Subsyndromally depressed hospitalized elderly patients

Recognizing that subthreshold symptoms for major depression impeded recovery of hospitalized elderly patients, Mossey et al. (1996) conducted a trial using a modification of

IPT called interpersonal counseling (IPC) (Klerman et al., 1987). Nonpsychiatric nurses treated geriatric, medically hospitalized patients with minor depressive symptoms for 10 1-hour sessions flexibly scheduled to accommodate the patient's medical status. Seventy-six hospitalized patients over age 60 who had subsyndromal depressive symptoms on two consecutive assessments were randomly assigned to either IPC or usual care (UC). A euthymic, untreated control group was also followed. Patients found IPC feasible and tolerable. Three-month assessment showed nonsignificantly greater improvement in depressive symptoms and on all outcome variables for IPC relative to UC, whereas controls showed mild symptomatic worsening. In the IPC and euthymic control groups, rates of rehospitalization were similar (11-15%), and significantly less than the subsyndromally depressed group receiving UC (50%). Differences between IPC and UC became statistically significant after 6 months on depressive symptoms and self-rated health, but not physical or social functioning. The investigators felt 10 sessions were not enough for some patients, and that maintenance IPC might have been useful.

OTHER APPLICATIONS

The success of IPT in treating unipolar mood disorders has led to its expansion to treat other psychiatric disorders. Frank and colleagues in Pittsburgh have been assessing a behaviorally modified version of IPT as a treatment adjunctive to pharmacotherapy for bipolar disorder. They report on this adaptation elsewhere in this volume (Chapter 15) (Frank, 1991b; Frank et al., 1999; 2000a;b).

Furthermore, IPT is increasingly being applied to a range of nonmood disorders. There are intriguing applications of IPT as treatment for bulimia (Agras et al., 2000; Fairburn et al., 1993; Wilfley et al.,1993; 2000) and anorexia nervosa, social phobia (Lipsitz et al., 1999), post-traumatic stress disorder, and other conditions. Life events, the substrate of IPT, are ubiquitous, but how useful it is to focus on them may vary from disorder to disorder. There have been two negative trials of IPT for substance disorders (Carroll et al., 1991; Rounsaville et al., 1983), and it seems unlikely that an outwardly focused treatment such as IPT would be useful for such an internally focused diagnosis as obsessive compulsive disorder. In the continuing IPT tradition, clinical outcome research should clarify the question of its utility. IPT is also being modified for use in other formats—for example, as group therapy (Klier et al., 2001; Wilfley et al. 1993,2000; Zlotnick et al., 2001) and as a telephone intervention. Weissman (1995) developed an IPT patient guide with worksheets for depressed readers that may be used in conjunction with IPT.

In summary, IPT is one of the best tested psychotherapies, particularly for mood disorders, where it has demonstrated efficacy as both an acute and maintenance monotherapy and as a component of combined treatment for major depressive disorder. It appears to have utility for other mood and nonmood syndromes, although evidence for most of these is sparser. Monotherapy with either IPT or pharmacotherapy is likely to treat successfully most patients with major depression, so combined treatment should probably be reserved for more severely or chronically ill patients (Rush & Thase, 1999). How best to combine time-limited psychotherapy with pharmacotherapy is an exciting area for future research: when is it indicated, in what sequence, and for which patients?

Comparative trials have begun to reveal moderating factors that predict treatment outcome. The NIMH TIDCRP, which compared IPT and CBT, suggested factors that might predict better outcome with either IPT or CBT. Sotsky and colleagues (1991) found that depressed patients with low baseline social dysfunction responded well to IPT, whereas those with severe social deficits (probably equivalent to the "interpersonal deficits" problem area) responded less well. Greater symptom severity and difficulty in concentrating responded poorly to CBT. Initial severity of major depression and of impaired functioning responded best in that study to IPT and to imipramine. Imipramine worked most efficaciously for patients with difficulty in functioning at work, reflecting its faster onset of action. Patients with atypical depression responded better to IPT or CBT than to imipramine or placebo (Shea et al., 1999).

