Interpersonal Psychotherapy Rationale

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Interpersonal therapy provides a pragmatic, time-limited and interpersonally focused approach to the treatment of major depression. It is modest in its use of psychotherapy jargon and promotes attention to the relationship-based issues that are central to the experience of many depressed patients. The treatment does not become entangled in questions of causation, acknowledging the capacity for depression to both precipitate and reflect interpersonal change, difficulty and loss. Instead it attends to difficulties arising in the daily experience of maintaining relationships and resolving difficulties while depressed. The fundamental clinical task of IPT is to help patients to learn to understand their depressive symptoms in an interpersonal context, and to work towards resolution of interpersonal difficulties such that they will no longer precipitate or sustain the depressive state and so facilitate more effective symptom management.

Evidence Base

Interpersonal psychotherapy (Klerman et al., 1984, Weissman, Markowitz & Klerman, 2000) was originally devised in a research context and has been developed and evaluated in a wide range of clinical trials, with both depressed and non-depressed populations and as both an acute intervention (Elkin et al., 1989) and as a maintenance therapy (Frank etal., 1991; Klerman etal., 1974). It has also been adapted for use with different age groups including depressed adolescents (Mufson et al., 1999) and older adults (Reynolds et al., 1999a, b), as well as depressed medically ill patients (Markowitz, 1998) and anti-partum and post-partum mothers (O'Hara et al., 2000; Spinelli, 1997). Interpersonal psychotherapy was originally designed as an individual therapy but it has been modified for use in a group setting (Wilfley et al., 1993) and as a conjoint therapy for couples with marital disputes (Foley etal., 1989).

Research evaluations comparing IPT to established treatments for depression, both medical and psychological, have repeatedly demonstrated its equivalence and in some instances superiority (DiMascio et al., 1979; Elkin et al., 1989). In the earliest study of IPT with an acutely depressed population, IPT and Amitriptyline were compared as individual and combined treatments and compared to a minimal contact control condition (DiMascio et al., 1979). Both active treatments were found to be superior to the control condition and the combined treatment was found to have a significantly superior additive effect. Medication was found to have a quicker initial effect on symptoms but this balanced out by the end of the treatment period. This study also revealed the slow release effect of IPT on social functioning, with significantly greater improvement being demonstrated for IPT subjects, whether receiving IPT alone or in combination than for the other conditions.

The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) provided a major evaluation of psychological treatments for depression (IPT and CBT) and comparison with a primarily medical approach (Elkin et al., 1989). Primary analyses revealed a pattern of significant symptomatic improvement but few significant differences between the active treatments and interestingly between the active and control conditions. When the initial severity of the depressive symptoms was used to define the sample, treatment with Imipramine primarily but in some instances IPT, demonstrated superiority over the placebo/clinical management in the more severely depressed sample. Cognitive-behavioural therapy failed to demonstrate significance over placebo under these conditions. Significantly, however, only 26 % of IPT subjects who recovered remained well over the 18-month follow-up period and one-third of those who had recovered at end of treatment relapsed during this period (Shea et al., 1992). Relapse was reported to come late in this period (mean 67 weeks) but it came nonetheless. This was very similar to the rates recorded for CBT and superior to the rates for Imipramine and placebo, although the latter figures may be attributable to the clinically unsound withdrawal of medication at the end of treatment. Numerous statistical reworkings of this landmark study have done little to change the outcome pattern (Gibbons et al., 1993; Klein & Ross, 1993). Schulberg et al. (1996, 1998) also reported a more rapid and effective outcome for IPT compared with GP treatment as usual in primary care patients with depression but found that initial severity of depression and functional ability were unrelated to clinical course.

