Your Social Rhythm Blueprint for Bipolar: Using Routine to Anchor Treatment

"This approach incorporates social rhythm therapy — which is a way to support patients so they develop consistent daily routines — with interpersonal psychotherapy — which focuses on improving relationships and functioning," explains Nissa Keyashian, MD, a psychiatrist in private practice in San Jose, California. "People with bipolar disorder benefit greatly from IPSRT, because erratic schedules can increase the risk of both depressive and manic or hypomanic episodes."

• Getting bright light in the morning
• Minimizing screen time in the evening
• Maintaining a regular bedtime and wake time
• Eating meals at consistent times
• Getting regular physical activity during the day but avoiding intense workouts near bedtime
• Limiting caffeine and alcohol

The circadian system dictates sleep-wake cycles, but also a whole host of hormonal, metabolic, and neurological processes that follow a certain rhythm over the course of the day and night — things like melatonin secretion, cortisol rhythms, body temperature, and dopamine sensitivity, explains Laura Gonzalez, MD, MPH, a psychiatrist with Orlando Health Medical Group Behavioral Health in Kissimmee, Florida.

"Because people with bipolar disorder have underlying neurobiological differences in how their circadian systems operate, they're more vulnerable to small changes, which end up leading to big disruptions downstream when it comes to activity levels, sleep, and mood," she says. "That's why IPSRT's focus on habits that support the circadian rhythm is so important."

Mood stabilizers and antipsychotics help control symptoms by regulating extremes in mood changes, says Dr. Gonzalez. But circadian rhythm dysfunction caused by poor habits like sleep irregularity, sedentary behavior, and inconsistent mealtimes can make those medications less effective because, basically, your whole system is thrown off, she says.

"These medications are important treatments for mania, psychosis, or depression," she says. "But when it comes to preventing these episodes, supporting the circadian clock by maintaining a consistent schedule and controlling for any disruptions becomes pivotal."

Although there are several aspects of circadian rhythm function, there are a few that IPSRT focuses on most, since they tend to make the biggest impact for those with bipolar disorder.

• Sleep Consistency This includes a regular bedtime and wake time, even on the weekends, and minimizing naps during the day.

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   "Sleep is critical for bipolar management," says Gonzalez. "Sleep is likely the biggest disruptor, or stabilizer, of the whole circadian system. Lack of sleep can directly trigger a manic episode." She adds that during acute periods, sleep is essential for shortening the duration of symptoms, and during stable phases, sleep consistency makes people with bipolar disorder less vulnerable to relapses.
• Meal Timing As part of establishing a routine, meal timing is an important part of IPSRT, says Dr. Keyashian. She adds that this habit can also play a role in managing other chronic illnesses that might be present along with bipolar, such as type 2 diabetes, high blood pressure, and high cholesterol. That's because research shows that aligning mealtimes with your natural circadian rhythm — such as eating breakfast within two hours of waking and avoiding food at least two hours before bed — helps regulate metabolism and improves blood sugar regulation.

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• Morning Light Getting at least some sunlight in the morning, or employing light therapy, is known to regulate the circadian system.

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  "Light is part of what the brain and body naturally use to identify its rhythm for regulating all the processes involved," says Gonzalez. "In bipolar disorder, because of how sensitive the circadian clock is, light therapy can support the brain and body’s recognition of a stable schedule."
• Interpersonal Relationships In addition to daily habits, IPSRT also addresses the social connections that can be affected by bipolar disorder, Keyashian says. That includes fostering communication skills, addressing major life changes that might come with tension, conflict resolution, and an effort to create predictable schedules with friends and family — for example, a regular dinnertime with a spouse and children. This can reduce stress and enhance social support, which is key for bipolar management.

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With IPSRT, it's helpful to track daily activities and mood levels as a way to understand whether new habits are effective, Gonzalez sugggests.

"Journaling or using a planner to first establish a schedule and then to monitor for disruptions can help with tracking," she says. There are also apps that are designed for mood and habit tracking, including:

• Health Storylines
• eMoods
• Bearable
• 90health
• Daylio

It's important to work with your mental health provider, particularly if you're struggling to create changes in your routine, says Keyashian. Your health team can assist with setting realistic goals and developing tools to achieve them.

• With bipolar disorder, medication is an important cornerstone for treatment, and its effectiveness can be boosted through lifestyle habits related to sleep, meal timing, and social interaction.
• Interpersonal and social rhythm therapy can be a helpful framework for creating routines and tracking which habits may be disrupting your everyday rhythm.
• Working with your mental health provider while making lifestyle habit changes is crucial so you can set realistic goals and feel a sense of progress.