Phases of Treatment

Acute IPT treatment has three phases. The first phase, usually lasting one to three sessions, involves diagnostic evaluation, obtaining a thorough psychiatric history, and setting the treatment framework. The therapist reviews symptoms, gives the patient a diagnosis the patient as depressed by standard criteria (such as ICD-10), and gives the patient the sick role. ('You have an illness called major depression which is treatable... it is not your fault.')

The psychiatric history includes the interpersonal inventory, which is not a structured instrument but a careful review of the patients' past and current social functioning and close relationships, their patterns and mutual expectations. The therapist should gain a sense of who the patient is with other people, how he or she interacts with them, and how relationships may have contributed to or have been altered by the depressive episode. Depressed patients frequently have difficulty in asserting their needs, confronting others or getting angry effectively, and taking social risks. Changes in relationships close to the onset of symptoms are elucidated: for example, the death of a loved one (potential complicated bereavement), children leaving home (a role transition), or worsening marital strife (a role dispute). The interpersonal inventory provides a framework for understanding the social and interpersonal context in which the depressive symptoms occur and should lead to a treatment focus.

The therapist assesses the need for medication, based on symptom severity, past illness history, treatment response, and patient preference, then provides psychoeducation by discussing the constellation of symptoms that define major depression, their psychosocial concomitants and what the patient may expect from treatment. The therapist next links the depressive syndrome to the patient's interpersonal situation in a formulation (Markowitz & Swartz, 1997) centred on one of four interpersonal problem areas: (1) grief; (2) interpersonal role disputes; (3) role transitions; or (4) interpersonal deficits. With the patient's explicit acceptance of this formulation as a focus for further treatment, therapy enters the middle phase.

Any formulation necessarily simplifies a patient's complex situation. It is important, however, to keep depression treatment focused on a simple theme that even a highly distractible depressed patient can grasp. When patients present with multiple interpersonal problems, the goal of formulation is to isolate one or at most two salient problems that are related (either as antecedent or consequence) to the patient's depressive episode. More than two foci make the treatment unfocused. Choosing the focal problem area requires clinical acumen, although research has shown IPT therapists agree in choosing such areas (Markowitz et al., 2000), and patients seem to find the foci credible.

In the middle phase, the IPT therapist follows strategies specific to the chosen interpersonal problem area. For grief - complicated bereavement following the death of a loved one - the therapist encourages the catharsis of mourning and, as that affect is released, helps the patient find new activities and relationships to compensate for the loss. For role disputes, which are overt or covert conflicts with a spouse, other family member, co-worker, or close friend, the therapist helps the patient explore the relationship, the nature of the dispute, whether it has reached an impasse, and available options to resolve it. Should these options fail, therapist and patient may conclude that the relationship has reached an impasse and consider ways to change or live with the impasse or to end the relationship. Patients with depression tend to have difficulty asserting themselves, which makes it difficult for them to resolve interpersonal conflicts. The IPT therapist helps the patient to consider ways to more effectively communicate thoughts and feelings and role-plays potential interactions with the patient.

A role transition is a change in life status defined by a life event: beginning or ending a relationship or career, a geographic move, job promotion or demotion, retirement, graduation, or diagnosis of a medical illness. Even a much-wanted new role such as getting married or having a child may be accompanied by unforeseen sense of loss. The patient learns to manage the change by mourning the loss of the old role while recognizing positive and negative aspects of the new role he or she is assuming, and taking steps to gain mastery over the new role. Frequently the new role, while undesired, is discovered to have previously unseen benefits. Interpersonal deficits, the residual fourth IPT problem area, is reserved for patients who lack one of the first three problem areas: that is, patients who report no recent life events. The category is poorly named, and really means that the patient is presenting without the kind of defining recent life event on which IPT usually focuses. Not surprisingly, patients whose treatment focuses on interpersonal deficits generally have worse outcomes in IPT than patients whose treatment focuses on one of the other problem areas. In an effort to improve the identification and potentially the treatment of patients with interpersonal deficits, Andrade, Frank and Swartz in Pittsburgh are developing a system to reclassify the category into sub-types of deficits. Interpersonal deficits recognizes that the patient is usually quite socially isolated, defines the patient as lacking social skills, including having problems in initiating or sustaining relationships, and helps the patient to develop new relationships and skills. Some, or indeed most, patients who might fall into this category in fact suffer from dysthymic disorder, for which separate strategies have been developed (Markowitz, 1998).

Interpersonal therapy sessions address current, 'here-and-now' problems rather than childhood or developmental issues. Each session after the first begins with the question: 'How have things been since we last met?' This focuses the patient on recent mood and events, which the therapist helps the patient to connect. The therapist provides empathic support for the patient's suffering but takes an active, non-neutral, supportive and hopeful stance to counter depressive pessimism. The therapist elicits the options that the patient has to make positive changes in his or her life in order to resolve the focal interpersonal problem, options that the depressive episode may have kept the patient from seeing or exploring fully. Simply understanding the situation is insufficient: therapists stress the need for patients to test these options in order to improve their lives and simultaneously treat their depressive episodes. It can be seen why this focus on interpersonal functioning might build social skills and lead the patient to make meaningful life changes in a relatively brief treatment interval.

The final phase of IPT occupies the last few sessions of acute treatment (or the last months of a maintenance phase). Here the therapist's goal is to build the patient's newly regained sense of independence and competence by having him or her recognize and consolidate therapeutic gains. The therapist anchors self-esteem by elucidating how the patient's depressive episode has improved because of the changes the patient has made in his or her life situation and in resolving his interpersonal problem area ('Why do you think you're feeling so much better?... It's impressive what you've accomplished!') - at a time when the patient had felt weak and impotent. The therapist also helps the patient to anticipate depressive symptoms that might arise in the future, and their potential triggers and remedies. Relative to psychodynamic psychotherapy, IPT de-emphasizes termination, which is simply a graduation from successful treatment. The therapist helps the patient see the sadness of parting as a normal interpersonal response to separation, distinct from depressive feelings. If the patient has not improved, the therapist emphasizes that it is the treatment that has failed, not the patient and that alternative effective treatment options exist. This is analogous to a failed pharmacotherapy trial; if one treatment fails, it is the illness rather than the patient who is resistant and thankfully other treatment options remain. Patients who have a successful acute response, but whose multiple prior depressive episodes leave them at high risk for recurrence, may contract for maintenance therapy as acute treatment draws to a close. Another strength of IPT is that its maintenance form, like its acute format, has also demonstrated efficacy in rigorous trials.

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