Bipolar disorder and major depressive disorder are recurrent mood disorders which have a huge impact on a person’s life and their ability to function.
At the moment, treatment of recurrent mood disorders in New Zealand involves treatment of an acute episode of mood disturbance and a period of “stabilisation” in mental health services, and then discharge to general practice. The treatment available is almost exclusively medications that may help some people but do not usually help the person to recover completely. In fact, many patients continue to have very significant problems including ongoing symptoms and relapses and significant cognitive and functional impairment.
Relapse rates for these disorders are high and have consequent high costs for the individual, their family, mental health services and New Zealand society. With usual care (predominantly medication) relapse rates for people with bipolar disorder are 44% within 1 year; 60% within 2 years and 77% within 4 years. In recurrent depression, the relapse rates are 50% within 6 months and 80% within 10 years. It is unlikely that this would be acceptable for any other health condition.
There is evidence that relapse in these disorders is associated with interplay between biological factors associated with the circadian pacemaker (a part of the brain that controls sleep and many other aspects of bodily function which change according to the time of day) and psychosocial factors. Psychosocial factors interact with biology to create two probable pathways to episode recurrence: (1) stressful life events; (2) disruptions in social rhythms.
There is increasing evidence both locally and internationally, that rather than simply using medication there are better outcomes if an evidence-based psychotherapy is also provided. There are a range of effective psychotherapies for recurrent mood disorders, one of which is Interpersonal and Social Rhythm Therapy.
In Christchurch, in the Department of Psychological Medicine at the University of Otago, we have been conducting trials of this psychotherapy for nearly 20 years. We initially used this psychotherapy for bipolar disorder but are now using it in studies of any recurrent depression and have found indications that in conjunction with medication it significantly improves the person’s ability to function at home with family, at work, with friends and with social activities. We are now combining this psychotherapy with cognitive remediation which targets memory, concentration, problem-solving and planning, which are specific areas of functioning impacted by recurrent mood episodes. It also decreases suicide attempts and self-harm.
Interpersonal and Social Rhythm Therapy is based on the evidence from chronobiology (circadian rhythm processes) and interpersonal therapy. The focus of the therapy is to 1) stabilise each individual’s social rhythms that underpin their natural circadian rhythms and 2) examine the interpersonal stressors that may precipitate mood episodes. The focus in sessions is on 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills. The therapy is usually delivered over 12 months going from weekly to fortnightly and then monthly, with people receiving about 24 sessions in total over the year. Our current study – The Enhancing Recovery Study – recruits people on discharge from mental health services and provides an integrated care package of Interpersonal and Social Rhythm Therapy, cognitive remediation and medication management.
People who have taken part in previous studies described how the psychotherapy provided them with an active role in their recovery rather than passively waiting for medications to work and gave them the necessary self-management skills. This psychotherapy is highly individualised to take account of the person’s lifestyle and needs. It gives them a role as an active participant in their recovery by identifying the precipitating and perpetuating patterns that trigger stress related to the onset of mood episodes and provides patients with skills to make changes to situations that contribute to mood episode recurrence.
If New Zealand is serious about improving the lives of people who experience serious mental disorders there needs to be funding of evidence-based psychotherapies to improve the costs to individuals, their families and wider society.
Professor Crowe has been a mental health nurse for nearly 40 years. She combines her work with people with mood disorders with research. She is an author of 120 publications as well as being involved in eight trials of psychotherapy for major major depressive disorder or bipolar disorder as well as many international collaborations.