Social Rhythm Therapy Research Articles

Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice.

Three interconnected pathways to relapse have been identified as stressful life events, medication non-adherence and disruptions in social rhythms (daily activity and routine). The role of medication and stressful life events is generally better understood than the role of social rhythms. There is no previous review of interventions that target social rhythms. To identify the evidence for the effectiveness of interventions that target social rhythms for improving mood symptoms. A quantitative systematic review was conducted. Results Seven studies were included in the review: four reporting interpersonal and social rhythm therapy (IPSRT) interventions and three sleep/light interventions. The results suggest that IPSRT may have a potential benefit in improving mood symptoms and relapse, but it is not clear whether this is of greater benefit than an intensive supportive care intervention of similar duration. The sleep/light interventions demonstrated rapid mood improvements; however, it was not clear how long this improvement was sustained. Attention to social rhythms and the implementation of interventions that target these could be useful for mental health nursing practice may provide people with BD a clinically effective adjunctive intervention to medication.

Telephone-administered psychotherapy in combination with antidepressant medication for the acute treatment of major depressive disorder

BackgroundTelephone-administered psychotherapies (T-P) provided as an adjunct to antidepressant medication may improve response rates in major depressive disorder (MDD). The goal of this study was to compare telephone-administered social rhythm therapy (T-SRT) and telephone-administered intensive clinical management (T-ICM) as adjuncts to antidepressant medication for MDD. A secondary goal was to compare T-P with Treatment as Usual (TAU) as adjunctive treatment to medication for MDD. Methods221 adult out-patients with MDD, currently depressed, were randomly assigned to 8 sessions of weekly T-SRT (n=110) or T-ICM (n=111), administered as an adjunct to agomelatine. Both psychotherapies were administered entirely by telephone, by trained psychologists who were blind to other aspects of treatment. The 221 patients were a posteriori matched with 221 depressed outpatients receiving TAU (controls). The primary outcome measure was the percentage of responders at 8 weeks post-treatment. ResultsNo significant differences were found between T-SRT and T-ICM. But T-P was associated with higher response rates (65.4% vs 54.8%, p=0.02) and a trend toward higher remission rates (33.2% vs 25.1%; p=0.06) compared to TAU. LimitationsShort term study. ConclusionsThis study is the first assessing the short-term effects of an add-on, brief, telephone-administered psychotherapy in depressed patients treated with antidepressant medication. Eight sessions of weekly telephone-delivered psychotherapy as an adjunct to antidepressant medication resulted in improved response rates relative to medication alone.

Bipolar II disorder, ketogenic diet, and social rhythm therapy: a case study

Bipolar II disorder, ketogenic diet, and social rhythm therapy: a case study

Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators.

Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT. Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials. Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.

Implementing a Web-Based Intervention to Train Community Clinicians in an Evidence-Based Psychotherapy: A Pilot Study.

The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health system. Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques. Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques. Internet-supported e-learning by community clinicians was found to be feasible and led to uptake of an evidence-based psychotherapy comparable to that by clinicians who received face-to-face training.

Psychosocial Approaches to the Treatment of Bipolar Disorder

Even when treated with best-practice pharmacotherapy, many patients with bipolar disorder have slow recoveries from illness episodes, high rates of recurrence, and considerable functional impairment. This article reviews randomized trials of psychotherapy as adjunctive to pharmacotherapy. There is evidence for the efficacy of family-focused interventions, group psychoeducation, interpersonal and social rhythm therapy, and cognitive-behavioral therapy in delaying or preventing relapses and stabilizing illness episodes. Although these treatments share many common strategies (e.g., psychoeducation), little is known about how they work, when in the illness progression they should be administered for maximal effect, and how to efficiently train large numbers of community clinicians. Online versions of psychoeducational care are being developed, with promising early results. Studies that identify changes in neural circuitry that mediate the effects of psychosocial intervention may be especially informative in clarifying targets of evidence-based psychosocial care.

Application of Cognitive Behavioral Therapies for Comorbid Insomnia and Depression.

