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Interpersonal psychotherapy

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Interpersonal Psychotherapy (IPT) is a time-limited treatment that encourages the patient to regain control of mood and functioning typically lasting 12–16 weeks. IPT is based on the common factors of psychotherapy: a "treatment alliance in which the therapist empathically engages the patient, helps the patient to feel understood, arouses affect, presents a clear rationale and treatment ritual, and yields success experiences.".[1] Interpersonal Psychotherapy of Depression was developed in the New Haven-Boston Collaborative Depression Research Project by Gerald Klerman, MD, Myrna Weissman, PhD, and their colleagues for the treatment of ambulatory depressed, nonpsychotic, nonbipolar patients.[2]

History

Interpersonal therapy began in 1969 at Yale University, where Dr. Gerald Klerman was joined by Dr. Eugene Paykel from London to design a study to test the relative efficacy of an antidepressant alone and both with and without psychotherapy as maintenance treatment of ambulatory nonbipolar depression.[3]

IPT takes structure from psychodynamic psychotherapy, but also from contemporary Cognitive Behavioral Therapy (CBT) approaches in that it is time-limited and employs homework, structured interviews, and assessment tools.[4]

Over the past 20 years, IPT has been carefully studied in many research protocols, has been demonstrated to successfully treat patients with depression, and has been modified to treat other psychiatric disorders (substance abuse, dysthymia, bulimia) and patient populations (adolescents, late-life, primary medical care). It has primarily been utilized as a short-term (approximately 16 week) therapy, but has also been modified for use as a maintenance therapy for patients with recurrent depression.[2]

From the beginning, IPT has been tested in various clinical trials [5] and found to be effective in treating acute episodes of depression and preventing or delaying the onset of subsequent episodes. A large multicenter collaborative study was conducted by the National Institute of Mental Health (NIMH), comparing IPT, CBT, imipramine and placebo. Results of the Collaborative Study were published in 1989,[6] demonstrating that IPT was quite effective in treating acute symptoms of depression during the first 6–8 weeks, with improvement in psychosocial function continuing after 16 weeks. Frank and her colleagues in Pittsburgh have demonstrated the efficacy of IPT as a maintenance treatment and have delineated some contributing factors.

Applications

Interpersonal Psychotherapy has been proven as an effective treatment for the following:

IPT for Adolescents
Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults.[7]

IPT for children is based on the premise that depression occurs in the context of an individual's relationships regardless of its origins in biology or genetics. More specifically, depression affects people's relationships and these relationships further affect our mood. The IPT model identifies four general areas in which a person may be having relationship difficulties: 1) grief after the loss of a loved one; 2) conflict in significant relationships; 3) difficulties adapting to changes in relationships or life circumstances; and 4) difficulties stemming from social isolation.[10] The IPT therapist helps identify areas in need of skill-building to improve the client's relationships and decrease the depressive symptoms. Over time, the client learns to link changes in mood to events occurring in his/her relationships, communicate feelings and expectations for the relationships, and problem-solve solutions to difficulties in the relationships.[11]

IPT has been adapted for the treatment of depressed adolescents (IPT-A) to address developmental issues most common to teenagers such as separation from parents, development of romantic relationships, and initial experience with death of a relative or friend [11] IPT-A helps the adolescent identify and develop more adaptive methods for dealing with the interpersonal issues associated with the onset or maintenance of their depression. IPT-A is typically a 12-16 week treatment. Although the treatment involves primarily individual sessions with the teenager, parents are asked to participate in a few sessions to receive education about depression, to address any relationship difficulties that may be occurring between the adolescent and his/her parents, and to help support the adolescent's treatment.[12]

IPT for the Elderly
IPT has been used as a psychotherapy for depressed elderly, with its emphasis on addressing interpersonally relevant problems. IPT appears especially well suited to the life changes that many people experience in their later years[13]

Strengths and Limitations

IPT is particularly accessible to patients who find dynamic approaches mystifying, or the ‘homework’ demands of Cognitive Behavioral Therapy (CBT) daunting. IPT has been specially modified for adolescents [14] who may find CBT too much like school work, whereas IPT addresses relationships — a primary concern. IPT is abstemious in its use of technical jargon — a bonus for those who distrust ‘ psychobabble’. Fairburn (1997) reports that both patients and therapists in his bulimia studies expressed a preference for IPT over CBT. This may have implications for compliance and therapist morale.

