Psychotherapy 2014, Vol. 51, No. 1, 180 –189

© 2013 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0034396

Early Intervention for Adolescents at High Risk for the Development of Bipolar Disorder: Pilot Study of Interpersonal and Social Rhythm Therapy (IPSRT) Tina R. Goldstein, Rachael Fersch-Podrat, and David A. Axelson

Alison Gilbert Long Island Jewish Medical Center

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Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center

Stefanie A. Hlastala

Boris Birmaher and Ellen Frank

University of Washington Medical Center

Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center

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-/parentreport 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. Keywords: bipolar disorder, offspring, high risk, early intervention, IPSRT

Up to 60% of adults with bipolar disorder (BP) report symptom onset in childhood (Perlis et al., 2004), yet few receive timely

diagnosis and treatment (Suppes et al., 2001). Early BP onset is particularly insidious because of its association with substance use, legal difficulties, and suicidal behavior (Goldstein et al., 2005; 2008). Evidence from adoption, twin, family, and high-risk studies indicates BP is among the most heritable psychiatric disorders (Goodwin & Jamison, 2007). The rate of BP among child and adolescent offspring of one parent with BP is 5%–15% (Birmaher et al., 2009; Lapalme, Hodgins, & LaRoche, 1997; Singh et al., 2007), and nears 30% for offspring of two parents with BP (Goodwin & Jamison, 2007). The concordance rate for BP in monozygotic twins is 50% to 60%, and 13% to 23% in dizygotic twins and nontwin siblings (Goodwin & Jamison, 2007). Greater familial loading for BP is not only associated with greater risk for developing BP, but also earlier illness onset (Lapalme et al., 1997; Pauls, Morton, & Egeland, 1992; Tsai, Lee, & Chen, 1999). The largest longitudinal study of offspring of probands with BP conducted to date indicates rates of mood disorders in offspring increase most during adolescence (Birmaher et al., 2009). Unfortunately, BP onset during these critical formative years may negatively impact normative psychosocial development (McClellan,

This article was published Online First December 30, 2013. Tina R. Goldstein, Rachael Fersch-Podrat, and David A. Axelson, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center; Alison Gilbert, Department of Psychiatry, Long Island Jewish Medical Center; Stefanie A. Hlastala, Department of Psychiatry and Behavioral Sciences, University of Washington Medical Center; Boris Birmaher and Ellen Frank, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center. The authors thank study therapists Tim Winbush, MSW; Amy Schlonski, MSW; and Benjamin Mullen, PhD; and database manager Jason Lyons, BA. This work was supported by National Institute of Mental Health (NIMH) Grants MH074581 (Tina R. Goldstein), MH070570 (Stefanie A. Hlastala), and pilot funds from The Fine Foundation and The Ryan Licht Sang Bipolar Foundation. Correspondence concerning this article should be addressed to Tina R. Goldstein, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, BFT#531, Pittsburgh, PA 15213. E-mail: [email protected] 180

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EARLY INTERVENTION FOR HIGH RISK YOUTH

Werry, & Ham, 1993). There are several psychosocial interventions at various stages of treatment development expressly designed for the treatment of youth with BP and their families (for a review, see West & Pavuluri, 2009). The two models with the greatest empirical support to date include Psychoeducational Psychotherapy (PEP; Fristad, Verducci, Walters, & Young, 2009) and Family-Focused Therapy for Adolescents (FFT-A; Miklowitz et al., 2008); both are associated with improvement in mood symptoms among youth with BP. Because adolescence is a critical period for interpersonal, educational, and occupational attainment, successful early intervention—prior to BP onset—for adolescents at greatest risk could have potent implications for psychosocial outcomes. Although a range of psychiatric disorders occur at elevated rates among offspring of parents with BP (e.g., attention deficit hyperactivity disorder, anxiety, and behavioral disorders) and frequently precede BP onset (Birmaher et al., 2009; Chang, Steiner, & Ketter, 2000; Duffy, Alda, Crawford, Milin, & Grof, 2007; Hillegers et al., 2005), few at-risk youth receive mental health services. A naturalistic study of offspring of parents with BP found that not 1 of 25 adolescent participants received any clinical care— even though ⬎50% endorsed clinically significant mood symptoms (Jones, Tsai, Evershed, Knowles, & Bentall, 2006). These findings may be attributable to the fact that little is known about effective interventions for this population. The only psychosocial intervention examined for offspring of parents with BP is Family-Focused Therapy for High-Risk Children (FFT-HR; Miklowitz & Chang, 2008), a 12-session psychoeducational program for school-aged (8 –12) mood-disordered offspring. In a pilot trial (n ⫽ 13), participants demonstrated improvements in mood and functioning with FFT-HR (Miklowitz et al., 2011). However, there is no psychosocial intervention for at-risk youth who do not already meet criteria for a mood disorder, and no model has been examined for adolescents. Interpersonal and Social Rhythm Therapy (IPSRT; Frank, 2005) is a psychotherapy approach developed for adults with BP. IPSRT is based on the Social Zeitgeber theory of mood disorders (Ehlers, Frank, & Kupfer, 1988), wherein psychosocial stress leads to disrupted sleep and social routines, resulting in the onset and exacerbation of mood episodes in individuals with a diathesis for mood disorder (Wehr & Sack, 1987). IPSRT helps patients regularize daily rhythms and facilitate good sleep hygiene to promote mood stability. Additionally, IPSRT builds on the model of Interpersonal psychotherapy for depression (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984) that targets the connection between mood symptoms and interpersonal difficulties in one of four interpersonal problem areas (grief, role disputes, role transitions, and interpersonal deficits). Data indicate IPSRT prevents or delays BP illness episode recurrence and ameliorates acute mood symptoms in adults by helping patients stabilize daily social routines and sleep/wake cycles (Frank et al., 2005; Miklowitz et al., 2007). Hlastala and Frank (2006) adapted IPSRT for adolescents diagnosed with BP (IPSRT-A). Developmental adaptations to the treatment include age-appropriate language and exercises. An open study of IPSRT-A shows promising preliminary findings, with high treatment acceptability and retention, and significant improvement in mood symptoms and functioning among youth diagnosed with BP (Hlastala, Kotler, McClellan, & McCauley, 2010).

