Stabilizing Circadian Rhythm Tied to Lower Suicide Risk in BD

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 (BD), 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 efficacy approximately 6 weeks into the 12-week therapeutic program, the researchers note.

Dr Hilary Blumberg

"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," study investigator Hilary P. Blumberg, MD, the John and Hope Furth Professor of Psychiatric Neuroscience, and director, Mood Disorders Research Program, Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News.

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 behaviors. 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 participants (mean age, 20.5 years) with BD and a score of 15 or more on the 29-item Hamilton Depression Rating Scale (HDRS-29) and/or a score of 12 or more on the Young Mania Rating Scale (YMRS).

Participants 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 participant was taking mood-stabilizing medications.

"We didn't ask them to come off medications because we didn't want to exacerbate things," said Blumberg. She added the therapeutic approach "could be adjunctive to further improve symptoms and reduce risk."

SRT was delivered in 12 weekly sessions. The majority occured on a secure video platform. Three were conducted in person.

Working with a therapist, participants were taught how to follow a daily routine. Blumberg noted this is not just a matter of going to sleep and getting up at the same time every day, but 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, participants 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 participants (nine females) completed all study procedures, for a retention rate of 77%. Treatment satisfaction was excellent (mean CSQ, 29.4).

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 (P = .016 for BSRS; .024 for HDRS-29; .028 for YMRS; and .028 for CHRT 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 noted 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 said.

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," said Blumberg.

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

A study limitation cited was the absence of a comparator condition. The investigators note the small sample size means the findings should be interpreted cautiously and verified in an adequately powered randomized controlled trial.

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 said.

The researchers are about to embark on a new study funded by a grant from the American Foundation of Suicide Prevention. It will investigate SRT in preventing suicide in adolescents and adults to age 29 years with depression or BD.

In addition, the researchers have secured support from the Klingenstein Third Generation Foundation to research prevention in youth at risk for BD ― and from Women's Health Access Matters to examine the therapy in women 50 and older with depression, a population possibly at increased risk for dementia.

"Promising" Results

Commenting on the findings for Medscape Medical News, Michael Thase, MD, professor of psychiatry, Perelman School of Medicine, University of Pennsylvania, and research psychiatrist at the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, 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," said 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 noted. Results from a previous study of the therapeutic approach in adults showed "probably half of the adults didn't take to it," he added.

However, not everyone in this new study benefited either, as some dropped out, which Thase noted is not atypical.

"No form of intervention is suitable for everyone," he said.

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.

Am J Psychother. 2021:74:4;172-177. Abstract

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