Other Applications

The success of IPT in treating unipolar mood disorders has led to its expansion to treat other psychiatric disorders. Frank and colleagues in Pittsburgh have been assessing a be-haviourally modified version of IPT as a treatment adjunctive to pharmacotherapy for bipolar disorder. Further, IPT is increasingly being applied for a range of non-mood disorders. There are intriguing applications of IPT as treatment for bulimia (Agras et al., 2000; Fairburn et al., 1993; Wilfley et al., 1993, 2000) and anorexia nervosa; social phobia (Lipsitz et al., 1999), posttraumatic stress disorder, borderline personality disorder and other conditions. Life events, the substrate of IPT, are ubiquitous, but how useful it is to focus on them may vary from disorder to disorder. There have been two negative trials of interpersonal therapy for substance disorders (Carroll, Rounsaville & Gawin, 1991; Rounsaville et al., 1983), and it seems unlikely that an outwardly focused treatment such as IPT would be useful for such an internally focused diagnosis as obsessive compulsive disorder. In the continuing IPT tradition, clinical outcome research should clarify the question of its utility. Interpersonal therapy is also being modified for use in other formats, for example as group therapy (Klier etal., 2001; Wilfley etal., 1993,2000; Zlotnick etal., 2001) and as a telephone intervention. Weissman (1995) developed an IPT patient guide with worksheets for depressed readers that may be used in conjunction with IPT.

In summary, IPT is one of the best tested psychotherapies, particularly for mood disorders, where it has demonstrated efficacy as both an acute and maintenance monotherapy and as a component of combined treatment for major depressive disorder. It appears to have utility for other mood and non-mood syndromes, although evidence for most of these is sparser. Monotherapy with either IPT or pharmacotherapy is likely to treat most patients with major depression successfully, so combined treatment should probably be reserved for more severely or chronically ill patients (Rush & Thase, 1999). How best to combine time-limited psychotherapy with pharmacotherapy is an exciting area for future research: when is it indicated, in what sequence and for which patients.

Comparative trials have begun to reveal moderating factors that predict treatment outcome. The NIMH Treatment of Depression Collaborative Research Program, which compared IPT and CBT, suggested factors that might predict better outcome with either IPT or CBT. Sotsky and colleagues (1991) found that depressed patients with low baseline social dysfunction responded well to IPT, whereas those with severe social deficits (probably equivalent to the 'interpersonal deficits' problem area) responded less well. Greater symptom severity and difficulty in concentrating responded poorly to CBT. Patients with greater initial severity of major depression and impaired functioning responded best to IPT and to imipramine. Imipramine worked most efficaciously for patients with difficulty functioning at work, reflecting its faster onset of action. Patients with atypical depression responded better to IPT or CBT than to imipramine or placebo (Shea et al., 1999).

Barber & Muenz (1996) studied TDCRP completers and found IPT more efficacious than CBT for patients with obsessive personality disorder, whereas CBT fared better for avoidant personality disorder. This finding did not hold for the intent-to-treat sample. Biological factors, such as abnormal sleep profiles on EEG, predicted significantly poorer response to IPT than for patients with normal sleep parameters (Thase et al., 1997). Frank et al. (1991) found that psychotherapist adherence to a focused IPT approach may enhance outcome. Moreover, sleep EEG and adherence, the first a biological and the latter a psychotherapy factor, had additive effects in that study. Replication and further elaboration of these predictive factors deserve ongoing study.

Another exciting development is the use of neuroimaging studies to compare IPT and pharmacotherapy outcomes. Martin et al. (2001) in Sunderland, using SPECT, found that IPT and venlafaxine had overlapping but also differing effects on right posterior cingulate (IPT), right posterior temporal (venlafaxine), and right basal ganglia activation (both treatments). Brody et al. (2001) in Los Angeles reported slightly different but roughly analogous findings using PET scanning of patients treated with IPT and paroxetine.

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