Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder.

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

Psychotherapies at a Glance: Consensus Guideline-Recommended Psychotherapies for Adults With Psychiatric Disorders.

Clinical decision making by psychiatrists and informed consent by patients require knowledge of evidence-based psychotherapies (EBPs) and their indications. However, many mental health professionals are not versed in the empirical literature on EBPs or the consensus guideline recommendations derived from this literature. The authors compared rigorous national consensus guidelines for EBP treatment of DSM-defined adult psychiatric disorders-derived from well-conducted randomized controlled trials and meta-analyses and from expert opinions from the United States, United Kingdom, and Canada-to create the Psychotherapies-at-a-Glance tool. Recommended EBPs are cognitive-behavioral therapy, family therapy, contingency management, dialectical behavior therapy, eye movement desensitization reprocessing, interpersonal psychotherapy, mentalization-based treatment, motivational interviewing, peer support, problem-solving therapy, psychoeducation, short-term psychodynamic psychotherapy, and 12-step facilitation. The Psychotherapies-at-a-Glance tool summarizes the indications, rationales, and therapeutic tasks that characterize these differing psychotherapies and psychosocial treatments. The tool is intended for use in clinical teaching, treatment planning, and patient communications.

Feasibility and Acceptability of Group Interpersonal and Social Rhythm Therapy for Recurrent Mood Disorders: A Pilot Study.

OBJECTIVE: Interpersonal and social rhythm therapy (IPSRT) was developed to empower patients with mood disorders by stabilizing underlying disturbances in circadian rhythms and by using strategies from interpersonal psychotherapy. Group IPSRT has not been studied with a transdiagnostic sample of patients across the life span with either major depressive disorder or bipolar disorder. METHODS: Thirty-eight outpatients, ages 26-80, with major depressive disorder or bipolar disorder in any mood state were recruited from clinics in the Netherlands and were treated with 20 sessions (two per week) of group IPSRT. Recruitment results, dropout rates, and session adherence were used to assess feasibility. The modified Client Satisfaction Questionnaire (CSQ) and a feedback session were used to measure treatment acceptability. Changes in mood symptoms, quality of life, and mastery were also measured. RESULTS: Participants' mean±SD age was 65.4±10.0 years. Participants were diagnosed as having major depressive disorder (N=14, 37%) or bipolar disorder (N=24, 63%). The dropout rate was relatively low (N=9, 24%). High CSQ scores (32.3±5.2 of 44.0 points) and low dropout rates indicated the acceptability and feasibility of group IPSRT for major depressive disorder and bipolar disorder. Quality of life 3 months after completion of treatment was significantly higher than at baseline (p<0.01, Cohen's d=-0.69). No significant differences were found between pre- and postintervention depressive symptom scores. CONCLUSIONS: Twice-weekly group IPSRT for older outpatients with major depressive disorder or bipolar disorder was feasible and acceptable. Future research should evaluate the short- and long-term efficacy of group IPSRT for major depressive disorder and bipolar disorder among patients of all ages.

Neurobiological and behavioral mechanisms of circadian rhythm disruption in bipolar disorder: A critical multi-disciplinary literature review and agenda for future research from the ISBD task force on chronobiology.

AIM: Symptoms of bipolar disorder (BD) include changes in mood, activity, energy, sleep, and appetite. Since many of these processes are regulated by circadian function, circadian rhythm disturbance has been examined as a biological feature underlying BD. The International Society for Bipolar Disorders Chronobiology Task Force (CTF) was commissioned to review evidence for neurobiological and behavioral mechanisms pertinent to BD. METHOD: Drawing upon expertise in animal models, biomarkers, physiology, and behavior, CTF analyzed the relevant cross-disciplinary literature to precisely frame the discussion around circadian rhythm disruption in BD, highlight key findings, and for the first time integrate findings across levels of analysis to develop an internally consistent, coherent theoretical framework. RESULTS: Evidence from multiple sources implicates the circadian system in mood regulation, with corresponding associations with BD diagnoses and mood-related traits reported across genetic, cellular, physiological, and behavioral domains. However, circadian disruption does not appear to be specific to BD and is present across a variety of high-risk, prodromal, and syndromic psychiatric disorders. Substantial variability and ambiguity among the definitions, concepts and assumptions underlying the research have limited replication and the emergence of consensus findings. CONCLUSIONS: Future research in circadian rhythms and its role in BD is warranted. Well-powered studies that carefully define associations between BD-related and chronobiologically-related constructs, and integrate across levels of analysis will be most illuminating.

