With this new manual, the World Health Organization (WHO) gives guidance on the use of interpersonal therapy (IPT) using a 8 session group protocol. The manual - which is part of WHO’s mhGAP programme - describes IPT in a simplified format for use by supervised facilitators who may not have received previous training in mental health.
Abstract
This article briefly describes the fundamental principles and some of theclinical applications of interpersonal psychotherapy (IPT), a time-limited,empirically validated treatment for mood disorders. IPT has been tested withgeneral success in a series of clinical trials for mood and, increasingly,non-mood disorders; as both an acute and maintenance treatment; and in differingtreatment formats. As a result of this research success, IPT is spreadingfrom research trials to clinical practice in various countries around theworld.
The recognition of depressive illness as prevalent, morbid, potentiallydeadly, and economically costly ()has spurred interest in its treatment. Pharmacotherapy has shown clear benefitsfor the acute and chronic treatment of the major mood syndromes, namely majordepressive disorder (MDD), dysthymic disorder, and bipolar disorder (2). Antidepressant medications work for mostpatients, and work for as long as those patients continue to take the medications,but all treatments have limits. A significant proportion of medication respondershave residual symptoms that predispose to recurrence or relapse of their mooddisorders. Other patients do not respond to medications, refuse to take them,or in many areas of the world simply cannot afford them. For all of thesepatients, psychotherapies may have utility.
The two principal empirically-based psychotherapeutic interventions formood disorders are cognitive behavioral therapy (CBT) (3) and interpersonal psychotherapy (IPT) (4). Both are diagnosis-targeted, time-limited, present-focusedtreatments that encourage the patient to regain control of mood and functioning.IPT is based on the so-called common factors of psychotherapy: a treatmentalliance in which the therapist empathically engages the patient, helps thepatient to feel understood, arouses affect, presents a clear rationale andtreatment ritual, and yields success experiences ().On this foundation IPT builds two major principles:
Depression is a medical illness, rather than the patient's fault or personaldefect; moreover, it is a treatable condition. This definition has the effectof defining the problem and excusing the patient from symptomatic self-blame.
Mood and life situation are related. Building on interpersonal theory andpsychosocial research on depression (6),IPT makes a practical link between the patient's mood and disturbing lifeevents that either trigger or follow from the onset of the mood disorder.
Research has demonstrated that depression often follows a disturbing changein one's interpersonal environment such as the death of a loved one (complicatedbereavement), a struggle with a significant other (role dispute),or some other life upheaval: a geographic or career move, the beginning orending of a marriage or other relationship, or becoming physically ill (arole transition). Once patients become depressed, symptoms of theillness compromise their interpersonal functioning, and bad events follow.Although these observations seem commonsensical, many depressed patients turninward, blaming themselves and losing sight of their environment. Whetherlife events follow or precede mood changes, the patient's task in therapyis to resolve the disturbing life event(s), building social skills and helpingto organize his or her life. If the patient can solve the life problem, depressivesymptoms should resolve as well. This coupled effect has been borne out inclinical trials demonstrating the efficacy of IPT for major depression.
STRUCTURE OF TREATMENT
IPT is a time-limited (acutely, 12-16 weeks) treatment with three phases:a beginning (1-3 sessions), middle, and end (3 sessions). The initial phaserequires the therapist to identify the target diagnosis (MDD) and the interpersonalcontext in which it presents. In diagnosing major depression, the therapistfollows DSM-IV (7) or ICD-10 criteriaand employs severity measures such as the Hamilton Depression Rating Scale(Ham-D) () or Beck Depression Inventory(BDI) (9) to reify the problem as anillness rather than the patient's idiosyncratic defect. The therapist alsoelicits an 'interpersonal inventory', a review of the patient's patterns inrelationships, capacity for intimacy, and particularly an evaluation of currentrelationships. A focus for treatment emerges from the last: someone importantmay have died (complicated bereavement), there may be a strugglewith a significant other (role dispute), or the patient mayhave gone through some other important life change (role transition);in the relatively infrequent absence of any of these, the default focus ison interpersonal deficits, a confusing term that really denotesthe absence of a current life event.
