Stabilizing Circadian Rhythm Tied to Lower Suicide Risk in Bipolar Disorder


Jan. 13, 2022 — Social rhythm therapy (SRT), which uses behavioral strategies to support healthy sleep and other routines, is linked to improved mood and reduced suicide risk in young people with bipolar disorder, early research suggests.

The small study also showed SRT is both feasible and acceptable in this patient population.

Results showed SRT, which was primarily delivered via telehealth sessions, began to show results about 6 weeks into the 12-week program, the researchers note.

“Improving the regularity of daily rhythms like sleep, physical activity, and social activities can be really robust in improving mental health and even reducing suicide risk,” says study researcher Hilary P. Blumberg, MD, the John and Hope Furth Professor of Psychiatric Neuroscience at Yale School of Medicine.

The findings are published in the December issue of The American Journal of Psychotherapy.

Trigger for Depression, Mania

Previous research shows unstable circadian rhythms may trigger depressive and manic symptoms — and are risk factors for suicidal thoughts and actions. Although interpersonal and social rhythm therapy (IPSRT) has shown promise in patients with mood disorders, there is little research focusing only on the social rhythm aspect of the therapy.

The researchers only examined SRT, modified to create a therapeutic program aimed at adolescents and young adults.

The study included 13 people (mean age 20) with bipolar disorder and a score of 15 or more on the Hamilton Depression Rating Scale (HDRS-29) and/or a score of 12 or more on the Young Mania Rating Scale (YMRS). They were enrolled in the National Institute of Mental Health Brain Emotion Circuitry Targeted Self-Monitoring and Regulation Therapy (BE-SMART) program, which requires MRI sessions at three in-person visits to assess brain changes with the therapy. All but one patient was taking mood-stabilizing medications.

SRT was delivered in 12 weekly sessions. Most were through on a secure video platform. Three were conducted in person.

Working with a therapist, the patients were taught how to follow a daily routine. Blumberg notes this is not just a matter of going to sleep and getting up at the same time every day, but also thoroughly reviewing details of all daily activities and routines, including who participants eat with and when, their exercise schedule, and social engagements.

Each week, participants completed the five-item version of the Social Rhythm Metric. At the end of the intervention, they also completed the Client Satisfaction Questionnaire (CSQ). Scores on

the CSQ range from 8 to 32, with scores of 26 to 32 indicating “excellent” satisfaction.

In addition, participants and therapists completed the Working Alliance Inventory, which assesses the client-therapist relationship by asking about such things as degree of comfort and respect.

Before and after the intervention, patients reported the regularity of their social rhythms using the Brief Social Rhythm Scale (BSRS) and risk for suicidal behavior using a subscale of the Concise Health Risk Tracking (CHRT) scale.

High Retention, “Excellent Satisfaction”

Results showed 10 of the 13 study participants completed all study procedures. Treatment satisfaction was excellent.

Both therapists and participants had high scores on all aspects of the Working Alliance Inventory scale.

“High treatment retention, excellent client satisfaction, and strong working alliance scores support the feasibility and acceptability of this intervention for adolescents and young adults with bipolar disorder,” the investigators write.

Participants showed significant improvement in social rhythm regularity and reductions in depression and manic symptoms as well as suicide propensity. Effect sizes were in the moderate to high range.

By the midpoint of the therapy, there were significant improvements in social rhythm regularity and suicide propensity and trend-level reductions in depression, suggesting the potential for early benefits.

Blumberg notes it is difficult to find a therapy that helps with both depressive and mania symptoms. “An antidepressant may reduce depression, but sometimes can worsen manic symptoms,” she says.

Impact on Emotional Brain Circuitry?

The association between improved regularity of social rhythms and reduced suicide propensity persisted even after controlling for mood symptom changes.

“Suicide risk was reduced not just because subjects were less depressed. There’s something about regularizing rhythms that can reduce suicide risk,” Blumberg says.

The reviewers note SRT administered remotely improves accessibility and that this intervention “is well suited to the future of psychotherapy delivery, which will undoubtedly include remote treatment delivery.”

They also note the small number of patients in the study means the findings should be interpreted cautiously.

The researchers now have early results from the brain scanning component of the study. “Preliminary findings suggest the intervention seems to benefit emotional brain circuitry,” Blumberg says.

“Promising” Results

Michael Thase, MD, professor of psychiatry at the University of Pennsylvania Perelman School of Medicine, praised the study.

“It’s a very, very promising initial study because even though there’s no control group, it does show that participants liked the program, most finished it, and on average, people got quite a bit better,” says Thase, who was not involved with the research.

The treatment may be especially beneficial for young patients with bipolar disorder who, just by their very age, experience lifestyle disruptions, Thase says. Results from a previous study of the therapeutic approach in adults showed “probably half of the adults didn’t take to it,” he says.

However, not everyone in this new study benefited either, as some dropped out. “No form of intervention is suitable for everyone,” he says.

The study was supported by grants from the National Institute of Mental Health, AIM Youth Mental Health Foundation, Klingenstein Third Generation Foundation, American Foundation for Suicide Prevention, International Bipolar Foundation, MQ Brighter Futures Program, For the Love of Travis Foundation, and the John and Hope Furth Endowment. Blumberg and Thase report no relevant financial relationships.


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