Interpersonal Psychotherapy's problem areas as an organizing framework to understand depression and sexual and reproductive health needs of Kenyan pregnant and parenting adolescents: a qualitative study.

BACKGROUND: Peripartum adolescents experience significant interpersonal transitions in their lives. Depression and emotional distress are often exacerbated by adolescents' responses to these interpersonal changes. Improved understanding of pregnancy-related social changes and maladaptive responses to these shifts may inform novel approaches to addressing the mental health needs of adolescents during the perinatal period. The paper aims to understand the sources of psychological distress in peripartum adolescents and map these to Interpersonal Psychotherapy's (IPT) problem areas as a framework to understand depression. METHOD: We conducted interviews in two Nairobi primary care clinics with peripartum adolescents ages 16-18 years (n = 23) with experiences of depression, keeping interpersonal psychotherapy framework of problem areas in mind. We explored the nature of their distress, triggers, antecedents of distress associated with an unplanned pregnancy, quality of their relationships with their partner, parents, and other family members, perceived needs, and sources of support. RESULTS: We found that the interpersonal psychotherapy (IPT) framework of interpersonal problems covering grief and loss, role transitions, interpersonal disputes, and social isolation was instrumental in conceptualizing adolescent depression, anxiety, and stress in the perinatal period. CONCLUSION: Our interviews deepened understanding of peripartum adolescent mental health focusing on four IPT problem areas. The interpersonal framework yields meaningful information about adolescent depression and could help in identifying strategies for addressing their distress.

Social Rhythm Disruption is Associated with Greater Depressive Symptoms in People with Mood Disorders: Findings from a Multinational Online Survey During COVID-19.

OBJECTIVES: Societal restrictions imposed to prevent transmission of COVID-19 may challenge circadian-driven lifestyle behaviours, particularly amongst those vulnerable to mood disorders. The overarching aim of the present study was to investigate the hypothesis that, in the routine-disrupted environment of the COVID-19, amongst a sample of people living with mood disorders, greater social rhythm disruption would be associated with more severe mood symptoms. METHODS: We conducted a two-wave, multinational survey of 997 participants (MAge=39.75±13.39,Female=81.6%) who self-reported a mood disorder diagnosis (i.e., major depressive disorder or bipolar disorder). Respondents completed questionnaires assessing demographics, social rhythmicity (The Brief Social Rhythm Scale), depression symptoms (Patient Health Questionnaire-9), sleep quality and diurnal preference (The Sleep, Circadian Rhythms and Mood questionnaire) and stressful life events during the COVID-19 pandemic (The Social Readjustment Rating Scale). RESULTS: The majority of participants indicated COVID-19-related social disruption had affected the regularity of their daily routines to at least some extent (n = 788, 79.1%). As hypothesised, lower social rhythmicity was associated with greater depressive symptoms when tested cross-sectionally (standardised ß = -.25, t = -7.94, P = 0.000) and when tested using a 2-level hierarchical linear model across two time points (b = -0.14, t = -3.46, df = 264, P ≤ 0.001). CONCLUSIONS: These results are consistent with the social zeitgeber hypothesis proposing that mood disorders are sensitive to life events that disrupt social rhythms.

Telehealth Social Rhythm Therapy to Reduce Mood Symptoms and Suicide Risk Among Adolescents and Young Adults With Bipolar Disorder.

