Interpersonal Psychotherapy: Evidence and ApplicationJoy E. Moel, Roberta Casko, Kimberly Nylen, & Tracy Moran

University of IowaIowa Depression and Clinical Research Center

History and Development

Developed in the 1970s by Gerald Klerman, Myrna Weissman and colleagues

Era of tricyclic antidepressants

IPT was not initially developed as an active treatment for depression

History and DevelopmentServed as the psychotherapy component in a drug treatment trial comparing the relative efficacy of antidepressants alone and in combination with psychotherapy

Originally called high contact, indicating that benefit to patients would be due to nonspecific effects rather than specific techniques

History and DevelopmentMaintenance studies showed the efficacy of high contact

Klerman and Weissman began to more fully describe the treatment, termed IPT, and published a manual (Klerman, Weissman, Rounsaville, 1984)

Designed an acute treatment trial of medication, IPT, and combination.

What is Interpersonal Psychotherapy?

Interpersonally based psychotherapyFocuses on modifying disrupted relationships or expectations about those relationships Time-limitedFocus on here-and-nowNon-transferentialPsychodynamically informed vs. psychodynamically oriented

What is Interpersonal Psychotherapy?

Manual based Empirically basedGoals of treatmentSymptom reliefImproved interpersonal functioningResolve acute interpersonal crisisIncrease social support

Therapeutic StanceUnderstand the clientActiveClient advocateSupportiveDirectiveNon-transferential

Client responsible for direction and change

IPT: Theoretical FrameworkBiopsychosocial modelAttachment Theory (Bowlby)Relationships are primaryAttachment is a biological driveAttachment is a cybernetic systemCapacity to form flexible attachment is principal feature of mental health

Attachment Styles

SecureAnxious AmbivalentAnxious Avoidant

Attachment Theory

Patterns of attachment develop early and tend to persist, but are not fixedPatterns of attachment persist within relationshipsPatterns of attachment persist across relationships

Attachment Theory

Those with less secure attachment are more prone to psychiatric symptomsDisruption of attachment increases vulnerability to psychiatric symptomsPsychiatric symptoms result from Biopsychosocial factorsDysfunction results from An acute crisis, attachment disruption, inadequate social support

Attachment Theory: Implications for Treatment

Focus on attachment i.e. interpersonal relationshipsResolution of here-and-now problems should result in symptom reliefFundamental personality change is unlikely in short-term treatment

Problem Areas

Grief & LossInterpersonal DisputesRole TransitionsInterpersonal Sensitivity

IPT TechniquesClarificationCommunication AnalysisInterpersonal IncidentsUse of AffectRole PlayingProblem SolvingHomeworkUse of the Therapeutic Relationship

ClarificationDirect questioningEmpathic listeningReflective listeningEncouragement of spontaneous discourse

Communication AnalysisImportance of clearly communicating needs and expectations to others.Clients understanding of her contribution to communication problems.Motivate client to communicate more clearly.Analyze quality of patients narrative.Analyze communications within sessions.

Interpersonal IncidentsAugment communication analysisProvide discrete examples of generalized beliefs/complaintsProvide specific incidents for the therapist and client to problem-solve

Use of AffectHelp client to- recognize her own affect - communicate affect to others- recognize suppressed or painful affect

Role PlayingAllows the therapist to model new modes of interpersonal behavior and communication.Allows the client to:- develop new insights into her interpersonal behaviors- practice new communication skills- gain new perspectives on the reaction of others to her communications

Problem SolvingCarefully examine the problem.Brainstorm potential solutions with clientSelect a course of action.Monitor outcomes and refine solution.