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Early intervention targeting sleep and circadian systems may have particular relevance for adolescents at-risk for BP. Multiple lines of investigation indicate sleep and circadian disturbances are not only classic symptoms of mood episodes in adults and youth with BP (American Psychiatric Association, 2000; Axelson, Bertocci, Lewin, et al., 2003; Hudson et al., 1992; Staton, 2008), but also serve as critical pathways to affective episode onset and relapse in those at-risk (Gruber et al., 2011; Wehr, Sack, & Rosenthal, 1987). Indeed, studies document greater rates of sleep and circadian abnormalities among offspring of parents with BP as compared with offspring of healthy controls (Giles, DelBello, Stanford, & Strakowski, 2007; Jones et al., 2006; Shaw, Egeland, Endictott, Allen, & Hostetter, 2005). Retrospective studies clearly indicate that such sleep disturbances in early adolescence are associated with risk for later onset of BP (for a review, see Ritter, Marx, Bauer, Lepold, & Pfennig, 2011). It is therefore not surprising that Duffy et al. (2007) reported the most common nonaffective disturbance preceding a mood disorder diagnosis in offspring of parents with BP was a sleep disturbance; sleep disorders were associated with subsequent BP onset in a larger cohort (Ritter et al., 2011). Insufficient and irregular sleep during adolescence are further exacerbated by normative biological changes in sleep– wake regulation at puberty, as well as increasing social influences (e.g., decreased parental control, early school start times) (Carskadon, 2002; Carskadon, Acebo, & Jenni, 2004; Dahl & Lewin, 2002). Sleep and circadian rhythms are therefore deemed critical targets for prevention and early intervention with adolescents, particularly among those with a biological diathesis for BP (Conus et al., 2008; McNamara, Nandagopal, Strakowski, & DelBello, 2010). Yet, to date, little is known about the extent to which regulation of sleep in at-risk populations impacts illness onset. In keeping with the Social Zeitgeber theory of mood disorders, the role of psychosocial stress in the onset of BP illness in biologically vulnerable individuals has been identified as an important target for early intervention for at-risk youth (Post, 1992). One source of psychosocial stress during adolescence is the family environment, and having a parent or sibling with a chronic illness like BP can contribute to familial stress (Chang, Steiner, & Ketter, 2003). Indeed, high levels of conflict characterize the family environments of offspring of parents with BP (GrigoroiuSerba˘nescu et al., 1989; Kuyler, Rosenthal, Igel, Dunner, & Fieve, 1980); in turn, family conflict positively correlates with severity of offspring psychopathology (LaRoche et al., 1985). Additionally, households with a parent with BP exhibit less cohesion and organization than normative households (Grigoroiu-Serba˘nescu et al., 1989; Kuyler et al., 1980), possibly contributing further to irregular social rhythms in offspring. Therefore, additional social support, particularly around the stressful life circumstance of having a parent or sibling with BP, may serve a protective function for high-risk adolescents. We therefore undertook a pilot study of IPSRT for adolescents at-risk for BP by virtue of a first-degree family history of the illness. The aims of the study were to modify a treatment manual for this population and gather preliminary data on feasibility and acceptability. Our primary hypothesis was that adolescents receiving IPSRT would demonstrate regularization of sleep and circadian rhythms with treatment. We did not hypothesize improvement in mood symptoms with the brief treatment, as we expected our at-risk sample, on average, to demonstrate minimal or no symp-

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toms at intake (thus creating a floor effect). However, we did explore changes in mood symptoms and functioning as secondary outcomes. Our ability to examine the effects of the intervention on distal outcomes (i.e., onset of BP) is limited by the scope of the current study, but remains a central long-term goal of this work.

