Treatment Strategies A hybrid model

Built on these overlapping paradigms, IPSRT fuses three distinct interventions— psychoeducation, social rhythm therapy, and IPT—into a single psychosocial treatment. IPSRT helps patients optimize daily schedules, resolve interpersonal difficulties, and understand their illness in order to achieve symptom remission and improve interpersonal functioning. By intervening in these potential pathways to recurrence, IPSRT ultimately strives to prevent new episodes of illness in a highly vulnerable population. Each treatment intervention (psychoeducation, social rhythm therapy, and IPT) will be described separately. In practice, however, these strategies are administered flexibly and fluidly, without distinct boundaries between modalities. During the course of a single session, the therapist moves seamlessly among the techniques, according to the particular needs of the patient. Thus, the IPSRT represents a true integration of these disparate approaches. Table 15.1 summarizes these three strategies and the treatment techniques associated with them.

Table 15.1 IPSRT treatment strategies

Strategy Techniques

Psychoeducation Provide education regarding:

□ medications and their side effects

□ course and symptoms of bipolar disorder Teach patients to recognize:

□ early warning signs of recurrence

□ prodromal symptoms Encourage patient to:

□ become "expert" on their illness

□ collaboratively manage illness with therapist and psychiatrist

Social rhythm therapy Balance stimulation and stability

Complete Social Rhythm Metric

□ monitor frequency/intensity of social interactions

□ monitor daily mood

Search for specific triggers of rhythm disruption Gradually regularize social rhythms

Interpersonal psychotherapy Conduct in-depth psychiatric evaluation

Link mood to life events

Establish interpersonal case formulation (focus on one or two problem areas):

□ role transition

□ interpersonal deficits Grieve for the lost "healthy self"

PSYCHOEDUCATION

Psychoeducation subsumes a heterogeneous group of interventions that are deployed in the service of treating a wide variety of disorders. Virtually all bipolar-specific psychotherapies incorporate psychoeducation—albeit to varying degrees. Psychoeducation is also an integral part of standard IPT (see discussion below). In IPSRT, psychoeducation focuses on (a) the illness and its consequences, (b) medications and their side effects, and (c) prodromal symptoms/detection of early warning symptoms. Patients receive information from the therapist about the symptoms and course of bipolar disorder, the impact of the illness on vocational and social functioning, and the medications used to treat bipolar disorder. In the course of IPSRT, patients are encouraged to become "experts" in bipolar disorder so that they can collaborate more effectively in the management of their illness. In the instance of a physician-clinician treatment team, the nonphysician therapist must also develop familiarity with the major classes of medications used to treat the disorder and their side effects in order to help the patient recognize medication-related problems and collaborate with the physician to manage them. Therapists are encouraged to work collaboratively with the patient to understand and remedy sources of nonadherence—including management of side effects—that interfere with optimal quality of life.

In order to encourage early identification of prodromal symptoms, the therapist reviews with the patient prior episodes of depression and mania. Jointly, the therapist and patient identify characteristic behaviors or symptoms that may herald the onset of an episode, and agree to assess the patient routinely for these harbingers of exacerbation. In addition, family members of IPSRT patients are encouraged to attend a 1-day psychoeducation workshop in order to facilitate medication compliance and help detect early warning signs of recurrence.

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