IPT for Major Depression

Overview● Major Depression

○ Symptoms○ Subtypes○ Prevalence○ Risk Factors○ Comorbidities○ Maintenance

IPT○ What is it○ How does it work ○ Course of therapy○ Strengths and weaknesses ○ Directions for research

Symptoms for Major Depression

● Depressed mood ● Diminished interest or pleasure of activities● Loss of appetite or significant weight loss● Insomnia or hypersomnia ● Psychomotor changes● Fatigue● Feelings of worthlessness or excessive guilt

daily● Recurrent thought of death or suicide● Diminished ability to think or concentrate

Major Depression subtypes● Related disorders: dysthymia ● Subtype:

○ Seasonal Affective Disorder ○ Atypical Depression ○ Melancholia○ Organic Mood Disorder○ Post Partum Depression ○ Melanchoilic Depression

Major Depression● 12 month prevalence in

United States is 7%● 3 times more likely in 18-

29 year old compared to those 60+ years old

● Females 1.5-3 times more likely than men

Risk Factors for Major Depression ● Being female (Edward&William, 1995) ● Stressful life events (Ian H. &Constance L. , 2002)

Interpersonal Risk Factors for depression (Ian H. &Constance L. , 2002)● Interpersonal vulnerability to depression falls into three

categories: ● impaired social skills as a risk factor● excessive interpersonal inhibition ● excessive interpersonal dependency

Comorbidities 0n Major Depression● The great majority 95 % of patients with Major Depression Disorder suffered one or more comorbid disorders.● mental disorder● anxiety disorder● substance abuse● conduct disorder ● somatic disorders

Factors that maintain Major Depression

● Even after successful treatment as judged by symptomatic recovery, formerly depressed outpatients may continue to have occupational and sexual difficulties.

● Personal experiences : evidence of impairment and incompetence, and negative responses from family members represent personal experiences.

● Persistent fear of its return and a hypervigilance about the fresh emergence of symptoms or an incipient breakdown functioning.

● Depressed persons avoid again in the position of being unable to meet demands of work, school, and close relationships

Theory of the disorder● general model of mental disorders of IPT (see

graphic)● diathesis+stress+social context!● depression associated with social dysfunction

Depression Model of IPT (Klerman at al. 1984)

● attachment theory (Bowlby, 1969)

● stress related to depressive symptoms (Pearlin and Lieberman, 1977)

● impaired relationships mental disorder(Briscoe & Smith, 1973)

“Interpersonal vicious cycle”

Components of a depressive episode

1)Symptom formation→ coming from psychobiological mechanisms

2)Social and interpersonal relations→ based on childhood learning, social reinforcement, disrupted by life events

3)Personality problems→ predisposition to depression, inhibited emotional expression, problematic communication and self-esteem

Strengths and limitations+ dynamic theory/interactive theory+ explains maintenance of depression

- hard to pinpoint the exact cause of MDD

- hard to falsify

Overview of intervention● Interpersonal Therapy (IPT)● developed by Gerald Klerman in the

1970’s as a short-term treatment for depression (Klerman et al. , 1984)

● Designed for weekly sessions● typically 12-16 sessions

Course of therapy (Klerman et al. , 1984) Phase 1 (Session 1 - 3): ● review of symptoms, onset of depression● assessment of interpersonal functioning

→ connecting symptoms to specific problem area

● grief● role disputes● role transitions● interpersonal deficits

Assessment of problem areas (Klerman et al. 1984)

Course of TherapyPhase 2 (Session 4 - 11):● address specific problem area● develop skills and strategies

→ intervention according to specific interpersonal problem area!

Intervention at specific problem area● grief:

facilitate mourning, establish new relationships, offer temporary attachment, reconstruction relationships to dead person

● interpersonal role disputes:help identify the dispute, developing

alternatives, changing maladaptive communication,

monitoring interactions (also in therapy!)

Intervention at specific problem area● role transitions:

help to regard new role as positive, explore previous role, encourage mastery, help to initiate new relationships

● interpersonal deficitsidentify past positive relationships, guiding to

new relationships→ often requires long-term treatment!

Course of Therapy Phase 3 (Session 12-16)● recognizing and consolidating

therapeutic gains● supporting the patient with his

interpersonal relationships● pointing out painful and good aspects

of therapy ending

IPT Visual Dialogue ● Ruth 62 years of age● husband has passed ● lived a very isolated lifestyle, focusing mostly on husband● relationships with children were rocky, had a hard time letting

them grow and venture off*Ruth’s anticipation of rejection and her feeling that she wouldn’t enjoy other people’s company differed with what actually happened when others asked her to join them in their social events

Dialogue-Techniques● exploratory techniques

● encouragement of affect

● clarification naming the client’s feelings

● behavior change techniques

Strengths and limitations of the intervention+ relationships are important+ treatment manuals+ straightforward/easy to understand+ short-term treatment possible

- what about partners/reactions?- ???

Meta-analysis I: Medication vs. IPT● 9 studies● 947 patients● 488 randomly assigned to solely IPT● 459 randomly assigned to solely medicationREMISSION:Medication-51 %IPT-43.8%

Efficacy

EfficacyMeta-analysis II: IPT & Meds vs. Meds alone

REMISSION:● IPT plus medication-76.8%● Medication alone-67.7%

EfficacyMeta-analysis III: IPT vs. Placebo● 9 studies● 653 patients● 337 randomly assigned to IPT● 316 randomly assigned to PlaceboREMISSION:IPT-68.1%Placebo-48.7%

EfficacyMeta-analysis IV: IPT vs. CBT● 3 studies ● 204 patients● 102 randomly assigned to IPT● 102 randomly assigned to CBTREMISSION:IPT-56.1%CBT-47.1%

Effect SizeIPT & Control Group● 38 studies ● 4,356 patients● overall effect size 0.63 (95%CI= 0.36

to 0.90)

Effect Size IPT vs. other Psychological Treatments● 10 studies comparing IPT and other

treatments● effect size 0.04 ( 95%CI= -0.14 to

0.21)

Future of IPT● determine if there are more ways to make IPT

even more effective than the data already proves● test generalizability of IPT to other populations

and extend research to other disorders● Parental involvement in therapy with

adolescents “parent-child conflict” ● shortening the numbers of sessions

References Abela, J. R. Z, & Hankin, B. L (Eds.), (2008). Handbook of Depression in Children and Adolescents. New York, NY. The Gilford Press

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author

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Bowlby, J. (1969): Attachment and Loss, vol 1. New York, Basic Books.

Briscoe, C. W. & Smith, J. B. (1973): Depression and marital turmoil. Arch Gen Psychiatry, 28, 811 - 817.

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ReferencesCuijpers, P., Geraedts, A., Oppen, P., Andersson, G., Markowitz, J., & Straten, A. (2011). Interpersonal Psychotherapy for Depression: A Meta-Analysis. American Journal of

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ReferencesPearlin, L. I. & Liebermann, M. A. (1977): Social sources of emotional distress, in research in community in mental health. Edited by Simmons R. Greenwich, C. T., JAI Press.

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