Three further randomized control trials have been conducted to evaluate the prophylactic effect of IPT as a continuation or maintenance therapy (IPT-M) for successfully treated patients with recurrent depression. The original research evaluation of IPT (Klerman et al., 1974) revealed the superiority of IPT and Amitriptyline over placebo and a similar non-significant trend for IPT alone. The IPT subjects also demonstrated superior social functioning gains over the one-year follow up period than either placebo or medication subjects (Weissman et al., 1974). Frank et al.'s (1991) work has specifically evaluated the additional effect of monthly IPT either alone or in combination with active or placebo medication following successful acute combination IPT and Imipramine. Unlike the originators, Frank's group argue for the importance of treating depression to recovery rather than a standard time-limited protocol, consequently the acute and consolidation period may be longer than the standard 16 sessions. This study revealed that those who received IPT over the follow up period remained well for significantly longer than those who did not, with those who received combined treatment remaining symptom free for longest. Subsequent work (Thase et al., 1997) demonstrated that the treatment combination necessary to achieve recovery was also necessary to keep patients well after treatment: effective combined therapy could not be reduced to monotherapy and produce similar effects. Frank et al. (1991) also revealed that those patients whose therapy was rated as more consistently and specifically interpersonal had a significantly greater survival time than those with lower IPT conformity. Reynolds et al. (1999a) reported that IPT-M and Nortriptyline combined and as monotherapy were superior to placebo in preventing relapse in older adults with recurrent depression. Combined therapy was significantly superior to IPT alone and had a trend towards superiority over medication alone. Comparison of effect for older adults and general adult population revealed a comparable but slower effect for the older population from combined treatment (Reynolds et al. 1996) and a higher and more rapid relapse rate in the older adults, although this was reported to respond well to brief periods of more intense therapy (Reynolds, 1994). Lenze et al. (2002) in an IPT maintenance study with older adults, found that social functioning was maintained in those receiving combined therapy (IPT and Nortriptyline) while it declined in those receiving monotherapy (pharma-cotherapy or psychotherapy). The specific needs of older adults with bereavement-related depression did not appear to be best served by IPT alone. While combined treatment produced the highest remission rate IPT with placebo produced the lowest (Reynolds et al. 1999b).

Various prognostic factors have been examined in relation to IPT. Marital adjustment in the NIMH study was reported to show significant improvement with treatment but no specific interaction with treatment type and was mediated by change in depression (Kung & Elkin, 2000). Poorer pre-treatment adjustment was revealed as an indicator of poor prognosis at the end of treatment and poorer end-of-treatment marital functioning was a negative indicator for follow up. Imber et al. (1990), reporting on the same sample, revealed the importance of tailoring therapy to patients' strengths as IPT produced better outcome in those patients with lowest social dysfunction at the start of treatment. Repeated studies have examined the impact of co-morbid anxiety symptoms and while GAD symptoms have been found to slow response to treatment they have not been associated with poorer outcome (Brown et al., 1996). Panic/agoraphobic symptoms however have been associated with higher early termination rates and poorer clinical outcome and delayed treatment response (Brown et al., 1996; Feske et al., 1998; Frank et al., 2000). Thase et al.'s (1997) meta-analysis examined the impact of initial symptom severity and found that outcome for IPT alone was not significantly different from combined therapy with milder depressions but it fared significantly less well in more severely depressed individuals.

Given the clear interpersonal perspective of IPT it is not surprising that it has also been tested for couples caught in a pattern of disputes. Foley et al. (1989) compared outcome for depressed outpatients randomised to the individual or couples version of the therapy. Both groups demonstrated significant reduction in depressive symptoms and improved general interpersonal functioning by the end of treatment, with neither showing an advantage over the other. When outcome was defined specifically in terms of marital satisfaction the conjoint worked fared better than the individual format, suggesting a limited advantage for couples work with this subgroup.

Clinical Practice

The major goals of IPT, namely to reduce depressive symptoms and improve interpersonal and social functioning, are achieved through the resolution of the primary interpersonal problem area. In IPT interpersonal problems are conceptualized under four principal headings: interpersonal role dispute, interpersonal role transition, unresolved grief and interpersonal deficits or sensitivity. At first this may appear to limit the application of this interpersonal model but in practice the challenge is more often to decide with clients which of the competing options generated by this framework will best contribute to their recovery and improved function. By proposing that a single focus be selected IPT does not assume that depressed individuals only experience one difficulty at a time. Rather it provides a framework whereby difficulties may be prioritized for attention based on their relevance to the current depressive symptoms and potential to respond to efforts to achieve change over the time-limited contract. Often presenting difficulties may overlap, such as marital disputes that emerge in the context of the stress generated by job loss - a dispute in the context of a transition. Interpersonal therapy helps to tell the patient's story in a manner that acknowledges the process through which difficulties emerge and offers sign posts and strategies to assist work towards change and resolution.