This article provides an overview of cognitive behavioral therapy (CBT) for insomnia and depression. Included is a discussion of how CBT for insomnia affects depression symptoms and how CBT for depression affects insomnia symptoms. The extant literature is reviewed on ways that depression/insomnia comorbidity moderates CBT response. The article concludes with an introduction to cognitive behavioral social rhythm therapy, a group therapy that integrates tenets of CBT for both disorders.

Psychotherapy of mood disorders.

In the last decades, psychotherapy has gained increasing acceptance as a major treatment option for mood disorders. Empirically supported treatments for major depression include cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), behavioural therapy and, to a lesser extent, short-term psychodynamic psychotherapy. Meta-analytic evidence suggests that psychotherapy has a significant and clinically relevant, though not large, effect on chronic forms of depression. Psychotherapy with chronic patients should take into account several important differences between patients with chronic and acute depression (identification with their depressive illness, more severe social skill deficits, persistent sense of hopelessness, need of more time to adapt to better circumstances). Regarding adolescent depression, the effectiveness of IPT and CBT is empirically supported. Adolescents require appropriate modifications of treatment (developmental approach to psychotherapy, involvement of parents in therapy). The combination of psychotherapy and medication has recently attracted substantial interest; the available evidence suggests that combined treatment has small but significant advantages over each treatment modality alone, and may have a protective effect against depression relapse or recurrence. Psychobiological models overcoming a rigid brain-mind dichotomy may help the clinician give patients a clear rationale for the combination of psychological and pharmacological treatment. In recent years, evidence has accumulated regarding the effectiveness of psychological therapies (CBT, family-focused therapy, interpersonal and social rhythm therapy, psychoeducation) as an adjunct to medication in bipolar disorder. These therapies share several common elements and there is considerable overlap in their actual targets. Psychological interventions were found to be useful not only in the treatment of bipolar depressive episodes, but in all phases of the disorder.

Randomized, controlled trial of Interpersonal and Social Rhythm Therapy for young people with bipolar disorder.

This randomized, controlled clinical trial compared the effect of interpersonal and social rhythm therapy (IPSRT) to that of specialist supportive care (SSC) on depressive outcomes (primary), social functioning, and mania outcomes over 26-78weeks in young people with bipolar disorder receiving psychopharmacological treatment. Subjects were aged 15-36years, recruited from a range of sources, and the patient groups included bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified. Exclusion criteria were minimal. Outcome measures were the Longitudinal Interval Follow-up Evaluation and the Social Adjustment Scale. Paired-sample t-tests were used to determine the significance of change from baseline to outcome period. Analyses of covariance were used to determine the impact of therapy, impact of lifetime and current comorbidity, interaction between comorbidity and therapy, and impact of age at study entry on depression. A group of 100 participants were randomized to IPSRT (n=49) or SSC (n=51). The majority had bipolar I disorder (78%) and were female (76%), with high levels of comorbidity. After treatment, both groups had improved depressive symptoms, social functioning, and manic symptoms. Contrary to our hypothesis, there was no significant difference between therapies. There was no impact of lifetime or current Axis I comorbidity or age at study entry. There was a relative impact of SSC for patients with current substance use disorder. IPSRT and SSC used as an adjunct to pharmacotherapy appear to be effective in reducing depressive and manic symptoms and improving social functioning in adolescents and young adults with bipolar disorder and high rates of comorbidity. Identifying effective treatments that particularly address depressive symptoms is important in reducing the burden of bipolar disorder.

Calculating the Social Rhythm Metric (SRM) and Examining Its Use in Interpersonal Social Rhythm Therapy (IPSRT) in a Healthy Population Study.

In psychiatry, the social zeitgeber theory argues that social life provides important social cues that entrain circadian rhythms. Disturbance of these social cues might lead do dis-entrainment of circadian rhythms and evoke somatic symptoms that increase the risk of mood disorders. In preventing and treating patients with bipolar disorders, the Interpersonal and Social Rhythm Therapy (IPSRT) relies on the Social Rhythm Metric (SRM) to (re)establish patients’ social cues and an re-entrain circadian rhythms. Since the SRM quantifies social rhythms that are derived from a patient’s interaction with a social environment, this contribution (a) calculates the SRM of the social environment of a representative healthy population study (n = 1249), (b) evaluates the robustness of the SRM as a quantifier of social rhythms by matching the scores of the pilot study, revealing the near absence of variance across population characteristics and investigation months—circadian rhythms need to be entrained for every month and for everyone—and (c) examines its use in IPSRT by relating high SRM-scores to lower psychological distress (p = 0.004) and low SRM-scores to higher social and emotional dysfunction (p = 0.018).

Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence.

Although pharmacotherapy is the mainstay of treatment for bipolar disorder, medication offers only partial relief for patients. Treatment with pharmacologic interventions alone is associated with disappointingly low rates of remission, high rates of recurrence, residual symptoms, and psychosocial impairment. Bipolar-specific therapy is increasingly recommended as an essential component of illness management. This review summarizes the available data on psychotherapy for adults with bipolar disorder. We conducted a search of the literature for outcome studies published between 1995 and 2013 and identified 35 reports of 28 randomized controlled trials testing individual or group psychosocial interventions for adults with bipolar disorder. These reports include systematic trials investigating the efficacy and effectiveness of individual psychoeducation, group psychoeducation, individual cognitive-behavioral therapy, group cognitive-behavioral therapy, family therapy, interpersonal and social rhythm therapy, and integrated care management. The evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. Whether delivered in a group or individual format, those who receive bipolar disorder-specific psychotherapy fare better than those who do not. Psychotherapeutic strategies common to most bipolar disorder-specific interventions are identified.

Inpatient treatment for mania: A review and rationale for adjunctive interventions.

To examine the evidence for adjunctive non-pharmacological interventions in the treatment of mania in an acute inpatient setting. A selective review of original and review papers was conducted. The electronic databases PsycINFO and PubMed were searched using the following MeSH terms: mania, mania treatment and inpatient. Four studies were identified in the search for non-psychopharmacological interventions for mania that commenced in an inpatient setting: Interpersonal and Social Rhythm Therapy (IPSRT), Group Cognitive Behavioural Therapy (G-CBT), sensory room, and dark room therapy. Only two of these were designed exclusively for patients with bipolar disorder and the other two included these patients in a heterogeneous group of acute psychiatric inpatients. Sleep and circadian regulation (Social Rhythm Therapy) that focuses on the establishment and maintenance of regular daily rhythms, particularly in relation to sleep-wake times, meal times and socialization, provides a potentially useful model for managing mania in the inpatient setting. However, there is an urgent need for further research into the effective treatment of mania.

Do Comorbid Anxiety Disorders Moderate the Effects of Psychotherapy for Bipolar Disorder? Results From STEP-BD

At least 50% of individuals with bipolar disorder have a lifetime anxiety disorder. Individuals with both bipolar disorder and a co-occurring anxiety disorder experience longer illness duration, greater illness severity, and poorer treatment response. The study explored whether comorbid lifetime anxiety in bipolar patients moderates psychotherapy treatment outcome. In the Systematic Treatment Enhancement Program randomized controlled trial of psychotherapy for bipolar depression, participants received up to 30 sessions of intensive psychotherapy (family-focused therapy, interpersonal and social rhythm therapy, or cognitive-behavioral therapy) or collaborative care, a three-session comparison treatment, plus pharmacotherapy. Using the number needed to treat, we computed effect sizes to analyze the relationship between lifetime anxiety disorders and rates of recovery across treatment groups after 1 year. A total of 269 patients (113 women) with a comorbid lifetime anxiety disorder (N=177) or without a comorbid lifetime anxiety disorder (N=92) were included in the analysis. Participants with a lifetime anxiety disorder were more likely to recover with psychotherapy than with collaborative care (66% compared with 49% recovered over 1 year; number needed to treat=5.88, small to medium effect). For patients without a lifetime anxiety disorder, there was no difference between rates of recovery in psychotherapy compared with collaborative care (64% compared with 62% recovered; number needed to treat=50, small effect). Participants with one lifetime anxiety disorder were likely to benefit from intensive psychotherapy compared with collaborative care (84% compared with 53% recovered; number needed to treat=3.22, medium to large effect), whereas patients with multiple anxiety disorders exhibited no difference in response to the two treatments (54% compared with 46% recovered; number needed to treat=12.5, small effect). Depressed patients with bipolar disorder and comorbid anxiety may be in particular need of additional psychotherapy for treating acute depression. These results need to be replicated in studies that stratify bipolar patients to treatments based on their anxiety comorbidity status.