HomeworkAssignments are interpersonal in nature and not paradoxical.Assignments involve:- direct communications with others- self-appraisalof her interactions- activities and behaviors with others

Use of the Therapeutic RelationshipThe ideal relationship includes:- mutual liking, caring, respect- importance to both parties- a degree of expertise on the part of the therapist

Overall Structure of IPTTreatment PhasesEvaluationInitial Sessions (1-2)Intermediate Sessions (3-12)Conclusions of Acute (13-14)Maintenance treatment (15+)

New Haven Boston Collaborative StudyFirst controlled study of IPT for acute depression

16 week treatment study of 81 depressed patientsIPT aloneAmitriptyline aloneCombinationControl: Nonscheduled psychotherapy

New Haven Boston Collaborative Study

IPT superior to nonscheduled psychotherapy

Medication superior to nonscheduled psychotherapy

Combination was more effective then either active treatment alone

IPT equivalent to AmitriptylineDifferential effects on symptoms

One-year follow-upPatients who received IPT (alone or in combination with medication) showed higher functioning than patients who received nonscheduled psychotherapy or medication alone

No effect of IPT on symptom relapse or recurrence

NIMH Treatment of Depression Study

NIMH Treatment of Depression StudyIPT superior to placebo

IPT equal to Imipramine for mild to moderate depression

IPT slightly better than CBT for severe depression

No long-term preventive effects were noted for IPT, CBT, or Imipramine at 6, 12, or 18 months

NIMH Treatment of Depression Study43% of patients entering IPT achieved remission of depression (HRSD

NIMH Treatment of Depression StudyTreatment response to IPT predicted by: low social dysfunctionhigh interpersonal sensitivityhigher satisfaction with social relationshipsacute onset of depressionendogenous depression

Maintenance TherapyMany patients have relapses and recurrences

Weissman and colleagues established that 8 months of antidepressant treatment could prevent relapse, and that maintenance IPT could enhance social functioning, but effects werent seen for 6-7 months

Pittsburgh Maintenance Therapy with IPT - Frank, Kupfer and colleagues studied the efficacy of IPT as a maintenance treatment for depression

Pittsburgh Maintenance Therapy

Pittsburgh Maintenance Therapy - Results3-year survival analysis indicates that Imipramine reduced relapse of depression

Combination of Imipramine and IPT did not further reduce relapse

Maintenance IPT not as effective as Imipramine

Maintenance IPT superior to placebo

Pittsburgh Maintenance TherapyMean 3 Year Survival (weeks)

Sheet:

IMI + IPT-M

IMI alone

IPT-M alone

IPT-M + placebo

placebo

Clinical Importance of Empirical Research

Selection of good candidates for IPT

Prediction of response

Conviction of treatment presentation

Conviction in treatment delivery

Additional Applications Research at the University of Iowa

Social Phobia (Stuart et al.)

Somatization Disorders (Stuart & Noyes, 1999)

IPT for Couples (Stuart, Temple et al)

Post-MI Depression (Stuart & Cole, 1996)

Additional ApplicationsInterpersonal Counseling in Primary Care (IPC; Klerman & Weissman, 1993)

Eating Disorders (Fairburn et al., 1998)

Adolescents (IPT-A; Mufson et al., 1999, 2004)

Bipolar Disorder (Swartz et al., 2002)

Drug Abuse (Rounsaville & Carroll, 1993)

Dysthmia (Browne, Steiner et al., 2002)

HIV Patients (Markowitz et al., 1992, 1997)

Groups (IPT-G; Wifley et al., 2000)

Who we are Iowa Depression and Clinical Research CenterScott Stuart and Mike OHaraIPT: A Clinicians guideUpcoming trainingIPT was developed by Gerald Klerman and Myrna Weissman in the 1970s, a time when the medical model of psychopathology was in the forefront.

IPT was not initially developed as an active treatment for depression, but instead began as a manualized treatment developed for an empirical research protocol.

In essence, IPT was constructed in retrograde fashion, rather than being derived from clinical observations which were then developed into a theory and tested empirically.

Specifically, IPT served as the psychotherapy component in a drug treatment trial comparing the relative efficacy of antidepressants alone and in combination with psychotherapy as maintenance treatments for depression.

Gerald Klerman and Myrna Weissman were interested in the efficacy of tricyclic antidepressants as a maintenance treatment for depression; however, they wanted to mimic clinical practice, which often consisted of patients receiving both psychotherapy and medication (either together or in sequence).

Thus, Klerman felt that a clinical trial of maintenance tricyclic antidepressants should include a psychotherapy component. The goal wasnt to find a psychotherapy effect, but test it in a clinical trial.

Following the medical model, Klerman and Weissman set out to define the specific procedures to be used in such a psychotherapy. Key concerns were that the therapeutic treatment be credible and reproducible.