Barber and Muenz (1996), in a study of the TDCRP completers, found IPT more efficacious than CBT for patients with obsessive personality disorder, whereas CBT fared better for avoidant personality disorder. This finding did not hold for the intent-to-treat sample. Biological factors, such as abnormal sleep profiles on EEG, predicted significantly poorer response to IPT than for patients with normal sleep parameters (Thase et al., 1997). Frank and colleagues (1991) found that psychotherapist adherence to a focused IPT approach may enhance outcome. Moreover, sleep EEG and adherence, the first a biological and the latter a psychotherapy factor, had additive effects in that study. Replication and further elaboration of these predictive factors deserve ongoing study.

Another exciting development is the use of neuroimaging studies to compare IPT and pharmacotherapy outcomes. In Sunderland, Martin et al. (2001), using SPECT, found that IPT and venlafaxine had overlapping but also differing effects on right posterior cingulate (IPT), right posterior temporal (venlafaxine), and right basal ganglia activation (both treatments). Brody et al. (2001) in Los Angeles reported slightly different but roughly analogous findings with positron-emission tomography (PET) scanning of patients treated with IPT and paroxetine.

TRAINING

Until very recently, IPT therapy was delivered almost entirely by research study therapists. As the research base of IPT has grown and it has become included in treatment guidelines, there has been a growing clinical demand for this empirically supported treatment. IPT training is now increasingly included in professional workshops and conferences, with training courses conducted at university centers in the UK, Canada, Continental Europe, Asia, New Zealand, and Australia, in addition to the USA. IPT is taught in a still small but growing number of psychiatric residency training programs in the USA (Markowitz, 1995) and has been included in family-practice and primary-care training. It was not, however, included in a recent mandate for psychotherapy proficiency of US psychiatric residency programs.

The principles and practice of IPT are straightforward. Yet, any psychotherapy requires innate therapeutic ability, and IPT training requires more than reading the manual (Rounsaville et al., 1988; Weissman et al., 1982). Therapists learn psychotherapy by practicing it. IPT training programs generally are designed to help already experienced therapists refocus their treatment by learning new techniques, not to teach novices psychotherapy. This makes sense, given its development as a focal research therapy: IPT has never been intended as a universal treatment for all patients, a conceptualization of psychotherapy that in any case seems naively grandiose in the modern era.

IPT candidates should have a graduate clinical degree (M.D., Ph.D., M.S.W., or R.N.), several years of experience conducting psychotherapy, and clinical familiarity with the diagnosis of patients they plan to treat. The training developed for the TDCRP (Elkin et al., 1989) became the model for subsequent research studies. It included a brief didactic program, review of the manual, and a longer practicum in which the therapist treated two to three patients under close supervision and monitored by videotapes of the sessions (Chevron & Rounsaville, 1983). Rounsaville et al. (1986) found that psychotherapists who successfully conducted an initial supervised IPT case often did not require further intensive supervision, and that experienced therapists committed to the approach required less supervision than others (Rounsaville et al., 1988). Some clinicians have taught themselves IPT with the IPT manual (Klerman et al., 1984) and peer supervision to guide them. For research certification, we recommend at least two or three successfully treated cases with hour for hour supervision of taped sessions (Markowitz, 2001).

There has been no formal certificate for IPT proficiency and no accrediting board. When the practice of IPT was restricted to a few research settings, this was not a problem, as one research group taught another in the manner described above. As IPT spreads into clinical practice, issues arise about standards for clinical training, and questions of competence and accreditation gain greater urgency. Training programs in IPT are still not widely available, as a recent US Surgeon General's report noted (Satcher, 1999). Many psychiatry residency and psychology training programs still focus exclusively on long-term psychodynamic psychotherapy or on CBT. In these programs, too, the lack of exposure to time-limited treatment has been noted (Sanderson & Woody, 1995).

The educational process for IPT in clinical practice requires further study. We do not know, for example, what levels of education and experience are required to learn IPT, or how much supervision an already experienced psychotherapist is likely to require. The International Society for Interpersonal Psychotherapy is currently debating how best to set standards for clinical practice of IPT, which doubtless varies from country to country. The UK is in better shape than most: IPT therapists in Britain have agreed on standards for clinical training and practice that are essentially equivalent to those for researchers. These rigorous standards should ensure high-quality IPT in the UK.

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Part II

BIPOLAR DEPRESSION

Free Yourself from Panic Attacks

Free Yourself from Panic Attacks

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