Method

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Treatment Development We started with the IPSRT-A treatment manual for youth with BP (Hlastala & Kotler, 2007) because of its developmental appropriateness. We first determined that an abbreviated treatment schedule might be warranted with at-risk youth, and thus decreased treatment length from 18 to 12 sessions. Given the differing populations, we made minor modifications to the psychoeducation materials to target adolescents at-risk for BP. The most significant modification to the IPSRT-A model for at-risk youth involves the selection of the interpersonal problem area. Unlike in standard IPT, IPSRT, and IPSRT-A, in which one of four interpersonal problem areas is selected (Frank, 2005; Hlastala & Frank, 2006; Klerman et al., 1984), in IPSRT for at-risk adolescents, the interpersonal problem area prioritizes the adolescent’s feelings about having a parent or sibling with BP. Our rationale was based on the perceived importance of providing at-risk youth the opportunity to discuss their experience, and related interpersonal stress, associated with having a family member with BP. There is sufficient flexibility in the IPSRT for at-risk adolescents model such that additional interpersonal problems of concern to the adolescent (e.g., with peers) may also be addressed. In IPSRT for at-risk youth, parents are involved throughout treatment. Contact with parents occurs at each session to a varying extent, based on treatment phase and adolescent’s developmental level. With younger adolescents, parents are generally more involved, particularly in working toward goals related to sleep and

social rhythm regularity. At minimum, parental involvement includes a 10-min check-in at the end of each session.

Treatment Structure The IPSRT intervention consists of 12 sessions delivered over 6 months. The visit schedule is not prescribed, to allow flexibility in scheduling for youth and their families. The intervention is composed of three treatment components: (1) Psychoeducation about risk for BP; (2) Social rhythm regularity; (3) Interpersonal problem area. These treatment components are interwoven throughout sessions in three treatment phases (Table 1): Initial phase (Sessions 1– 4). The first 1–2 sessions prioritize developing rapport with the adolescent. The alliance is further built through conduct of the interpersonal inventory, wherein the therapist invites the teen to identify the important individuals in his or her life and describe the relationship he or she has with each. The therapist ensures the adolescent’s first-degree relative(s) with BP is included in the interpersonal inventory, and explores how the relative’s illness impacts their relationship. Sessions 3– 4 consist of psychoeducation about risk for BP. Psychoeducation sessions are conducted with parents and children together to provide information regarding risk for BP. The therapist invites adolescents and parent(s) to draw a “family tree” depicting family history of psychiatric conditions to highlight the rationale for the intervention based on genetic risk. Next, the therapist reviews symptoms of BP with the family, providing family members an opportunity to discuss their experiences with symptoms of mania and depression. A biopsychosocial model for the development of BP is presented to the family, highlighting the multitude of factors that contribute to development of BP. The therapist also explains the association between stress and mood, with a specific focus on stress from interpersonal relationships; we highlight the protective role of social support.

Table 1 Interpersonal Social Rhythm Therapy for At-Risk Youth: Treatment Content Treatment phase

Primary focus

Session number

Content Conduct the interpersonal inventory Construct “family tree” with familial psychiatric disorders Review symptoms of bipolar disorder Introduce biopsychosocial model of bipolar disorder Discuss association between stress and mood (with focus on stress from interpersonal relationships) Introduce the SRM-A Establish target times on SRM-A for sleep and social rhythms Develop strategies to regularize sleep patterns and stabilize daily rhythms Explore the adolescent’s feelings about being at-risk for bipolar disorder Mourn for the “lost healthy family member” Link stressful family/interpersonal events and mood and social rhythm disruptions Review goals and progress Identify strategies for future management of interpersonal problems and social rhythm disruptions Create plan for management of emergent mood symptoms

Initial

Develop rapport Conduct psychoeducation about risk for bipolar disorder

1–2 3–4

Intermediate

Enhance social rhythm regularity

4–8

Resolve interpersonal problem area

Final

Termination

9–12

Note. The three treatment components (1. Psychoeducation about risk for bipolar disorder; 2. Social rhythm regularity; 3. Interpersonal problem area) are interwoven throughout treatment phases.

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EARLY INTERVENTION FOR HIGH RISK YOUTH