The therapist links the target diagnosis to the interpersonal focus: 'Aswe've discussed, you are suffering from major depression, which is a treatableillness and not your fault. From what you've told me, your depression seemsrelated to what's happening in your life right now. You stopped sleeping andeating and began to feel depressed after your mother died, and you've haddifficulty in coming to terms with that terrible loss. We call that complicatedbereavement, which is a common, treatable form of depression. I suggestthat we spend the next 12 weeks working on helping you deal with that bereavement.If you can solve this interpersonal problem, not only will your life be better,but your mood will improve as well'. This formulation defines the remainderof the therapy (10). The connectionbetween mood and life events is practical, not etiological: there is no pretensethat this is what 'causes' depression. With the patient's agreement on thisfocus, treatment moves into the middle phase.
Purchase photoshop elements 8 for mac. Other facets of the opening phase include giving the patient the 'sickrole', a temporary status recognizing that depressive illness keeps the patientfrom functioning at full capacity, and setting treatment parameters such asthe time limit and the expectation that therapy will focus on recent interpersonalinteractions (4).
In the middle phase of treatment, the therapist uses specific strategiesto deal with whichever of the four potential problem areas is the focus. Thismight involve appropriate mourning in complicated bereavement,resolving an interpersonal struggle in a role dispute, helpinga patient to mourn the loss of an old role and assume a new one in a roletransition, or decreasing social isolation for interpersonaldeficits. Whatever the focus, the therapy is likely to address thepatient's ability to assert his or her needs and wishes in interpersonal encounters,to validate the patient's anger as a normal interpersonal signal and to encourageits efficient expression, and to encourage taking appropriate social risks.In the last few sessions, the therapist reminds the patient that terminationis nearing, helps the patient to feel more capable and independent by reviewinghis or her often considerable accomplishments during the treatment, and notes thatending therapy is itself a role transition, with inevitable good and painfulaspects. Since IPT has also demonstrated efficacy as a maintenance treatmentfor recurrent MDD, and since patients who have had multiple episodes are verylikely to have more, therapist and patient may decide to end acute treatmentas scheduled and then to recontract for ongoing treatment, perhaps of lessintensive dosage: e.g., monthly rather than weekly sessions.
The IPT therapist's stance is relaxed and supportive. The goal is to bethe patient's ally. The acute time limit pressures the patient to take action.No formal homework is assigned, but the goal of solving the focal interpersonalproblem area provides an overall task. Treatment centers on the patient'soutside environment, not on the therapy itself. The scheduling of sessionsonce weekly accentuates that the emphasis is on the patient's real life, notthe office. In sessions therapist and patient review the past week's events.When the patient succeeds in an interpersonal situation, the therapist actsas a cheerleader, reinforcing healthy interpersonal skills. When the outcomeis adverse, the therapist offers sympathy, helps the patient to analyze whatwent wrong in the situation, brainstorms new interpersonal options, and roleplays them with the patient in rehearsal for real life. The patient then teststhem out. Given this emphasis on interpersonal interaction, it is not surprisingthat depressed patients learn new interpersonal skills from IPT that theyhave not seen with pharmacotherapy ().
CLINICAL APPLICATIONS
In the 1970s, Klerman, Weissman, and colleagues demonstrated the efficacyof IPT in treating MDD in repeated randomized controlled trials. The utilityof IPT has been tested for other mood and non-mood disorders by several investigatorsin several countries, including the United States, Canada, United Kingdom,the Netherlands, New Zealand, Uganda, and elsewhere. From the start, the approachhas been a scientific one. IPT has been tested in clinical trials for eachproposed application; it has never been intended as a treatment for all disorders.
Mood disorders
The utility of IPT for MDD has been strengthened by landmark studies suchas the National Institute of Mental Health (NIMH) Treatment of DepressionCollaborative Research Program, in which IPT was statistically comparableto imipramine on several measures and better than a placebo control for moreseverely depressed patients (). Thisstudy, the first direct comparison with CBT, also provided a glimpse at potentialdifferential predictors of treatment outcome ().Other trials have found IPT efficacious in treating depression in medicallyill patients (, ), peripartum women (-), depressed adolescents (), and geriatric depressed patients (). Two trials have demonstrated benefits for monthly IPTas a three year maintenance treatment for recurrent depression (, ).