Early intervention for adolescents at high risk for the development of bipolar disorder: Pilot study of Interpersonal and Social Rhythm Therapy (IPSRT).

Interpersonal and Social Rhythm Therapy (IPSRT) delays bipolar disorder (BP) recurrence in adults by stabilizing daily routines and sleep/wake cycles. Because adolescence is a key developmental stage for illness onset and altered social and sleep patterns, this period may prove optimal for intervention with adolescents at-risk for BP. We describe a treatment development trial of IPSRT for adolescents at-risk for BP by virtue of a positive family history. Adolescents with a first-degree relative with BP were evaluated for Axis I psychopathology via semistructured interview, and relatives' BP diagnoses were confirmed via record review. IPSRT consisted of 12 sessions delivered over 6 months. Outcome variables including sleep, mood symptoms, and functioning were assessed via clinician interview and self-/parent-report at pretreatment, 3 months, and posttreatment (6 months). Thirteen adolescents attended at least one IPSRT session. Half of the sample denied Axis I psychopathology at intake; the remainder met criteria for a range of internalizing and externalizing disorders. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BP illness severity. Data indicate significant change in select sleep/circadian patterns (i.e., less weekend sleeping in and oversleeping) with treatment. Preliminary data suggest the IPSRT focus on stabilizing daily rhythms and interpersonal relationships may be beneficial for adolescents at-risk for BP. Controlled trials with longitudinal follow-up are needed to examine whether early intervention for at-risk youth helps prevent or delay disorder.

Facilitators and Barriers Associated With Implementation of Evidence-Based Psychotherapy in Community Settings

OBJECTIVE Despite widespread use of individual outpatient psychotherapies among community mental health centers (CMHCs), few studies have examined implementation of these psychotherapies. This exploratory qualitative study identified key themes associated with the implementation of an empirically supported psychotherapy in CMHCs. METHODS The authors conducted semistructured interviews with 12 key informants from four CMHCs that had implemented interpersonal and social rhythm therapy (IPSRT). Their responses were categorized into key themes. RESULTS Five major themes were identified: pretraining familiarity with IPSRT, administrative support for implementation, IPSRT fit with usual practice and clinic culture, implementation team and plan, and supervision and consultation. Discussion of these themes varied among participants from clinics considered successful or unsuccessful implementers. CONCLUSIONS Participants identified both key themes and several strategies for facilitating implementation. The findings suggest that when these key factors are present, outcome-enhancing treatments can be implemented and sustained, even in clinics with limited resources.