OBJECTIVE: Social rhythm irregularities are associated with increased bipolar disorder symptoms and suicide risk. This study was the first to examine the feasibility and acceptability of a 12-week social rhythm therapy (SRT) delivered predominantly via telehealth (three in-person sessions, nine via video teleconferencing) to adolescents and young adults with bipolar disorder. The primary aim was to determine the feasibility and acceptability of SRT delivered predominantly via telehealth. Secondary aims were to explore the intervention's impacts on social rhythm regularity, mood symptoms, and suicide propensity. METHODS: Thirteen adolescents and young adults with bipolar disorder received a modified SRT called Brain Emotion circuitry-targeted Self-Monitoring And Regulation Therapy for Daily Rhythms (BE-SMART-DR) administered mostly remotely, adjunctive to treatment as usual. Retention rates, client satisfaction, therapeutic alliance, and pre- to postintervention changes in social rhythm regularity, mood symptoms, and suicide propensity were assessed. RESULTS: BE-SMART-DR was associated with high retention rates (77%), high mean±SD scores on the Client Satisfaction Questionnaire (29.4±2.7), and high participant global scores on the Working Alliance Inventory (231.3±8.1), indicative of strong therapeutic alliance. Secondary outcome measures on social rhythm irregularities, mood symptoms, and suicide propensity decreased from pre- to posttherapy. Increased social rhythm regularity was associated with reduced suicide propensity after analyses were controlled for reductions in mood symptoms. CONCLUSIONS: These preliminary results indicate that SRT delivered largely by telemedicine is feasible and acceptable. The intervention appeared to reduce mood symptoms, and suicide propensity independent of mood symptoms, among adolescents and young adults with bipolar disorder.

Social rhythm therapy-A potentially translatable psychosocial intervention for bipolar disorder.

INTRODUCTION: The aim of this paper was to present Social Rhythm Therapy, which has been modified from Interpersonal and Social Rhythm Therapy, by drawing on implementation science to describe a process that for integrating this into routine clinical practice. METHOD: On the basis of the principles of user-centred design, we aimed to modify an existing psychosocial therapy for bipolar disorder to make this readily translatable into a range of clinical practice models which could be further modified based on feedback from end users. RESULTS: Social Rhythm Therapy has been adapted from Interpersonal and Social Rhythm Therapy which has demonstrated efficacy in research settings. The adaptation was developed in order to facilitate implementation of some of the key components in routine clinical practice. It is short, relatively simple, easily learned and intended to be flexible. CONCLUSIONS: Social rhythm therapy for bipolar disorder has many characteristics which may make it translatable into clinical practice in different settings. There is a need for studies into the clinical effectiveness of this intervention that has been modified from an evidence-based intervention.

Psychotherapy in the Digital Age: What We Can Learn From Interpersonal Psychotherapy.

The digital age poses new challenges for psychotherapy. More than four billion people worldwide use the Internet, and most of them engage with social media. Therapists are increasingly asked to help patients navigate the complex interface between online technology and relationships, but few are prepared to address this issue therapeutically. Interpersonal psychotherapy (IPT) is an evidence-based psychotherapy for depression and is focused on addressing interpersonal problems. The authors use the IPT framework to explore how therapists can discuss, during in-person sessions, the impact of technology on communication and relationships. The authors describe how therapists can preserve IPT's overarching goal of resolving interpersonal problems by adapting specific techniques to meet the needs of patients who routinely rely on technology to connect with others. Case vignettes illustrate techniques used to evaluate and modify technology-based communication, including problematic text-based interactions. Recommendations are provided for therapists seeking to meet the interpersonal needs of patients in the digital age.

The chronotherapeutic treatment of bipolar disorders: A systematic review and practice recommendations from the ISBD task force on chronotherapy and chronobiology.

AIMS: To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD)-bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT), and cognitive behavioral therapy adapted for BD (CBTI-BP)-and propose treatment recommendations based on a synthesis of the evidence. METHODS: PRISMA-based systematic review of the literature. RESULTS: The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, three randomized controlled trials (RCTs), and one pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3%, and 59.4% in eight case series, 11 uncontrolled, studies, and one RCT, respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The seven studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67%, and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in two RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated. CONCLUSIONS: The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.

Psychosocial Interventions for Bipolar II Disorder.

Bipolar II disorder causes significant suffering among patients and their families, some of which may be alleviated by psychotherapy alone or as an adjunct to pharmacotherapy. Psychotherapies may be more effective if modified to meet the specific needs of patients with bipolar II disorder.

Changes in inflammation with treatment for bipolar II depression: Pilot trial data on differential effects of psychotherapy and medication.