Studies are also examining the benefits of IPT for dysthymic disorder (23) and as an adjunctive treatment to medicationfor bipolar disorder. Frank and colleagues have grafted IPT to a behavioral,social rhythms therapy, thus yielding interpersonal social rhythms therapy(IPSRT) for bipolar disorder. The behavioral component aims to stabilize diurnalactivities, and in particular to help control sleep patterns and thus avoidmanic episodes (). Exciting preliminaryneuroimaging studies have found that IPT changes brain blood flow in a mannersimilar to that of serotonin reuptake inhibitors (, ).
Non-mood disorders
Success with mood disorders has also led to the exploration of IPT as atreatment for other conditions. Two trials for substance abuse showed no benefitsfor IPT (, ). On the other hand, there have been promising developmentsof IPT as a treatment for social phobia (),posttraumatic stress disorder (30)- both anxiety disorders with clear interpersonal components - and eatingdisorders (-). Further explorations are adapting IPT to borderlinepersonality disorder, primary insomnia, body dysmorphic disorder, and otherdisorders (4).
FORMATS
Developed as an individual psychotherapy to be delivered by mental healthprofessionals, IPT has also been modified as interpersonal counseling (IPC; 4, ),a streamlined, heavily scripted treatment for subsyndromal mood and anxietysymptoms for use by non-mental health medical nurses. It is also being testedas a group (35), couples (4), and telephone ()intervention.
More research is needed to determine the optimal use and dosage of allforms of IPT. Furthermore, it is unclear for it – as for all psychotherapies– when and how it is best to augment IPT with medication, and vice versa.IPT is also being transplanted to other cultures ().
PROCESS
Most research on psychotherapy has been on process rather than outcome.IPT has been the exception to this rule, with research focusing almost exclusivelyon outcome: that is, whether treatment works. Now that IPT has demonstratedefficacy for various disorders, it makes sense to explore what the activeingredients of this treatment might be. There has thus far been little researchin this area ().
TRAINING
IPT was developed as a research intervention, and until recently essentiallyall practitioners of IPT were researchers. Research training requires readingthe manual (4, 39), attending an orientation workshop, and completing 2-3cases supervised by review of audio- or videotapes of each session. This systemhas worked well for research purposes, but it is highly labor intensive.
The research success of IPT has led to its inclusion in clinical treatmentguidelines and to growing interest in IPT among clinicians. The standardsfor clinical training for non-researchers are still being defined. The InternationalSociety for Interpersonal Psychotherapy (ISIPT), an international umbrellaorganization, has developed a web site (www.interpersonalpsychotherapy.org), is deliberating training issues, and is allowing countries to developtheir own credentialing processes for IPT. IPT therapists in the United Kingdomhave designed the most detailed and rigorous curriculum for clinical accreditationto date. There is interest in IPT training in Australia, Austria, Brazil,Canada, Finland, Germany, Ireland, Italy, the Netherlands, New Zealand, Norway,Spain, Switzerland, and elsewhere.
IPT is taught in some psychiatric residency programs in the United States,but it is not required training ().Because IPT is an add-on therapy, not intended to apply to all disorders,all therapists who have learned IPT have come to it with backgrounds in othertherapies, usually either psychodynamic or cognitive.
CONCLUSIONS
IPT is a relatively young psychotherapy targeted to particular psychiatricdiagnoses. Relative to many other psychotherapies, its characteristics arewell defined and its efficacy is well understood. Nonetheless, far more remainsunknown about its indications for various conditions, its optimal dosing,its combination with pharmacotherapy, its utility in different formats, andso forth. Although one of the best studied interventions in outcome research,particularly for mood disorders, IPT is only now spreading into clinical practice.It is a fairly simple treatment for already experienced psychotherapists tolearn, but its effectiveness in the hands of less trained therapists is moot.Thus the spread of this still relatively 'pure' treatment carries both opportunitiesand dangers.
Acknowledgement
Supported in part by an Independent Investigator Award from the NationalAssociation for Research on Schizophrenia and Affective Disorders.
References