Finally, with the adolescent individually, the therapist introduces the Social Rhythm Metric for Adolescents (SRM-A; Hlastala & Frank, 2006), the primary method for assessing and stabilizing sleep and social rhythms. On the SRM-A, adolescents record the timing of seven routine daily activities (e.g., out of bed, start school) that act to set the circadian system, as well as mood (⫺10 to ⫹10 scale) and energy (⫺10 to ⫹10 scale). The therapist first encourages the adolescent to complete the SRM-A daily without altering routines or setting target times. This allows for assessment of the teen’s sleep and social routines, and permits the therapist and adolescent to make connections between sleep/wake, social rhythms, and mood/energy. Using these data, the therapist and adolescent begin to identify unstable social rhythms and set goals to stabilize problematic sleep and social routines. Examples include large discrepancies between weekday and weekend sleep patterns (e.g., ⬎2 hr difference between bedtime and wake time on weekdays vs. weekends), and engaging in stimulating nighttime activities that interfere with sleep onset and maintenance (e.g., cell phone by the bed that beeps when the teen receives a text message). The therapist and adolescent aim to identify optimal total sleep time for the adolescent and set reasonable goals to work toward optimal sleep time while also balancing goals related to circadian regularity. Intermediate phase (Session 4 – 8). Among individuals atrisk for BP, social rhythm disruptions, particularly those related to sleep, may serve as the final pathway to the development of syndromal illness. Therefore, during the intermediate phase, the therapist continues to use the SRM-A to help the adolescent establish target times for sleep and social rhythms, and develop strategies to regularize sleep patterns and stabilize daily social rhythms. The therapist asks the adolescent to complete the SRM-A daily and bring the completed forms to each session. The therapist and adolescent review the prior weeks’ ratings, and identify ageappropriate short-term, intermediate, and long-term goals to gradually decrease variability in rhythms through planful behavioral changes. Sessions during the intermediate phase also include the interpersonal focus. The therapist conducts the interpersonal portion of the treatment largely with the adolescent individually. Therapists use many of the techniques used in the “grief for the lost healthy self” problem area of IPSRT for diagnosed individuals (Frank, 2005). This discussion begins by exploring the adolescent’s feelings about having a parent or sibling with BP, the knowledge that he or she has increased risk to develop BP, and how he or she copes with this knowledge. He or she is given the opportunity to mourn for the parent or sibling who might have been able to fulfill his/her familial role in a different or more satisfying way had he/she not developed BP. The therapist highlights links between stressful family life events (particularly those related to living with a relative with BP) and mood. Such life events are viewed not only as sources of mood symptoms, but also as potential triggers for sleep and circadian rhythm disruption. The therapist also invites the adolescent to discuss his or her feelings and experiences with the stigma involved with having a mentally ill family member. Additional interpersonal problem areas identified during the interpersonal inventory that are of particular relevance for the at-risk adolescent may be addressed during the intermediate phase. Similarly, the therapist helps the adolescent draw associations

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between interpersonal relationships and mood and social rhythm disruptions. Final phase (Sessions 9 –12). During the final phase of IPSRT-A, the therapist focuses on termination of treatment, and reviews treatment successes and remaining goals. A central focus during the final phase of treatment is on helping the adolescent identify strategies for future management of interpersonal problems and social rhythm disruptions, as well as any emerging symptoms of illness.

Pilot Study Participants. High-risk adolescents were recruited from three sources: (1) a sample of 205 offspring of BP parents between 12 and 18 years of age enrolled in the NIMH-funded Bipolar Offspring Study at the University of Pittsburgh (BIOS, PI: Birmaher); (2) offspring of adults receiving treatment for BP at Western Psychiatric Institute and Clinic (WPIC); and (3) siblings of youth receiving treatment for BP at the Child and Adolescent Bipolar Services clinic (CABS) at WPIC. Inclusion criteria. (1) age 12 to 18 years; (2) English language fluency and at minimum third grade literacy level; (3) a biological parent and/or sibling with a diagnosis of BPI or II confirmed via record review and/or semistructured diagnostic interview; (4) able and willing to give informed consent/assent to participate. Exclusion criteria. (1) a diagnosis of BPI, II, or Not Otherwise Specified (NOS) by the Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL; Chambers et al., 1985); (2) current unstabilized psychiatric symptoms evidenced by a Clinical Global Impressions Scale (CGI; Guy, 1976) severity score of ⬎5 (markedly ill) and/or a Children’s Global Assessment Scale (C-GAS; Shaffer et al., 1983) rating of ⬍50 (denotes serious symptoms); (3) evidence of mental retardation, pervasive developmental disorder, or organic central nervous system disorder by the K-SADS-PL, parent report, or medical history. Demographics. The sample includes 13 adolescents (seven boys), with a mean age of 15.2 years. Twelve participating youth had a parent diagnosed with BP (four fathers, eight mothers; nine BPI, three BPII), and one had a sibling (brother, BPI). Seven (54%) participants met DSM–IV criteria for at least one current Axis I disorder at study intake; two participants met criteria for two disorders each. Participants met criteria for depressive (n ⫽ 3), behavioral (n ⫽ 5), and anxiety (n ⫽ 1) disorders. Additional demographic characteristics are presented in Table 2.

Procedures The University of Pittsburgh Institutional Review Board approved all study procedures, in accordance with the Helsinki Declaration of 1975. Study staff explained all procedures to interested parents and their children, who provided informed consent for all study procedures. Diagnostic evaluation. Trained research staff with a master’s degree in a mental health field conducted the diagnostic evaluations. After consent and assent were obtained, parents were interviewed about their children and children were directly interviewed for the presence of Axis I psychiatric disorders using the

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GOLDSTEIN ET AL.

