Acute Treatment of Major Depression

The first acute study of IPT was a four-cell, 16-week randomized trial comparing IPT, amitriptyline (AMI), combined IPT and AMI, and a non-scheduled control treatment for 81 outpatients with major depression (DiMascio etal., 1979; Weissman etal., 1979). Amitripty-line more rapidly alleviated symptoms, but at treatment completion there was no significant difference between IPT and AMI in symptom reduction. Each reduced symptoms more efficaciously than the control condition, and combined AMI-IPT was more efficacious than either active monotherapy. One-year follow-up found that many patients remained improved after the brief IPT intervention. Moreover, IPT patients had developed significantly better psychosocial functioning at one year, whether or not they received medication. This effect on social function was not found for AMI alone, nor was it evident for IPT immediately after the 16-week trial (Weissman et al., 1981).

The ambitious, multi-site National Institute of Mental Health Treatment of Depression Collaborative Research Program (NIMH TDCRP) (Elkin et al., 1989), randomly assigned 250 outpatients with major depression to 16 weeks of IPT, CBT, or either imipramine (IMI) or placebo plus clinical management. Most subjects completed at least 15 weeks or 12 sessions. Mildly depressed patients (17-item HDRS score <20) showed equal improvement in all treatments. For more severely depressed patients (HDRS >20), IMI worked fastest and most consistently outperformed placebo. Interpersonal therapy fared comparably to IMI on several outcome measures, including HDRS, and was superior to placebo for more severely depressed patients. The great surprise of this study was that CBT was not superior to placebo (albeit not significantly worse than IPT or IMI) among more depressed patients. Reanalysing the NIMH TDCRP data using the Johnson-Neyman technique, Klein & Ross (1993) found 'medication superior to psychotherapy, [and] the psychotherapies somewhat superior to placebo... particularly among the symptomatic and impaired patients' (Klein & Ross, 1993, p. 241), and 'CBT relatively inferior to IPT for patients with BDI scores greater than approximately 30, generally considered the boundary between moderate and severe depression' (Klein & Ross, 1993, p. 247).

Shea etal. (1992) conducted an 18-month naturalistic follow-up study of TDCRP subjects and found no significant differences in recovery among remitters across the four treatments. Twenty-six per cent of IPT, 30 % of CBT, 19 % of imipramine, and 20 % of placebo subjects who had acutely remitted remained in remission 18 months later. Among acute remitters, relapse over the year and a half was 33 % for IPT, 36 % for CBT, 50 % for imipramine (medication having been stopped at 16 weeks), and 33 % for placebo. The authors concluded that 16 weeks of specific treatments were insufficient to achieve full and lasting recovery for many patients.

Hoencamp and colleagues (JCM personal communication, 1996, 2002) in the Hague are completing a study of IPT versus nefazodone, alone and in combination, for acute treatment of major depression.

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