Bipolar Treatment Study Assesses Psychotherapy Efficacy

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessBipolar Treatment Study Assesses Psychotherapy EfficacyEve BenderEve BenderSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.11a25AbstractA highly intensive form of psychotherapy may help patients with bipolar disorder who are depressed and also have a comorbid anxiety disorder, according to new data from the STEP-BD study.Depressed patients with bipolar disorder and a coexisting anxiety disorder were more likely to recover with an intensive form of psychotherapy than they were with a brief psychoeducational approach, according to a study comparing the two types of treatments.The findings come from the National Institute of Mental Health’s Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and were published September 30 online in AJP in Advance. STEP-BD is a large multisite study to examine the effectiveness of treatments for bipolar disorder. There are 4,361 subjects with bipolar disorder enrolled at 21 sites across the United States.The findings point to the importance for psychiatrists of screening their patients with bipolar disorder for comorbid conditions, said lead author Thilo Deckersbach, Ph.D. “If depressed patients with bipolar disorder also have an anxiety disorder,” he told Psychiatric News, “intensive psychotherapy such as cognitive-behavioral therapy (CBT), family-focused therapy (FFT), or interpersonal and social-rhythm therapy (IPSRT) may be the best treatment options,” in addition to pharmacotherapy.Deckersbach is an associate professor of psychology at Harvard Medical School and director of psychology at the Bipolar Clinic and Research Program at Massachusetts General Hospital.He and his colleagues analyzed data from 293 subjects who were randomized to receive either intensive psychotherapy consisting of up to 30 sessions over a nine-month period of either CBT, FFT, or IPSRT or to three sessions over a six-week period of a brief psychoeducational intervention, which the authors referred to as collaborative care. The intervention was designed to help patients learn to recognize signs that a relapse may be imminent and to seek help before a full-blown depressive or manic episode takes hold. The researchers monitored the clinical status of subjects at each outpatient visit using the Clinical Monitoring Form.Of the subjects in this phase of the study, 66 percent had a current or lifetime anxiety disorder and 34 percent did not. For subjects with lifetime comorbid anxiety, 66 percent of the participants recovered with the intensive form of psychotherapy, while only 49 percent recovered with the psychoeducation program, the researchers reported. Recovery status was defined as having two or fewer moderate mood symptoms for eight or more consecutive weeks.However, for patients without comorbid lifetime anxiety disorders, there was no difference in recovery rates between those assigned to intensive psychotherapy or to psychoeducation: 64 percent of patients without an anxiety disorder recovered with psychotherapy, and 62 percent of patients without a lifetime anxiety disorder recovered with psychoeducation. When Deckersbach and colleagues examined the relationship between specific types of lifetime anxiety disorder and treatment outcome for depressed patients with bipolar disorder, they found a large difference in recovery rates for patients with generalized anxiety disorder or posttraumatic stress disorder (PTSD) depending on the intervention to which they were assigned. Sixty percent of patients with a lifetime generalized anxiety disorder recovered with intensive psychotherapy, while only 27 percent recovered with psychoeducation. Where the anxiety disorder was PTSD, 63 percent of patients recovered with psychotherapy versus 44 percent with psychoeducation. Only small differences in recovery rates between the two types of treatments were found for other types of current anxiety disorders such as social phobia, obsessive-compulsive disorder, and panic disorder, for example. In addition, the researchers looked at the number of lifetime anxiety disorders of the study participants and found that 84 percent of those with one lifetime anxiety disorder recovered after treatment with psychotherapy, while only 53 percent recovered with the psychoeducation intervention. However, for participants with two or more lifetime anxiety disorders, the benefits of the intensive psychotherapeutic treatment seemed to be lost—the recovery rates were similar regardless of the treatment used. The researchers speculated that it is possible that “individuals with one anxiety disorder need the more-intensive intervention to achieve recovery, whereas individuals with multiple anxiety disorders have more treatment-resistant symptoms and are unlikely to achieve recovery even with intensive psychosocial approaches.” Deckersbach acknowledged that more research is needed to further clarify the results of the analysis. For example, research more fully exploring the effects of medication changes from baseline assessments on treatment effects throughout the trial or an analysis further exploring the components of various types of the intensive psychotherapy (problem solving or cognitive restructuring) used in the study on anxiety symptoms may further elucidate the results, he said. ■“Do Comorbid Anxiety Disorders Moderate the Effects of Psychotherapy for Bipolar Disorder?” is posted at http://ajp.psychiatryonline.org/data/Journals/AJP/0/appi.ajp.2013.13020225.pdf. ISSUES NewArchived

Feasibility Evaluation of an Interpersonal and Social Rhythm Therapy Group Delivery Model

The effectiveness of psychotherapies, such as interpersonal and social rhythm therapy (IPSRT), is supported by randomized controlled trials. These trials provide minimal direction regarding feasibility of psychotherapy delivery models. The study purpose was to identify factors facilitating implementation and sustainability of an IPRST group for patients with bipolar disorder. Qualitative data were assessed by the normalization process model (NPM). The results demonstrate feasibility of implementation with experienced clinicians, program coordination, and leadership support. Sustainability challenges include aftercare groups, space, and clinician time. The NPM provides a useful framework for evaluation of factors influencing the feasibility of psychotherapy delivery models.