Table 2 Pilot Sample Demographics (n ⫽ 13)

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Sex (male) 7 (54%) Age 15.2 (SD ⫽ 1.6, range ⫽ 13–18) a SES 2.6 (SD ⫽ 1.2, range ⫽ 1–4) Race Caucasian 9 (69%) African-American 4 (31%) b Current Axis I Diagnosis No Axis I diagnosis 6 Depressive disorder 3 Attention deficit hyperactivity disorder 3 Anxiety disorder 1 Oppositional defiant disorder 2 a

Socioeconomic status, Hollingshead 1979 criteria. b Diagnoses obtained via the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL; Chambers et al., 1985); two participants met criteria for more than one category of disorder.

K-SADS-PL and the K-SADS Mania Rating Scale (MRS; Axelson, Birmaher, Brent, et al., 2003). K-SADS symptom ratings and diagnoses were based on consensus ratings incorporating all available data; in the event of conflicting information, summary ratings were guided by clinical judgment. A child psychiatrist or psychologist confirmed all diagnoses subsequent to the interview. Interrater reliability between the first author and the study-independent evaluator for presence/absence of Axis I psychiatric disorders on the K-SADS-PL was ⱖ0.8 (kappa). To confirm the BP diagnosis in the subject’s first-degree relative, study staff obtained the relative’s consent and releases of information to obtain psychiatric records. Study staff reviewed psychiatric records for a diagnosis of BPI or II disorder in the first-degree relative to determine the subject’s eligibility. IPSRT sessions. Master’s and doctoral level mental health professionals with experience conducting therapy with adolescents and their families conducted IPSRT sessions. All study therapists attended IPSRT training with the treatment developer (E.F.), as well as study-specific training with the first author (T.G.) focused on manual review, prior to treating study participants. Study therapists participated in weekly individual and/or group supervision meetings involving videotape review and discussion of session content. Study therapists completed a clinical note following each IPSRT session in which they summarized session content. The first author reviewed all clinical notes to quantify session content into the three treatment components (i.e., Psychoeducation, Social Rhythm Therapy, and/or Interpersonal Therapy). In keeping with the manualized treatment protocol, sessions may include more than one content area. No formal assessment of adherence to the treatment model was conducted in this preliminary study.

Studies support the validity of the measure for adolescents, and indicate strong correlations with daily prospective sleep diary and actigraphy variables for both school- and weekend-nights. Mood symptoms. Affective symptoms were monitored using the K-SADS Depression (DRS; Chambers et al., 1985) and MRS, semistructured interviews designed to elicit affective, cognitive, and physiological symptoms associated with depression and mania. Mood symptom ratings reflect summary scores incorporating both child- and parent-report. Interrater reliability for K-SADS mood items were good (DRS intraclass correlation coefficient, ICC ⫽ 0.84; MRS ICC ⫽ 0.96). Participants also completed the child- and parent-report versions of the Mood and Feelings Questionnaire (MFQ), a measure of pediatric depression with demonstrated validity (Angold, Costello, Pickles, Winder, & Silver, 1987; Daviss et al., 2006). New-onset Axis I psychiatric disorders, as well as status of disorders for which participants met full criteria at intake were coded using the Longitudinal Follow-Up Examination (LIFE) (Keller et al., 1987). LIFE Psychiatric Status Ratings (PSR; Warshaw, Dyck, Allsworth, Stout, & Keller, 2001) are assigned weekly on a 1 to 6 severity scale (1 ⫽ no symptoms, 2– 4 ⫽ increasing levels of subthreshold DSM–IV symptoms and impairment, 5– 6 ⫽ full threshold DSM–IV criteria) based on consensus scores from interviews with parents and their children. Taken together, weekly ratings reflect periods of recovery and recurrence. ICC for LIFE PSR mood disorder ratings were acceptable (ICC ⫽ 0.75). Psychosocial functioning. At each assessment, the study evaluator rated severity of overall psychiatric illness, as well as improvement since intake, on a 0 to 7 scale using the CGI. Additionally, evaluators quantified the adolescent’s best and worst week of functioning over the prior 3 months on a 0 to 100 scale using the C-GAS. Treatment satisfaction. Following completion of the treatment protocol, participants and parents completed a Treatment Satisfaction Questionnaire consisting of 12 items rated on a 7-point Likert scale.

Data Analysis We utilized linear mixed effects models to examine the primary hypothesis regarding within-group changes in sleep and circadian rhythms as a function of time. Mixed effects models were also constructed to examine secondary hypotheses regarding change in mood symptoms and functioning with time. All analyses were conducted among those study participants who attended at least one IPSRT session.

Results Instruments Participants and parents completed assessments with an independent trained master’s level study evaluator at intake to determine the subject’s eligibility and establish pretreatment ratings; eligible participants repeated this battery at 3 months and posttreatment (6 months). Variables were assessed in the following domains: Sleep and circadian rhythms. Youth completed the 29-item self-report School Sleep Habits Survey (Wolfson et al., 2003).