In its original form, IPT was termed high contact, indicating that the benefit to patients would be due to nonspecific effects rather than specific techniques.

In sum, these studies were designed to determine how long treatment with tricyclic antidepressants should continue, and what the role of psychotherapy was in maintenance treatment.In contrast to investigators expectations, the early studies of IPT demonstrated that it had a therapeutic effect. Klerman et al. subsequently described the treatment more fully and began to develop a theory to explain why it worked.

Because IPT was largely conceived of as a social work or social support intervention, it was hypothesized that change in social circumstances and social relationships was largely the driving force behind improvement (now supported by empirical data)

They termed the therapy Interpersonal Psychotherapy and designed an acute treatment trial of medication, IPT, and the combination The New Haven Boston Collaborative Study.

To bring about changeTime-limited maintenanceNon-transferential not addressed directly in therapy given the short term nature of IPT, but the way they act with you is usually the way they interact with others, and to assess attachment styleKlerman & Weismann, 1984Improved interpersonal functioning recognize needs for attachment and reassurance and express those needs to others in a way they can respond toBiopsychosocial model genes, medication, temperment, attachment, social supportAttachment theory-Relationships are primary past and present relationships define who we are and conflict is disruptiveBiological drive to form relationships child checking in, whats 1st thing you do when something good/bad happensCybernetic system relationships form around a particular set pointFlexible attachment and ability to ask for help and receive helpAttachment styles: people come by them honestly due to real experienceSecure flexibleAnxious Ambivalent attachment glass is half emptyAnxious Avoidant learn other people do not take care of you learn to do it on your own, cannot trust othersInterpersonal formulationGrief and loss: Goals facilitate the mourning process, a balanced perspective, and extend experience to social supportsInterpersonal Disputes: Role Transitions: Life cycle transitions (adolescence, childbirth); Situational treansitions (job loss, graduation); Acquisitive transitions (financial windfall, new house); Relationship transitions (marriage, loss of spouse, partners becoming parents)Evaluation: Best candidates are those with relatively secure attachment style, ability to relate a coherent and detailed narrative, specific interpersonal focus for distress, good social support systemInitial sessions: Provide interpersonal framework/review symptoms in interpersonal context, begin interpersonal inventory, Identify problem and set goals within context of problem areasThe first major large scale comparative trial of IPT for the treatment of acute depression was the New Haven Boston Collaborative study, conducted by Myrna Weissman and colleagues in 1973.

Specifically, it was a 16-week treatment study of 81 depressed patients (including both men and women).

There were four conditions: IPT aloneamitriptyline alonetheir combinationa control condition termed nonscheduled psychotherapy.

IPT was delivered once a week by a psychiatrist. Results indicate that both active treatments were superior to the control treatment, and that the combined treatment was superior to either treatment alone.

Although IPT and amitriptyline were equivalent, patients who took antidepressants reported greater improvement in biologically based symptoms (e.g. improvement in sleep, concentration, energy).

Patients who received IPT reported greater improvement in social relationships, interest in activities, and sense of hopefulness for the future. Weissman and colleagues followed these depressed patients for one year and found that the therapeutic benefit of IPT was sustained for many patients.

For example, patients who had received IPT (either in combination with medication or alone) showed higher functioning than patients who received nonscheduled psychotherapy or medication alone.

Interestingly, however, there were no significant findings for IPT on symptom relapse or recurrence - A portion of the patients in all treatments had relapsed and required additional treatment.

The positive results of this acute study then led to the NIMH Treatment of Depression Collaborative Research ProgramMany of you are likely familiar with the NIMH study, which was a multicenter, contolled clinical trial of imipramine, IPT, and CBT in the treatment of acute depression the gold standard for psychotherapeutic outcome research.

In this study, a group of 250 outpatients were randomly assigned to one of four conditions CBT, IPT, imipramine, or placebo-clinical management combination), each of which lasted 16 weeks.

68% of those patients completed at least 15 weeks and 12 sessions of treatment. In general, the results suggested that all active treatments were superior to the placebo in reduction of symptoms over a 16 week period.

Regardless of treatment, over half of the patients were symptom free at the end of treatment, indicating that the degree of improvement was clinically significant.

