What we’ve said about Social rhythm therapy

Lifestyle is the third major category in treating any bipolar disorder: regulating sleep and the daily life cycle. It is even its own psychotherapy, interpersonal and social rhythm therapy.

It comes in levels, from full IPSRT to SRT to a simplified version. Everyone agrees sleep is the central ingredient, so you can start with just a regular pattern of sleep.

The role of circadian rhythm in what bipolar disorder is keeps getting more prominent, and social rhythm therapy goes right after that basic cause of the mood disturbances. Think of a hierarchy of goals: the patient wants quality of life and function, we get there through stable mood, we get stable mood by going after the circadian rhythm, and we do that by using social rhythms.

Simplified social rhythm therapy is the number one mood stabilizer, followed by lamotrigine and low-dose lithium.

It gets you out of choosing between antidepressants and antipsychotics. Weighed against an antipsychotic, social rhythm therapy is a no-brainer on risk and benefit, and lamotrigine can be seen in a similar light.

Learn how to do the simplified version. You are already encouraging a regular bedtime and a regular rise time; make it part of your standard approach to everyone with a mood disorder.

Aim for regular sleep hours: a regular bedtime and a regular rise time, about seven to eight hours, preferably a little closer to eight. Start from whatever the patient's most common bedtime is now; if it is 2 in the morning, go with that.

Move sleep gradually: not from 2 a.m. to 10:30 p.m. in one step, but in 15-minute steps every couple of nights, so the patient can see progress.

Start with sleep, and with light and darkness as they set sleep timing. More darkness at night makes it easier to fall asleep at the bedtime the regular rhythm needs.

Getting out of bed at a regular time is the hardest part of the simple version, so make it easy: no snooze (once the alarm goes off, get up), then make the bed fully, throw pillows and all, so there is no getting back into it.

Compare how the patient lives with the idealized rhythm and go for the lowest-hanging fruit: the realistic change that will make the biggest difference (waking at the same time is probably the most important). See how it goes over a month; if it goes well, add the next change, and if not, work out what made it difficult and tinker.

Do not lecture; listen. Ask why they are going to bed at two in the morning and how they got there, and acknowledge that they already know it would be a good idea to change.

When we say mood stabilizers, we do not only mean lithium and valproate. Sleep and diet are mood stabilizers too, and framing them that way is very helpful.

Use the idealized rhythm as the roadmap: activity through the day, sunlight slowly fading around 5 to 6 p.m., no light at all from 7 to 10, falling asleep naturally at 10 and waking to a slowly rising sun.

Build motivation before giving instructions: explain why it matters, because a patient simply told to wake at the same time will ask why. Most are not motivated enough to go out after the appointment and buy a light box, dawn simulator, sunglasses and blackout shades, and buy-in usually grows once they start and see improvement.

Do not judge a very late rise time as laziness. It is part of the consequence of a shifted rhythm, and the job is to help the patient cope with it.

Do not be paternalistic about late nights; a patient simply told no will not listen. Be clear that staying up till two with a few beers comes at a cost, leave the decision to them, and negotiate a plan through natural behavioral experiments that show how risky it is for them.

Building structure and stability helps every aspect of mental health. It is a big focus for patients with personality disorders and trauma, not only mood disorders.

In ADHD, too, the very first step is getting enough sleep, because sleep loss makes it harder to focus attention.

Woven into medication visits, this work is psychotherapy in that respect: 25-minute visits, billed with psychotherapy codes as well as medication management codes, for nearly everybody.

Keeping a regular bedtime is a common sticking point: there are zillions of reasons for it not to happen, while the rise time at least has an alarm clock and usually work, family or school behind it. Staying up late and then getting up early leaves people short of sleep and makes getting out of bed hard.

An occasional later night is okay, maybe an hour later, not five hours. Know that it is a risk to the rhythm, build in extra protection over the following days and get back on schedule as quickly as possible.