OBJECTIVES: Limited prospective data, mostly focused on bipolar I disorder, suggests that pro-inflammatory cytokines are elevated in abnormal mood states. We evaluated whether treatment normalizes peripheral markers of inflammation in bipolar II disorder. METHODS: Using data from a randomized clinical trial of Interpersonal and Social Rhythm Therapy (IPSRT) + quetiapine vs. IPSRT + placebo for bipolar II depression, we examined whether these treatments for bipolar II depression impact inflammatory cytokines and whether observed changes in cytokines are associated with changes in depressive symptomatology as measured by the Hamilton Rating Scale for Depression (HRSD-17). RESULTS: Cytokine values were available for 33 participants who completed baseline and 20-week followup visits. After excluding those with CRP values >=10 mg/L, there were 27 patients available for analysis (IPSRT+quetiapine N=10, IPSRT+placebo N=17). Baseline measure of inflammation did not appear to moderate treatment response, nor was change in HRSD-17 score correlated with changes in cytokines. Those who received IPSRT+quetiapine had significantly greater increases in IL-6 (p=0.02) and TNF-α (p=0.04), even after adjusting for changes in body mass index, than the IPSRT alone group. Descriptively, the quetiapine group showed increases in pro-inflammatory and decreases in anti-inflammatory cytokines and the psychotherapy group showed reduced pro-inflammatory cytokines. CONCLUSIONS: Despite both groups showing depression improvement, this small study suggests a more pro-inflammatory cytokine profile over time with quetiapine plus psychotherapy compared to psychotherapy alone. Elevated risk of cardiovascular morbidity and mortality among those with bipolar II disorder underscores the importance of delivering treatments that do not exacerbate these risk factors.

Moderators and mediators of a maternal depression treatment study: Impact of maternal trauma and parenting on child outcomes.

OBJECTIVE: Treatment of maternal depression with psychotherapy has been shown to confer indirect benefits to school-age offspring with psychiatric disorders. The current study sought to understand mechanisms by which improvement in depressed mothers, with and without histories of trauma and treated with psychotherapy, produce changes in children who struggle with psychiatric illnesses themselves. We hypothesized that maternal history of childhood trauma would moderate the relationship between maternal and child outcomes and that increased positive and decreased negative parenting behaviors would mediate the relationship between maternal and child outcomes. We also examined whether maternal history of trauma would moderate the mediational effects of parenting behaviors. METHODS: Participants were dyads (n = 62) of mothers with major depressive disorder and their children, ages 7-18, with at least one internalizing disorder. Mothers were treated with nine sessions of psychotherapy and children were treated openly in the community. Dyads were evaluated every three months over one year. RESULTS: Maternal improvement in depressive symptoms was associated, in a lagged fashion, with child improvement in functioning six months later. There was a significant interaction of time and change in maternal symptoms [F(1, 45) = 5.84, p = 0.02], where change in maternal depressive symptoms from baseline to six months was robustly associated with change in child functioning from baseline to 12 months (ß = 0.49, p = 0.0002). Maternal history of childhood sexual abuse moderated the association between change in maternal and child depressive symptoms [F(1,87) = 5.8, p = 0.02], and maternal history of physical neglect moderated the relationship between improvement in maternal depression and improvement in child functioning [F(1,36) = 4.34, p = 0.04], where significant associations between maternal and child outcomes were only found in mothers without histories of sexual abuse or physical neglect. Increase in positive parenting strategies (acceptance) by mothers mediated 6-month lagged associations between maternal and child outcomes, but reduction in negative parenting strategies (psychological control) did not. Maternal history of childhood emotional neglect moderated the mediational model, such that improved positive parenting did not explain lagged improvement in child depression among the subset of mothers with childhood histories of emotional neglect. CONCLUSIONS: In dyads comprised of depressed mothers and school-age children with internalizing disorders, children improved when mothers improved, but not among those whose mothers who had histories of sexual abuse or physical neglect. Increased use of positive parenting strategies among mothers accounted for lagged relationships between improvement in maternal depressive symptoms and improvement in child functioning. This pattern was not, however, observed among mothers with childhood histories of emotional neglect. Interventions that directly enhance positive parenting and more rapidly change these behaviors may hasten improvement in offspring. Offspring of depressed mothers with histories of early trauma are at high risk for poor outcomes, even when their mothers receive depression treatment.

