Showing posts with label sleep. Show all posts
Showing posts with label sleep. Show all posts

Interpersonal Social Rhythms Therapy: Good, Bad, and Ugly (Mostly Good)

Following #bipolar on Twitter for the last few years, I am often dismayed. So many people seem to spend so much time struggling with their medications and so little time focused on anything else that could help.

Don't get me wrong. Medication is an important tool for managing bipolar disorder. But it can't do the whole job. Education and life style changes are crucial for getting off the roller coaster of constant med adjustments to address the episode du jour.

I decided it was time to revisit my 2011 review of Ellen Frank's Treating Bipolar DisorderIt was a four-part review. The last three posts describe the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the educational foundation, describing the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory


How the Social Zeitgeber Theory Works, for Good or Ill - IPSRT

This -- this system is the gift I wish I could give to the people I meet on Twitter who struggle with their bipolar, who are in endless rounds of medication adjustments and medication failures and medication despair. Medication isn't the only thing you can do. I'm not saying quit your meds. I'm saying, add social rhythms therapy. Originally posted in 2011:

Ellen Frank - Treating Bipolar Disorder, Part 2

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 Disorderin which she describes this therapy of her invention.

What Happens In IPSRT

Are You Asking Your Meds to do All the Work?

Where is my magic pill? They say it takes a while to find the right medication, you just have to stick with it.

But for how long? How many chemistry experiments? When? WHEN will my bipolar get fixed?

This was me, resisting therapy, resisting exercise, resisting every other suggestion my doctor made. Alas, here are the pills that finally did the trick:

Pills are not enough.

A Few More Holiday Survival Tips for Loonies

I know, I know.  This post is late in coming.  People have been googling prozac and holidays and bipolar and holidays for weeks.  Good for you.  You are following your therapists' advice to reduce your anxiety by thinking through your triggers and how you will handle them.

Most of what follows was first posted on November 20, 2010.  In light of recent developments in Loony Land (referring to them this time, not us) I added a section on prejudice.  Think of it as tweaking the traditional Thanksgiving fare with this year's rage for bacon and Brussels sprouts.

So here we go:


Ah, the holidays!  Time when far flung family members travel home and grow close around the turkey table.  Time to renew friendships in a round of parties and frivolity.  Time to go crazy?

Holiday Survival Tips for Loonies


People are already googling prozac and holidays and bipolar and holidays.  This is excellent.  You are following your therapists' advice to reduce your anxiety by thinking through your triggers and how you will handle them.

So as a public service to my readers, I repost a slightly editted Holiday Survival Tips for Loonies from November 20, 2010:


Ah, the holidays!  Time when far flung family members travel home and grow close around the turkey table.  Time to renew friendships in a round of parties and frivolity.  Time to go crazy?

Stages of Recovery - AKA Hope

It gets better.  It really does.

People who get tired of the Chemistry Experiment go off their meds.  Why?  Because the meds don't work.  Or they make us sick.  And the doctor doesn't hear us, because the doctor has one tool in his/her toolbox.  [Hint: It's not an ear.]  And he/she thinks that the solution to our problem is compliance, because there isn't time for listening and problem solving.

When you walk into a hammer store, they will try to sell you a hammer.  Fair enough.  If you are trying to rebuild the life that your illness took from you, chances are you will need a hammer.  Chances are you will need some other tools, as well.

The doctor doesn't have those other tools.  But they are out there.  And so is the map.

You are angry that the meds promised what they could not deliver.  Get over it.  Pull out the map.  Or the toolbox.  Mixed metaphor.  Whatever.  Get over it.  Get to work on your recovery.

The Recovery Map

Treating Bipolar Disorder Part IV -- Summing Up

Intending to review Ellen Frank's Treating Bipolar Disorder, I spent most of April describing the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the foundation in work done on the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

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?

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

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.

Health Policy of Sleep

Pharma/Research/Medicine Industrial Complex

A psychiatrist friend directed me to PharmedOut.org, a  source for all things seedy in medical research, medical education, and the sale of pharmaceuticals.  I don't need to repeat what you already know about ghost writing research articles, how pharma gets around restrictions on bribes by paying doctors to "teach," the sample scam, etc.  I am not spending time this week on what I didn't know until now about the editorial/advertising relationship in medical journals, or that the drug companies are the major subscribers to these journals and give them to doctors, and are the major purchaser of reprints (at inflated prices) to be distributed by drug reps to doctors.  But it is more of the same.  Just thought I'd mention it.

We go round and round about this.  Still, every research article ends with a cry for more funding, which will come from just one source.  Every doctor gets everything he/she knows about medications ultimately from just one source.  Every friend and family member who wants to help repeats the message taught by one source -- Keep trying.  Translation: keep buying drugs.

Addicted To Big Pharma

Sleep -- The Real Antidepressant

Your sink has backed up three times in as many weeks.  This time the plunger won't work, and it's beginning to stink.

The hardware salesman says you need a new garbage disposal -- $169.00.

Your plumber takes the pipes apart and clears the plug.  Depending on the plumber, she might show you how to do it yourself next time.  (My plumber is a woman.) -- $60.00 in my neighborhood.

Your brother says, stop putting banana peels in the garbage disposal.  (My brother owns rental property, and tells me what the plumbers almost always find in the plug.) -- $0.00.

The hardware salesman says a better garbage disposal could handle banana peels, and whatever else might also be causing that plug -- $249.00.

All of them are trying to help.  Each of them is working with the tools at his/her disposal.

Okay, now let's look at your depression.

Remember last week's list?