Interpersonal therapy emphasises the interpersonal environment through assessment, problem resolution and termination. Depressive symptoms are understood not simply in terms of presence or absence but within a particular timeframe, which promotes attention to particular life events and interactions that triggered or arose from depressive symptoms. The interpersonal implications of depressive symptoms are similarly given marked attention -for example, does excessive guilt lead to a pattern or subservience, withdrawal or demands for reassurance? Effective management of depressive symptoms is held as a primary goal and the optimal utilisation of interpersonal resources is a recurrent theme to support efforts in this direction: the question is not simply 'what can you do to help yourself feel better?' but 'who can help you to do that?' In order to facilitate this IPT therapists conduct a thorough review of the person's interpersonal world, the interpersonal inventory, considering availability, utilisation, reciprocity, satisfaction and importantly connection to the current depressive symptoms. The selection of a focus for treatment, derived from the assessment process, has an additional benefit in modelling an effective problem solving strategy and relieving the person of the burden of simultaneously trying to resolve all the difficulties with which he or she is faced. Conjoint IPT, in which both partners in a relationship are present throughout, follows a similar course but additionally takes both parties history of the depression and their relationship.

Middle Sessions

During the middle sessions the therapist helps the patient to link the weekly onset of symptoms to the interpersonal context or vice versa, clarify the issues and themes which emerge, and attends to the associated emotional experience. Sessions focus on here and now concerns and events, and strategies are selected and implemented as appropriate to the stage of therapy and the experiences of the week. Patients are helped to understand their experiences within the focus framework and to consider and ultimately attempt alternative responses, which may disentangle their relationships and role performance from their depressive symptoms.

Role transition is the most commonly selected focus area, reflecting the multitude and diversity of roles held by each individual. The IPT model identifies three interrelated phases of the intervention, during which the patient is assisted in moving away from the old role through realistic evaluation and mourning, reflecting on the process of change and its impact on successful transition, and finally re-evaluating the possibilities and opportunities in the new role and clarifying and mastering the current demands to restore self-esteem.

The disputes focus attention on a significant relationship that is the primary area of difficulty in relation to this episode of depression. This may be a recent conflict or the exacerbation of a longer standing dispute. The objective is then to understand the mechanisms by which the dispute is perpetuated through detailed replaying of affect-laden exchanges. Attention is then directed to modifying those aspects that are amenable to change, facilitating more effective and productive communication patterns to allow resolution. In conjoint work IPT assumes that disputes are the focus and unlike some other couples therapies continues to focus primary attention on the problems of the depressed individual rather than equal attention to both parties.

The grief focus attends to the difficulties experienced when the patient maintains a significant attachment to a person who has died such that it interferes with current functioning, through the onset and maintenance of depressive symptoms. Interpersonal therapy helps the patient to review the relationship that has been lost, considering all its dimensions, and helps the patient to become more engaged with the current social environment by realigning expectations with the members of the patient's current network.

The patients for whom interpersonal sensitivity is the primary focus often have a history of interpersonal difficulties or isolation extending far beyond the period of the most recent episode of depression. This distinguishes them from many of the other IPT patients, as they may not have experienced a higher level of social functioning prior to the onset of depressive symptoms. Given the more pervasive nature of the interpersonal difficulties these patients experience, it is important to tailor the expectations of therapy accordingly. The authors of IPT recommend that if a reasonable alternative to sensitivity is available this should be negotiated as the primary focus. While this is certainly one of the more difficult areas to work with in IPT, interpersonal deficits is not one to be avoided at all costs. As a secondary focus in particular interpersonal deficits can provide a very helpful framework with which to understand the recurrent and pervasive difficulties these patients experience with other people.

Termination

As with any time-limited therapy, the end of treatment is in focus from the start of the contract, which by definition draws attention to the ending, as is monitored with a weekly countdown of sessions to keep therapist and patient oriented in treatment. The IPT model makes more explicit and direct reference to the end of treatment during the last four sessions, although this issue may be broached earlier if this is appropriate to the patient's needs, history and response. Patients are actively invited to reflect on their experience and response to the end of treatment and to look back over the experience to review progress and evaluate the impact. It is important that progress in terms of depressive symptoms and interpersonal functioning is reviewed at this stage. Patients are encouraged to reflect on their own contribution to their recovery but the facilitative impact of engaging interpersonal support within and beyond the therapy relationship is also highlighted. Plans are made in terms of management of anticipated life events, which may increase the risk of depressive symptoms returning, and also to address needs that have emerged through the course of therapy but may have been beyond the limit of the specific focus. The recurrent nature of depressive illness is directly addressed in the final stages of treatment to ensure that more active use of personal resources and links to more formal support are thought through to facilitate their use at a subsequent stage.

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Anxiety and Depression 101

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