Evidence-Based Psychosocial Treatments for Child and Adolescent Bipolar Spectrum Disorders

Pediatric bipolar spectrum disorders (BPSDs) are serious conditions associated with morbidity and mortality. Although most treatment research has examined pharmacotherapy for pediatric BPSDs, growing literature suggests that psychosocial interventions are also important to provide families with an understanding of symptoms, course, and treatment of BPSDs; teach youth and parents methods for coping with symptoms (e.g., problem solving, communication, emotion regulation, cognitive-behavioral skills); and prevent relapse. Thirteen psychosocial intervention trials for pediatric BPSDs were identified via a comprehensive literature search and evaluated according to the Task Force on the Promotion and Dissemination of Psychological Procedures guidelines. All interventions were examined adjunctive to pharmacotherapy and/or treatment as usual (TAU). No well-established or questionably efficacious treatments were identified. Family psychoeducation plus skill building was probably efficacious (i.e., Multi-Family Psychoeducational Psychotherapy, Family-Focused Treatment); cognitive-behavioral therapy (CBT) was possibly efficacious. Dialectical behavior therapy (DBT) and interpersonal and social rhythm therapy (IPSRT) were experimental. Limited research precluded subdivision of treatments by format and age. Only single- and multiple-family psychoeducation plus skill building and CBT were evaluated with children. Only single-family psychoeducation plus skill building and DBT, and individual (commonly with limited familial involvement) CBT and IPSRT were evaluated with adolescents. In conclusion, psychosocial interventions that involve families, psychoeducation, and skill building may offer added benefit to pharmacotherapy and/or other TAU. Limitations of current research include few outcome studies, small samples, and failure to use stringent control conditions or randomization. The review concludes with a discussion of mediators and moderators, recommendations for best practice, and suggestions for future research.

A Meta-Study of Qualitative Research Into the Experience of ‘Symptoms’ and ‘Having a Diagnosis’ for People Who Have Been Given a Diagnosis of Bipolar Disorder

The purpose of this study is to review the current state of the literature reporting qualitative studies that depict the experiences of ‘symptoms’ and ‘having a diagnosis’ for people who have been given a diagnosis of bipolar disorder. The method attempted to combine empirical and discursive approaches and was strongly influenced by guidance from Paterson, Thorne, Canam, and Jillings (2001) on conducting a meta-review. Meta-data analysis was used to compare the studies and, subsequently, nine common themes emerged: ‘struggles with identity’, ‘loss of control’, ‘disruption, uncertainty and instability’, ‘negative impact of symptoms across life and the experience of loss’, ‘negative view of self’, ‘positive or desirable aspects of mania’, ‘struggling with the meaning of diagnosis’, ‘stigma’, and ‘acceptance and hope’. The meta-method explored and evaluated the qualitative methods that have been used to study this phenomenon, and the meta-theory considered the theoretical underpinnings and contributions of this research. The review concludes that an awareness of these themes could support clinical work with service-users and inform the development of relevant interventions such as interpersonal social rhythm therapy, cognitive behavioural therapy and mindfulness-based cognitive therapy. Further qualitative research is recommended to extend this literature base and include a greater representation of men and people living in non-westernised countries. Note This is a newer version of an article published in EJOP, Vol. 9 Issue 2 (2013) . In the following publication some section headings were added which had been lost during document production.

Bipolar Depression in Pediatric Populations

Depression in children and adolescents with bipolar disorder is more commonly observed than mania or hypomania, and is associated with significant functional disability in multiple environmental realms. Optimal management of pediatric bipolar depression is often defined by its multimodal nature with emphasis on both psychopharmacological and psychosocial treatment. This article provides a brief overview of the epidemiology and clinical course of pediatric bipolar depression, a clinically-oriented guide to the evidence-based psychopharmacological and psychosocial management of bipolar depression in youth, and suggestions on how best to integrate medication and therapy. Recommended treatment for bipolar depression in pediatric populations usually includes both medication and psychosocial interventions given a paucity of double-blind, placebo-controlled psychopharmacological studies. Lithium and lamotrigine are feasible and tentatively efficacious options; however, treatment with quetiapine monotherapy may be no better than placebo. Furthermore, some youth may be at heightened risk for developing manic symptoms after treatment with selective serotonin reuptake inhibitors (SSRIs). Psychotherapy, either alone or adjunctively with medications, provides practitioners with a safe and feasible alternative. Interpersonal and Social Rhythm Therapy for Adolescents (IPSRT-A), Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT), Dialectical Behavior Therapy for Adolescents (DBT-A), family psychoeducation, and Family Focused Therapy for Adolescents (FFT-A) are evidence-based treatments available to clinicians treating youth with bipolar depression.