DSM On Depression -- The Chinese Menu

More on Sleep and Mental Illness

Last week's post on postpartum depression and sleep led me to a ring of articles about the link between sleep and mood.  So here we go again -- I have stumbled on another series!

My opening shot is piece my son and I used to watch from a Sesame Street bedtime video.  If it inspires you to go take a nap, that's fine by me.  You can read this post later.



Only, one line isn't correct.  It really doesn't matter, don't you know it's so.  'Cuz you sleep in so very many ways.

Sleep Matters

It does matter.  That guy yawning over his book might have pulled an all-nighter.  If he does that often, or stays up late, or changes shifts, he might be sleep-deprived.  Which puts him at risk for depression and suicidal thoughts.

Really.

Not to mention that goose egg.

What Is Suicidality

The studies I will be citing refer to suicidality.  So let's start by defining that term.  Actually, the word is used loosely, refering to a range of behaviors, in some places as the intent or attempt to kill oneself, in other places as anything from occasional thoughts to attempts.  Any of which is unpleasant, much of which is terrifying.

Suicidality And Depression

Doctors used to think that only people who were depressed committed suicide.  If somebody with schizophrenia committed suicide, they concluded that the diagnosis had been in error, because people with schizophrenia don't commit suicide.  So the theory went.  Notwithstanding what you have been taught about people who call themselves scientists, even in science it is easier to change your facts than to change your mind.

The general public still tends to accept that idea, suicide=depression.  When somebody they know commits suicide, the assumption is that they missed the signs of depression.

The vast majority of those who commit suicide are depressed.  However, not necessarily so.  People who have other mental disorders, or are in chronic pain, or have been diagnosed with a terminal illness, or have suffered a failure or humiliation, or just too many things and finally one thing too many are all at risk.  As David Conroy explains, Suicide is not chosen; it happens when pain exceeds resources for coping with pain.  Whatever the pain. 

Suicidality As The Tip Of The Iceberg

The Diagnostic and Statistical Manual of Mental Disorders (DSM -- psychiatry's bible) lists suicidal thoughts and behavior as just one symptom in their Chinese menu approach to depression -- one from column A, five from columns A and B.  You don't have to be suicidal to get the diagnosis.  But it is the symptom that really gets their attention.


If you have suicidal thoughts or behavior, then something is going on.  The odds are depression, but at least something.  And obviously, it's not fun.  So it is worth addressing, before it sinks your ship.


Sleep Disturbances And Suicidality

So here is a study that discovered, whatever else is going on in your life -- insomnia more than doubles your risk of suicidal thoughts, planning, action.

It doesn't matter whether you have depression, anxiety disorder or other mood disorders, or chronic medical conditions such as stroke, heart disease, lung disease and cancer.  It doesn't matter whether or not you are abusing drugs or alcohol.  Age, gender, and marital and financial status don't matter.  All of these are risk factors in themselves.  But whatever risk factors you may or may not have, insomnia more than doubles your risk of suicidal thoughts, planning and/or action.

Insomnia comes in three flavors in the medical world: trouble falling asleep, waking in the middle of the night, and waking too early in the morning.  The last has the greatest risk.

Irregular Bedtime And Suicidalality

There are other studies that examine particular applications of the poor sleep/suicidality connection.  Here is one that examines what happens to young adults when they don't go to bed at the same time every night.

The Florida State University Laboratory for the Study of the Psychology and Neurobiology of Mood Disorders, Suicide, and Related Conditions discovered that actively suicidal undergraduates got an average of 6.3 hours of sleep a night -- way not enough sleep.  This we could anticipate.

Then they examined another factor, how much their bedtimes varied -- an average 2.8 hours.  For example, they might go to bed some nights at midnight, other nights at 3 AM.  So they sorted subjects by the second factor, how much bedtime varied.  Regardless of the severity of an individual's depression, the more variable the bedtime, the more suicidal the student became over the course of three weeks.

Get that?  All by itself, how much bedtime varied, all by itself, predicted increasing suicidality.

Varied bedtime also predicted the intensity of mood swings.  Which is significant, because suicide is associated with mania as well as with depression.  Both are indicators of poor cognitive function and poor impulse control.

Not to mention a bad report card.

Adolescent Bedtimes And Suicidality

So here is one more, this one on teenagers.  (Teen do not have the highest suicide rates.  But they do seem to get the most press and the most research dollars.)

James Gangwisch, PhD, of Columbia University studied the sleep habits of 15,659 teens.  He reports that teens whose parents enforced a midnight bedtime were 24% more likely to have depression and 20% more likely to have suicidal thoughts than teens whose parents enforced a 10 PM bedtime.

The 10 o'clockers got an average of eight hours and ten minutes of sleep at night, compared to seven hours and thirty minutes for the midnight crowd.  Both were short of the nine hours that teenagers need, which would account for the general crankiness of most teenagers you know or are.

Oh, and that Nobody else's parents make them... argument?  More than half of parents enforce the 10 PM bedtime.  And 70% of teens comply.

I didn't find a study on the relationship of sleep and report cards.  But some scientists surmise from this and other studies that sleep deprivation may be the real reason for the United States' slip in global competitiveness.

The Good News About Sleep Deprivation and Suicidality

The good new is coming next -- implications for treatment of mood disorders and other causes of suicidal thoughts and behavior.

Now get off the computer and go to bed.

photo of scales from Deutsche Fotothek of the Saxon State Library
 photo of Chinese menu by Hoicelatina, permission to copy under the terms of the GNU Free Documentation License
photomontage of iceberg created by Uwe Kils (iceberg) and User:Wiska Bodo (sky), permission to copy under the terms of the GNU Free Documentation License
flair from facebook 

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