Interpersonal Psychotherapy

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For at least a century, since Sigmund Freud invented psychoanalysis, psychotherapy has been an important part of psychiatric treatment. Yet until recently, the utility of talking treatments rested on therapists' belief rather than research data. Hundreds of psychotherapies arose, many developed by charismatic therapists, but none had an empirical basis. Only in the last 30 years have psychotherapies been carefully tested to see when they are helpful and when they are not. Interpersonal psychotherapy (IPT) is one of still few psychotherapies to have undergone rigorous testing and been shown to help patients with specific psychiatric diagnoses.

IPT was developed in the early 1970s by the late Gerald L. Klerman, MD; Myrna M. Weissman, PhD; and their colleagues at Harvard and Yale. In planning a medication treatment study for outpatients with Major Depressive Disorder (serious clinical depression), and recognizing that many patients in clinical practice received talking therapy as well as pills, Klerman and Weissman decided to add a psychotherapy to their study. Being researchers, they developed a manual-based treatment that relied on known psychosocial aspects of depression. They knew that serious life events can trigger depressive episodes in individuals who are vulnerable to developing depression, and that, once depressed, many individuals have difficulties in interpersonal functioning that result in further demoralizing life events. In other words, life events affect mood, and mood affects life circumstances, in a potentially vicious cycle. Further, research had shown that social supports provide protection against developing depression, whereas conflicted relationships increase depressive risk.

Based on such findings, and on interpersonal theories by psychiatrists from the 1950s such as Harry Stack Sullivan and the attachment theory of John Bowlby, Klerman and Weissman constructed a psychotherapy manual and trained psychotherapists to use it. What emerged as IPT is a life events-based, diagnostically targeted, straightfor ward, pragmatic, optimistic, forward-looking rather than past-focused, and empirically rather than theoretically driven treatment. Principles of IPT include

1. A formal time limit, to allow comparison to medications in research trials, and to accelerate treatment results.

2. A supportive, encouraging relationship with the patient.

3. Two definitions of the patient's situation. First, the patient is given the diagnosis of major depression, which is presented as a treatable medical illness rather than a character flaw (which is how the patient often perceives it). Patients are given the "sick role," a temporary status that recognizes they are suffering from an illness and probably cannot function at full capacity. Depressed patients learn to blame the illness when appropriate, rather than guiltily blaming themselves as they are wont to do. The sick role also incorporates the responsibility to work in treatment toward recovery, at which point the patient reassumes a healthy role.

4. The time-limited treatment is then focused on one of four areas: complicated bereavement (an aberrant response to the death of a significant other), role dispute (a struggle with a significant other), role transition (a major life change, such as in job, geography, marital status, or health), or interpersonal deficits (a poorly named category that really denotes absence of any of the first three kinds of life events).

In each weekly, 50-minute session, therapist and patient review what has happened between sessions and connections between the patient's recent mood and recent life situations. Sessions focus on the patient's interpersonal skills; for example, depressed patients typically struggle to assert themselves, confront other people, and take social risks. When patients handle interpersonal situations appropriately, therapists reinforce their use of social skills and underscore the link between good social functioning and improved mood. When interpersonal events go badly, therapists help patients to understand what went wrong and to prepare to handle future encounters more adap-tively.

Randomized controlled trials of IPT showed that it relieved depression better than control conditions and with roughly equivalent efficacy to antidepressant medications. Moreover, IPT helped patients to build social skills, which medication alone did not. The success of IPT in studies of outpatients with Major Depressive Disorder led to its testing for patients with other mood and nonmood diagnoses, including major depression in medically ill patients, depressed geriatric and adolescent patients, mothers with postpartum depression, Dysthymic Disorder, and as an ad-junctive treatment for bipolar disorder; it has also been tested for bulimia, social phobia, Post-Traumatic Stress Disorder, and other conditions. For many of these syndromes, researchers developed new manuals to adapt IPT to the particular psychosocial needs of patients with the target diagnoses. Only in two studies of patients with substance abuse has IPT not been shown to be helpful.

Used mainly as an acute (12 to 16 week) individual treatment, IPT increasingly has been tested in other formats: as couple's therapy, group therapy, telephone therapy, and as a 3-year maintenance treatment for patients with recurrent depression who improved after acute treatment. Indeed, IPT is the only psychotherapy fully tested as a maintenance treatment for patients with recurrent episodes of major depression. Even in a low, once monthly dosage, it protected against relapse better than pill placebo, although not as effectively as high dose maintenance antidepressant medication. In some acute studies and one of the two maintenance studies, the combination of IPT and medication worked better than either treatment alone.

Research on IPT has focused largely on outcome, that is, symptomatic improvement. Its success in this area has led to the inclusion of IPT in American and international treatment guidelines for depression and bulimia. Other research domains also deserve exploration: which of the eclectic ingredients of IPT help which patients; when IPT might be preferable to, or less helpful than, other treatments such as cognitive-behavioral therapy; and how well IPT works in general practice. Some research has begun to reveal biological and psychological outcome predictors as well as neuro-imaging brain changes due to IPT. Initially a purely research therapy, IPT is now beginning to expand beyond its research origins into clinical practice, spawning an International Society for Interpersonal Psychotherapy and addressing questions of appropriate standards for certification of IPT proficiency by nonresearch therapists.

John C. Markowitz

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