Feasibility As can be seen in Figure 1, to yield the study sample of 13 adolescents, we screened 85 interested families. The 57 families who declined participation prior to determining eligibility most commonly cited unwillingness on the part of the adolescent or concerns regarding ability to attend weekly sessions. Of the 28 adolescents assessed for eligibility, 19 met study inclusion criteria; six of these did not attend any IPSRT sessions.

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Contacted about study par
cipa
on (n=85)

Declined to par
cipate (n=57)

Assessed for eligibility (n=28)

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Did not meet inclusion criteria (n=9)

Allocated to IPSRT (n=19)

Did not aend treatment (n=6)

Aended at least one IPSRT Session (n=13) Figure 1.

Pilot IPSRT for high-risk adolescents flow diagram.

Of the 13 adolescents who attended at least one IPSRT session, the mean number of sessions attended was 7.7 ⫾ 4.3 (range: 2–16). Study therapists recorded the reason for missed visits; over half of missed visit forms may implicate parental illness severity, namely, parental incapacity and/or disorganization associated with affective symptoms were commonly cited reasons for missed visits. We quantified session content into the three major IPSRT content areas based on a clinical note completed by the therapist postsession; of the 96 total study IPSRT sessions for which a clinical note was completed (96% of all study sessions), 43% (n ⫽ 41) included Psychoeducation, 54% (n ⫽ 52) included Social Rhythm Therapy, and 61% (n ⫽ 59) included Interpersonal Therapy.

Patient Satisfaction Adolescents and their parents reported high levels of satisfaction with IPSRT (scale ⫽ 1 [very dissatisfied] to 7 [very satisfied]; mean adolescent score ⫽ 5.8 ⫾ 1.3; mean parent score ⫽ 6.2 ⫾ 0.8), as well as with the adolescent’s progress at posttreatment (mean adolescent score ⫽ 5.4 ⫾ 0.9; mean parent score ⫽ 5.2 ⫾ 1.5). On average, adolescents rated the treatment length as appropriate (scale ⫽ 1 [much too short] to 7 [much too long]; M ⫽ 4.4 ⫾ 0.9), whereas parents rated the treatment as slightly too short (M ⫽ 3.4 ⫾ 0.9). Both adolescents and parents felt that the frequency of visits was appropriate (mean adolescent rating ⫽ 4.0 ⫾ 0; mean parent rating ⫽ 4.0 ⫾ 0).

Treatment Response Sleep and circadian rhythms. Table 3 summarizes the average self-reported bed times, wake times, and total sleep times on

school nights/mornings and weekend nights/mornings by assessment timepoint (i.e., pretreatment, 3 months, and posttreatment/6 months). Mixed-effects models indicate a significant effect of time on school night bed times (F ⫽ 55.78; p ⬍ .01), whereby bed times on school nights became later over the course of the study. Weekend morning wake times (F ⫽ 7.43; p ⫽ .01) became significantly earlier with time, indicative of less “sleeping in” on weekends. Weekend night total sleep times (F ⫽ 6.34; p ⫽ .02) decreased over the course of the study, signaling less oversleeping on weekends. However, school morning wake times (F ⫽ 0.68; p ⫽ .5), school night total sleep times (F ⫽ 1.22; p ⫽ .4), and weekend night bed times (F ⫽ 1.07; p ⫽ .4) did not significantly change with time. Mood symptoms. On average, clinician, self-, and parentreport ratings of mood symptoms at pretreatment reflected mild symptoms (Mean DRS ⫽ 13.85 ⫾ 12.69; Mean MRS ⫽ 6.31 ⫾ 4.21; Mean MFQ-Child-Report ⫽ 12.09 ⫾ 11.41; Mean MFQParent-Report ⫽ 10.54 ⫾ 10.01). There were no significant changes on any of these mood symptom scales as a function of time (DRS F ⫽ 0.75; p ⫽ .50; MRS F ⫽ 1.47; p ⫽ .28; MFQ-Child Report F ⫽ 0.49; p ⫽ .63; MFQ-Parent-Report F ⫽ 5.10; p ⫽ .06). PSR ratings indicated that two participants with subthreshold depressive symptoms at pretreatment developed a full threshold major depressive episode by the 3-month assessment. One of these youth exhibited a brief episode, and was in partial remission by posttreatment (6 months). Of the three adolescents who met criteria for major depressive episode at pretreatment, one was in partial remission at posttreatment. There were no emergent threshold episodes of hypomania or mania documented in the sample. No other classes of new-onset psychiatric disorder were reported.