For general psychiatrists the major limitation of IPT is that the model has not so far been modified for the management of psychoses. However, this is true of most psychotherapies. The CBT model requires such expertise for use with this patient group that it would be considered risky for a trainee to attempt its use without expert training and support.[15]

In the case of treating depression, this therapy is time consuming and can take several years for a patient to fully recover. As with any face-to-face therapy, it is demanding of the individual in that effort must be made to attend the pre-arranged dates for the therapy sessions. Whereas effort isn't needed for 'homework' tasks, the therapy involves the reenactment of past negative feelings which, as well as creating a danger of emotional harm, does require more effort than is needed in CBT sessions. Studies, such as the one conducted by Paley et al. (2008), have found little different in the effectiveness between CBT and IPT. A meta-analysis by Robinson et al. (1990) found that CBT was superior to a no treatment control group, however, when compared to a placebo control group, there was no significant difference. If CBT and placebo therapies have similar effectiveness, and CBT and IPT have similar effectiveness, it is rational to presume that IPT and placebo therapies have similar effectiveness. Barkham et al. (1996) concluded after his experiment that both IPT and CBT showed a tendency for symptoms to recur, thus limiting the long term-effectiveness of these psychological therapies. Any study showing the success of such therapies often fail to take into account poor attrition rates, which are very common among psychological therapies as many patients drop out because they feel the therapy isn't working. If those that complete the therapies remain to complete them, they are more likely to be benefiting from it, thus when an average is taken of the success of the therapy (not including the patients that drop out) it appears to be more successful than it actually is.

References

  1. ^ Frank J. Therapeutic factors in psychotherapy. Am J Psychother 1971;25:350-61.
  2. ^ a b Cornes, C. L., & Frank, E. (1994). Interpersonal psychotherapy for depression. The Clinical Psychologist, 47(3), 9-10.
  3. ^ Weismann, M.M., (2006). A Brief History of Interpersonal Psychotherapy. Psychiatric Annals. 36:8.
  4. ^ Weissman, M. M, Markowitz, J. C., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal psychotherapy. New York: Oxford University Press.
  5. ^ Klerman et al., Am J. Psychiatry 131: 186-191, 1974; Weissman et al., Am J. Psychiatry 136: 555-558, 1979
  6. ^ (Elkin et al. Arch Gen Psychiatry 46: 971-983)
  7. ^ a b c d e Weissman, M. M. & Markowitz, J. C. (1998). An Overview of Interpersonal Psychotherapy. In J. Markowitz, Interpersonal Psychotherapy (pp. 1 – 33).Washington D.C.: American Psychiatric Press.
  8. ^ Joiner, T. E., Brown, J. S., & Kistner, J. (2006). The interpersonal, cognitive, and social nature of depression. Mahwah, N.J.: Lawrence Erlbaum Associates.
  9. ^ Markowitz, 1999
  10. ^ Weissman, M. M. & Markowitz, J. C. (1998). An Overview of Interpersonal Psychotherapy. In J. Markowitz, Interpersonal Psychotherapy (pp. 1 – 33).Washington D.C.: American Psychiatric Press.
  11. ^ a b Swartz, H. (1999). Interpersonal therapy. In M. Hersen and A. S. Bellack (Eds). Handbook of Comparative Interventions for Adult Disorders, 2nd ed. (pp. 139 – 159). New York: John Wiley & Sons, Inc.
  12. ^ Mufson L, Weissman MM, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56(6):573-579
  13. ^ Hinrichsen, G.A. (1999). Treating older adults with Interpersonal Psychotherapy for depression. Psychotherapy in Practice, 55 (*8). 949-960.
  14. ^ Mufson, L., Moreau, D., Weissman, M. M., et al (1993) Interpersonal Psychotherapy for Depressed Adolescents. New York: Guilford Press
  15. ^ Morris, J. (2002) Interpersonal psychotherapy — a trainee's ABC? The Psychiatrist. 26: 26-28 doi: 10.1192/pb.26.1.26
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