How obstetric settings can help address gaps in psychiatric care for pregnant and postpartum women with bipolar disorder.

To elucidate (1) the challenges associated with under-recognition of bipolar disorder in obstetric settings, (2) barriers pregnant and postpartum women with bipolar disorder face when trying to access psychiatric care, and (3) how obstetric settings can identify such women and connect them with mental health services. Structured, in-depth interviews were conducted with 25 pregnant and postpartum women recruited from obstetric practices who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II, or not otherwise specified using the Mini International Neuropsychiatric Interview. Quantitative analyses included descriptive statistics. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach. Most participants (n = 19, 79.17%) did not have a clinical diagnosis of bipolar disorder documented in their medical records nor had received referral for treatment during pregnancy (n = 15, 60%). Of participants receiving pharmacotherapy (n = 14, 58.33%), most were treated with an antidepressant alone (n = 10, 71.42%). Most medication was prescribed by an obstetric (n = 4, 28.57%) or primary care provider (n = 7, 50%). Qualitative interviews indicated that participants want their obstetric practices to proactively screen for, discuss and help them obtain mental health treatment. Women face challenges in securing mental health treatment appropriate to their bipolar illness. Obstetric providers provide the bulk of medical care for these women and need supports in place to (1) better recognize bipolar disorder, (2) avoid inappropriate prescribing practices for women with undiagnosed bipolar disorder, and (3) ensure women are referred to specialized treatment when needed.

Revising Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for the bipolar disorders: Phase I of the AREDOC project.

OBJECTIVE: To derive new criteria sets for defining manic and hypomanic episodes (and thus for defining the bipolar I and II disorders), an international Task Force was assembled and termed AREDOC reflecting its role of Assessment, Revision and Evaluation of DSM and other Operational Criteria. This paper reports on the first phase of its deliberations and interim criteria recommendations. METHOD: The first stage of the process consisted of reviewing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and recent International Classification of Diseases criteria, identifying their limitations and generating modified criteria sets for further in-depth consideration. Task Force members responded to recommendations for modifying criteria and from these the most problematic issues were identified. RESULTS: Principal issues focussed on by Task Force members were how best to differentiate mania and hypomania, how to judge 'impairment' (both in and of itself and allowing that functioning may sometimes improve during hypomanic episodes) and concern that rejecting some criteria (e.g. an imposed duration period) might risk false-positive diagnoses of the bipolar disorders. CONCLUSION: This first-stage report summarises the clinical opinions of international experts in the diagnosis and management of the bipolar disorders, allowing readers to contemplate diagnostic parameters that may influence their clinical decisions. The findings meaningfully inform subsequent Task Force stages (involving a further commentary stage followed by an empirical study) that are expected to generate improved symptom criteria for diagnosing the bipolar I and II disorders with greater precision and to clarify whether they differ dimensionally or categorically.

Access to Pharmacotherapy Amongst Women with Bipolar Disorder during Pregnancy: a Preliminary Study.

Bipolar disorder among pregnant women has deleterious effects on birth and child outcomes and is currently under-detected, not addressed effectively, or exacerbated through inappropriate treatment. The goal of this study was to identify perspectives of pregnant and postpartum women with bipolar disorder on barriers and facilitators to psychiatric treatment during pregnancy. In-depth interviews were conducted with pregnant and postpartum women who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II or not otherwise specified using the Mini International Neuropsychiatric Interview version 5.0. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach to identify barriers and facilitators to bipolar disorder treatment access in pregnancy. Participant identified barriers included perception that psychiatric providers lack training and experience in the treatment of psychiatric illness during pregnancy, are reluctant to treat bipolar disorder among pregnant women, and believe that pharmacotherapy is not needed for psychiatric illness during pregnancy. Facilitators included participants' perception that providers' acknowledge risks associated with untreated or undertreated psychiatric illness during pregnancy and provide psycho-education about the risks, benefits and alternatives to pharmacotherapy. Psychiatric providers are critically important to the treatment of bipolar disorder and need knowledge and skills necessary to provide care during the perinatal period. Advancing psychiatric providers' knowledge/skills may improve access to pharmacotherapy for pregnant women with bipolar disorder.