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Table 3 Adolescents’ (n ⫽ 13) Self-Reported Mean Bed Times, Wake Times, and Total Sleep Timesa Over the Course of IPSRT Pretreatment

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Sleep domain

School nights

3 months

Weekend nights

School nights

Weekend nights

Posttreatment (6 months) School nights

Weekend nights

Bed time 10:25 p.m. 12:38 a.m. 10:53 p.m. 12:29 a.m. 10:55 p.m.b 12:39 a.m. SD 0.78 2.0 1.3 1.05 0.66 1.0 Range 9:30–11:45 p.m. 11:00 p.m.–6:00 a.m. 9:30 p.m.–1:00 a.m. 11:00 p.m.–2:00 a.m. 10:00 p.m.–12:00 a.m. 11:40 p.m.–2:00 a.m. Wake time 6:03 a.m. 9:48 a.m. 6:50 a.m. 10:02 a.m. 6:18 a.m. 8:54 a.m.b SD 0.6 1.1 1.72 0.73 0.98 0.52 Range 4:30–7:00 a.m. 8:00 a.m.–12:00 p.m. 5:30–11:00 a.m. 7:55–9:30 a.m. 5:20–8:00 a.m. 7:55–9:30 a.m. Total sleep time (hr) 7.28 9.0 7.44 9.66 6.83 7.9b SD 1.28 2.1 1.43 0.64 1.21 1.29 Range 5.0–9.0 5.0–14.0 5.0–10.0 6.75–10.5 5.0–8.0 6.0–9.0 a

School Sleep Habits Survey (Wolfson et al., 2003).

b

p ⬍ .05 for within-group effect of time.

Psychosocial functioning. At pretreatment, clinicians rated adolescents’ best week of functioning in the preceding three months on average in the good range (Mean C-GAS ⫽ 75.77 ⫾ 17.42), indicating “no more than slight impairment in social, occupational, or school functioning; if symptoms are present, they are transient and expectable reactions to psychosocial stressors” (American Psychiatric Association, 2000). Clinician ratings of the worst week of functioning in the preceding 3 months fell, on average, in the mild range (Mean C-GAS ⫽ 63.9 ⫾ 15.58), “some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well” (American Psychiatric Association, 2000). Neither best week C-GAS rating (F ⫽ 0.73; p ⫽ .50) nor worst week C-GAS rating (F ⫽ 0.13; p ⫽ .88) significantly changed with time. The mean CGI-Severity score for overall psychiatric illness at pretreatment fell into the “borderline mentally ill” category (M ⫽ 2.23 ⫾ 1.36), reflecting little or no impairment from psychiatric symptoms, a rating assigned for an individual who does not meet criteria for a psychiatric disorder. Mean CGI-Severity score did significantly change with time (F ⫽ 9.27; p ⬍ .01; posttreatment M ⫽ 2.0 ⫾ 1.4). With respect to CGI-Improvement scores, on average, clinician ratings reflect “minimal improvement” in overall psychiatric illness since pretreatment at both the 3-month (M ⫽ 3.5 ⫾ 1.57) and posttreatment (6-month) assessments (M ⫽ 3.14 ⫾ 0.90).

Discussion Results from this preliminary open pilot trial of IPSRT for adolescents at-risk for developing BP by virtue of a positive family history suggest the IPSRT focus on sleep and interpersonal relationships may be beneficial for youth at-risk for BP. In line with study hypotheses, data support significant change in select sleep and circadian patterns (i.e., less oversleeping on weekends) over the course of treatment. Given the small sample size and (on average) minimal mood symptom severity displayed by this at-risk sample at study intake, it was not surprising that we did not detect improvement in mood symptom severity with treatment. However, clinician ratings did reflect minimal improvement in overall psychiatric illness with IPSRT. Our primary goal was to demonstrate feasibility and acceptability of an IPSRT model for at-risk adolescents. Our recruitment efforts indicated that, although parents were interested and highly

motivated for their children to engage in psychotherapy, many of the offspring did not want therapy. Of the 85 parents who expressed interest in having their child participate, 67% of those families ultimately declined. Many adolescents asserted that because they felt there was “nothing wrong” with them, they did not need therapy. Similarly, some had come to view therapy as a service for individuals with severe mental illness (based on their experience with their ill family member), and therefore desired to distance themselves from any implication that they may be ill themselves. These responses may be considered developmentally normative, as the drive for peer acceptance during adolescence is at odds with any reminder that one is different from one’s peers. We used this information to hone our approach to engaging at-risk youth. Specifically, highlighting the IPSRT focus on sleep and circadian rhythms appears to minimize the stigma associated with “therapy” for this group. Future studies aiming to intervene with at-risk youth may also consider conducting sessions in “neutral” community settings like schools, community centers, or libraries rather than mental health clinics to enhance accessibility for this population. A group format for intervention delivery might also be considered as a means of diminishing youths’ concerns about stigma. These findings serve to underscore the importance of enhanced acceptability and engagement efforts with this population. In keeping with the literature on offspring of parents with BP (Birmaher et al., 2009; Chang et al., 2000), our pilot sample displayed substantial clinical heterogeneity. Over half the sample met criteria for at least one Axis I condition, including depression, behavioral, and anxiety disorders, whereas nearly half displayed no psychopathology. Early assessment for offspring of parents with BP is therefore warranted, as well as timely intervention for psychiatric conditions known to precede BP onset (Duffy et al., 2007). Given that many at-risk adolescents displayed disorders at intake for which evidence-based treatment exists, we propose a two-pronged approach to the treatment of high-risk youth: (1) appropriate evidence-based treatment for antecedent and/or independent psychiatric conditions; and (2) IPSRT, consisting of targeted psychoeducation, regularization of sleep and circadian rhythms, and support surrounding the relative’s illness and perceived risk to develop BP. In this way, we target two potential avenues for modifying the trajectory of psychiatric disorder among at-risk adolescents.

