy focuses first on getting your daily activities on a regular schedule.  That will support your body's internal schedule and reduce the manias, hypomanias and depressions of bipolar.  Then the therapy turns to the classic issues of talk therapy, particularly those that interfere with a regular schedule, like grief and conflict.  The long term goal is to anticipate and manage whatever would throw your routine off track, so that new episodes are not triggered, or are identified and interrupted quickly.

IPSRT was designed for bipolar I, but can also be used for bipolar II.  For the latter, the therapist is not so concerned to get you to take your meds.  Which is good, because while there are always people for whom an ineffective med is effective, mostly the meds for bipolar II depend on the placebo effect.  Now that the placebo effect has worn off for me, I am delighted to learn the following:

Medication Is Not The Only Thing That Works -- STEP-BD

IPSRT is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

The other psychotherapies studied were family focused therapy and cognitive behavioral therapy.  None showed an advantage over the others.  Each was better than medication alone.

Circadian Rhythms -- Your Interior Clock

IPSRT is unique in its attention to circadian rhythms, the biochemical, physiological and behavioral processes that are driven by the twenty-four hour cycle of the day.  There are lots of these rhythms.  If your schedule is relatively regular, your body prompts you to wake up, feel hungry, have peaks and lows of energy and get sleepy at about the same time of day every day.

These are not simply habits.  Your body signals each of these by releasing hormones like cortisol and neurotransmitters like melatonin on a cycle.  Your body temperature rises and falls on a cycle.  Your digestive juices flow on a cycle.  Your kidneys even empty into your bladder on a cycle.

These cycles are called a circadian rhythms.  They are interrelated and are regulated by an interior clock.

Circadian rhythms are why people get so grumpy by the time change every year, all that springing forward and falling backward, why changing work shifts interferes with sleep, and why travel across time zones causes jet lag.  Our clocks don't like to be messed with.

Some people don't mind the time change.  They fall asleep whenever anybody tells them to go to bed.  The day after a transcontinental flight, they are as perky as ever.  They can reset their interior clocks on demand.  These people do not have bipolar disorder.

The clocks of those who do have bipolar disorder are less flexible.  And those who do not expect their medication to do all the work, who work on recovery, pay attention to their cycles, learn from each other -- these people know this.  We respect our circadian rhythms, because when you mess with our clocks, they mess with us.

Insomnia And Mood Disturbance: Chicken And Egg

When I told my former pschiatrist that the antidepressant-induced insomnia was making my depression worse, she countered that insomnia is a symptom of depression, and would go away as the antidepressant took effect.  That was the end of the discussion.  But there has been considerable research on circadian disregulation and mood disorders, some of it supporting my side of this chicken and egg argument.

Prozac Monologues has made recent forays into the possibility of treating depression by treating sleep disorders directly, sleep cycles being a foundational circadian rhythm.  Treating Bipolar Disorder reviews the basic research behind the miscellaneous studies I mentioned, endearing the book to my heart.  It made me feel very smart.

But seriously, when you are the lab rat in the chemistry experiment, trying to find the medication that works, it is first frustrating and eventually flat out scary when the doctor rejects the reported results of the experiment because it conflicts with her theory.

So how extraordinary to find a treatment that was developed when a doctor listened!

The IPSRT Story

Treating Bipolar Disorder begins with a story, how Dr. Frank invented IPSRT in one flash at the end of a fly in/fly out day at a convention for the National Depressive and Manic-Depressive Association (now called the Depression and Bipolar Support Alliance, DBSA).  It was for her an unusual exposure to people who actually live with bipolar.  Contrary to her understanding that bipolar disorder was a problem solved, she heard the real stories of people living with stigma, underemployment and doctors who discouraged them from participating in activities that meant something to them.  She discovered the planners of the convention had anticipated that people would have problems from overstimulation, and had prepared for it with an emergency hospitalization protocol.  She found people hungry for more attention to and information about the psychosocial dimensions of the illness.

As the door to the limousine closed... I knew with absolute certainty that I needed to dedicate the next decade of my life to doing better by these patients and their family members.  No sooner were the words formed in my head than I knew exactly what to do: Combine IPT [interpersonal therapy] with a social rhythm regulation treatment.

As Dr. Frank describes it, My colleagues and I had argued in papers... that the major mood disorders (major depression and bipolar disorder) reflected, among other things, a disruption in circadian rhythms, a disturbance in the body's 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, even mood itself.  Furthermore, we said that 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 body's clock.  When social factors function in this way, they become social zeitgebers.

Zeitstorers/Time Disturbers

We had also argued that changes or interferences in social routines, which we termed zeitstorers (or time disturbers), could disrupt the body's clock and destroy the body's naturally synchronized rhythms.  We concluded that, in those who were vulnerable to mood disorders, it was the loss of social zeitgebers or the appearance of zeitstorers that led to new illness episodes (depression or mania).


During that flash in the limo, I knew that it would be relatively easy to borrow some of the scheduling and monitoring techniques of cognitive therapy and refashion them for the purpose of helping patients to establish and maintain regular social rhythms.  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...

Next week: what happens in IPSRT.

photo of weightlifter in public domain from the Bundesarchiv
flair from facebook
book cover from
photo of clockworks by HNH and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license

Saturday, April 2, 2011

The Termites Ate My Blogpost

They ate my baseboards, actually.  But the effect, as zeitstorers, was the same.  My apologies to regular readers who are waiting for my next post.  It will tell you what zeitstorers are, in the first installment of a review of Ellen Frank's Treating Bipolar Disorder.  The image here is a hint.

Coming soon...