Focusing solely on IPT, it was superior to placebo and equivalent to imipramine for mild to moderate depression, and slightly better than CBT for severe depression.

There were no long term preventive effects for IPT, CBT, or imipramine at 6, 12, or 18 months, which contrasted with the expectations of many psychotherapy advocates who believed psychotherapy would yield prophylactic effects relative to medication.Focusing solely on IPT, READ BULLET POINTS.Interestingly, the treatment response to IPT was predicted by several factors including low social dysfunction, high interpersonal sensitivity, and higher satisfaction with social relationships.

In other words, patients who need IPT the least benefit the most the rich get richer. It had become apparent to investigators and clinicians that many depressed patients have relapses and recurrences of depression that require long-term treatment.

In their original study (begun in 1968), Klerman, Weissman and colleagues had established that 8 months of antidepressant treatment could prevent a relapse, and that maintenance IPT could enhance social functioning (although effects werent seen until 6-7 months out).

In the early 1980s, Frank and Kupfer conducted a landmark study involving acute and continuation treatment of patients with recurrent depression wasIn this study, patients were acutely depressed and had suffered at least 3 previous episodes of depression were treated with a combination of IPT and imipramine. (IPT for 12 weeks and were maintained on 150-300 mg of imipramine). Patients who responded to imipramine + IPT were randomly assigned to one of five treatments: Of 230 patients who entered the study, 128 ultimately entered into the maintenance therapy phase. Imipramine alone, imipramine + IPT, IPT alone, IPT + placebo, placebo alone.

Notably, Imipramine was delivered in the highest doses (over 200 mg/day) and IPT was administered monthly in the lowest dose ever used in clinical trials.

Important findings from this study suggest that although monthly sessions of IPT alone were not as effective as medication in preventing recurrence, monthly IPT was significantly more effective in reducing recurrence than placebo treatment.

Interestingly, adding IPT to imipramine did not confer additional protection from recurrence. The next slide illustrates these results graphically. Based on these results, the investigators concluded that:

Continued treatment with antidepressants warranted for patients with recurrent depression even patients treated with imipramine had a high risk for recurrence of depression.that antidepressants should remain the treatment of choice for patients with recurrent depression, but maintenance treatment with IPT is clearly indicated for those who cannot or do not wish to take medications (e.g. pregnant, postpartum women, medically ill, etc.).

In addition to the studies Ive just reviewed, IPT has also been demonstrated to be efficacious for several specific populations of depressed patients, as well as for other axis I disorders. In addition to providing evidence of efficacy, empirical research on IPT can guide clinical practice in several ways. For example, empirical research answers questions relating to who is a good candidate for IPT, and how a particular patient will respond. In addition, clinicians have a good deal of evidence supporting the treatment, which bolsters conviction of treatment presentation and delivery.Some of the ongoing projects at the University of Iowa involve IPT for social phobia, somatization disorders, IPT for couples, and Post-MI depression. In addition, several researchers outside the University of Iowa are actively studying IPT as a treatment for several disorders and populations. Specific modifications have been described by authors in the reference list we will provide, but here is a brief overview (Dont need to go into this).

IPC is a brief treatment of six 15-20 minute sessions, with initial session being longer. Designed for routine use in medical settings. Administered by healthcare professional without special training in mental health. Focus is on psychosocial functioning with nonpsychiatric patients who are in distress, but do not have serious psychiatric disorders or medical conditions. Actual scripts for each session have been outlined and homework added to accelerate process. Patients encouraged not to use all six sessions if they feel improved with fewer.

IPT has been adapted for adolescents (IPT-A). Tx well-defined in a manual (Mufson 1993). Three major modifications: shortening treatment duration from 16-20 sessions to 12, reconceptualization of the sick role, and involvement of parents in adolescents treatment. Patients and parents are told that the teen has an illness that may affect school performance and energy to do normal activities. The therapist informs them that it is important for the teen to engage in as many normal activities as possible, but shouldnt be punitive when performance isnt as good as it was previous to depression. Also been adapted to address developmental issues common to adolescents (e.g. separation from parents, exploration of authority, relationships with members of opposite sex, peer pressures, initial experiences with death of relative or friend).