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EARLY INTERVENTION FOR HIGH RISK YOUTH

Despite high satisfaction ratings, treatment attendance in this pilot study was sporadic (on average, 64% of scheduled sessions attended). Missed sessions were largely attributable to parental BP illness severity. Indeed, multiple studies document the profound impact that BP illness has on family functioning (GrigoroiuSerba˘nescu et al., 1989; Kuyler et al., 1980; Sanchez-Moreno et al., 2009). Additionally, these figures further reinforce the importance of providing at-risk youth an opportunity in the context of the interpersonal psychotherapy portion of IPSRT to candidly discuss their experience of having a relative with BP. It is possible that offering coordinated appointments for both parents and their offspring in a single setting may maximize attendance. We assert that mechanistically, the regularization of social rhythms, particularly during the vulnerable period of adolescence, may help protect at-risk youth from the onset or exacerbation of mood symptoms. Our pilot data indicate that select sleep and circadian rhythms did shift significantly with IPSRT—namely, adolescents reported a shift toward earlier wake times on weekend mornings, as well as less overall total sleep time on weekend nights. Additionally, school night bed times became later over the course of treatment; this finding could be explained by literature indicating adolescents go to bed later as they get older (Crowley, Acebo, & Carskadon, 2007). Large discrepancies between school night and weekend night sleep patterns is in keeping with recent epidemiological findings on adolescent sleep patterns (Gradisar, Gardner, & Dohnt, 2011). Yet, experts recommend adolescents keep discrepancies to no ⬎2 hr difference between bed time and wake time on weekdays versus weekends (Dahl, personal communication). In the social rhythms component of the pilot study intervention, when adolescents displayed such large discrepancies (2 ⫹ hr), the therapist and adolescent worked together to identify goals related to regularization of such patterns. One important consideration when interpreting these findings is the role of academic year; studies indicate adolescents have later bed times and wake times during summer vacation than during the school year (Crowley, Acebo, Fallone, & Carskadon, 2006). Limited power within our sample of 13 adolescents precluded the ability to statistically control for academic year status at each assessment timepoint. Future studies examining adolescents’ sleep and circadian rhythms should examine the role of the effects of academic year. Additionally, recommended total sleep time for adolescents is between 8.5 and 9.25 hr per night (National Sleep Foundation, 2012). On average, study participants reported ⬍8 hr of total sleep time on school nights, and exhibited a decrease over the course of treatment in total sleep time on weekend nights. These findings are in keeping with epidemiological data indicating total sleep times well below recommended levels among adolescents in the United States (National Sleep Foundation, 2006). Decreased total sleep time with treatment may be related to a relative prioritization of circadian regularity in the intervention; optimal total sleep time was determined on an individualized basis, and targeted in treatment in the context of a broader focus on circadian regularity. Future studies should aim to identify the specific association between risk for BP onset and modification of distinct circadian disturbances (i.e., sleep deficits vs. circadian irregularity). Overall, our findings indicate that IPSRT may be beneficial in targeting sleep patterns that may contribute to increased risk for poor outcomes.

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Limitations We aimed to demonstrate feasibility and acceptability of an IPSRT model for at-risk adolescents. As such, we did not include a control group in this preliminary study. Therefore, it is not possible to determine whether the observed changes in sleep patterns and functioning were uniquely attributable to IPSRT, or rather may be associated with adolescent development or other factors. Furthermore, statistical power to detect significant changes in outcome domains over time is limited owing to the small sample size. Outcome domains assessed were limited to mood, sleep, and functioning; future studies should also examine other relevant outcome domains of interest that may inform mechanisms of treatment outcome, including family members’ knowledge about BP and adolescents’ self-efficacy in coping with family member symptoms. Additionally, we followed at-risk youth for 6 months, from pre- to posttreatment. We are thus not able to determine from the current study design whether IPSRT helps to delay or prevent the onset of BP in at-risk youth. Future controlled studies using longer follow-up with larger samples are needed to examine these important questions.

Summary Our experience conducting this pilot study of IPSRT for adolescents at-risk for developing BP indicates that the intervention is feasible and acceptable to families. The focus on sleep/wake regulation appears more acceptable to at-risk adolescents who exhibit sensitivity to stigma associated with more traditional psychotherapy approaches. This evidence points to the potential for a targeted IPSRT intervention to reduce risk for negative outcomes in adolescents at-risk for BP.

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Received March 6, 2013 Revision received June 13, 2013 Accepted July 31, 2013 䡲