Recent studies demonstrate the poor psychosocial outcomes associated with bipolar disorder. Occupational functioning, a key indicator of psychosocial disability, is often severely affected by the disorder.
The authors describe the effect of acute treatment with interpersonal and social rhythm therapy on occupational functioning over a period of approximately 2.5 years.
Participants were enrolled in the Maintenance Therapies in Bipolar Disorder study, which was conducted from 1991 to 2002 through the Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA.
Participants were eligible for study entry if they were acutely ill, ages 18‚Äì60, had a lifetime diagnosis of bipolar I disorder and schizoaffective disorder, manic type, and were experiencing their third or more lifetime affective episode. A score of ?15 on the 17-item HAM-D or ?15 on the Bech-Rafaelsen Mania Scale was required for study entry. Patients were excluded if they met criteria for rapid cycling (?4 episodes/year), borderline or antisocial personality disorder, an active eating disorder, or chronic drug or alcohol abuse or if they had an uncontrolled medical illness that would preclude protocol pharmacotherapy or were pregnant.
Study used mixed-effects repeated measures analysis to examine the data, with the subject as a random variable and the assessment points (baseline, end of acute treatment, end of 1 year of maintenance treatment, and end of 2 years of maintenance treatment) as fixed variables. Acute treatment assignment and acute treatment by assessment time point interaction were also included in the model. The covariance matrix was unstructured. Vocational functioning scores were also examined by gender.
Each study participant was randomly assigned to one of four treatment groups: one of four psychosocial treatment strategies: 1) acute and maintenance interpersonal and social rhythm therapy, 2) acute and maintenance intensive clinical management, 3) acute interpersonal and social rhythm therapy followed by maintenance intensive clinical management, or 4) acute intensive clinical management followed by maintenance interpersonal and social rhythm therapy. All participants received pharmacotherapy according to a standardized algorithm, which is described in detail elsewhere.
Patients with bipolar I disorder were randomly assigned to receive either acute and maintenance interpersonal and social rhythm therapy, acute and maintenance intensive clinical management, acute interpersonal and social rhythm therapy and maintenance intensive clinical management, or acute intensive clinical management and maintenance interpersonal and social rhythm therapy, all with appropriate pharmacotherapy. Occupational functioning was measured with the UCLA Social Attainment Scale at baseline, at the end of acute treatment, and after 1 and 2 years of maintenance treatment.
The main effect of treatment did not reach conventional levels of statistical significance; however, the authors observed a significant time by initial treatment interaction. Participants initially assigned to interpersonal and social rhythm therapy showed more rapid improvement in occupational functioning than those initially assigned to intensive clinical management, primarily accounted for by greater improvement in occupational functioning during the acute treatment phase. At the end of 2 years of maintenance treatment, there were no differences between the treatment groups. A gender effect was also observed, with women who initially received interpersonal and social rhythm therapy showing more marked and rapid improvement. There was no effect of maintenance treatment assignment on occupational functioning outcomes.
In this study, interpersonal and social rhythm therapy, with its emphasis on amelioration of interpersonal and role functioning, improved occupational functioning significantly more rapidly than did a psychoeducational and supportive approach with no such emphasis on functional capacities.