Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_205_библиотеки_им_акад_М_И_Перельмана
.pdf
422 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
Conducting Interpersonal Psychotherapy
Techniques
IPT therapists define depression as a treatable medical illness that is not the patient’s
fault. This definition displaces burdensome blame from the patient to the illness. It also
provides hope for improvement: an illness is far more treatable than a self-perceived
intrinsic flaw. The IPT therapist uses DSM-5 (American Psychiatric Association 2013)
to diagnose a mood disorder and a rating scale such as the Hamilton Rating Scale for
Depression (HAM-D; Hamilton 1960) or the Beck Depression Inventory (BDI; Beck
1978) to assess and explain depressive symptoms. These instruments provide psychoeducation to help the patient to recognize that he or she is struggling with a common
disorder with a predictable set of symptoms. The HAM-D and BDI have been used for
decades, reinforcing that the problem is not a personal flaw but a long-recognized syndrome. The therapist gives the depressed patient the sick role (Parsons 1951), which
excuses what the illness prevents him or her from doing, while still conferring respon
sibility to work in treatment to recover the lost healthy role. By solving an interpersonal problem—addressing complicated bereavement, a role dispute or transition, or
an interpersonal deficit—the IPT patient can both improve his or her life situation and
relieve symptoms of the depressive episode. This coupled formula, validated in repeated RCTs, can be offered with confidence and optimism.
IPT is an eclectic therapy that uses techniques seen in other treatment approaches
yet can be clearly distinguished from other therapies by adherence ratings (Amole et
al. 2017; Hill et al. 1992; Markowitz et al. 2000b). Its medical model of depressive ill
ness mimics, and makes it highly compatible with, pharmacotherapy. Marital therapists find its approach to interpersonal issues familiar. IPT shares role-playing and a
here-and-now focus with cognitive-behavioral therapy (CBT; Beck et al. 1979; Mar
kowitz 2001). Akin to CBT as a time-limited, syndrome-targeted treatment, IPT is less
structured, assigns no homework, and focuses on interpersonal problem areas and
associated affect rather than automatic thoughts and core beliefs. Affect-focused, IPT
overlaps with psychodynamic psychotherapies, and many early IPT research therapists came from psychodynamic backgrounds. Yet IPT also meaningfully differs from
psychodynamic therapies in its focus on the present, not the past; its focus on real-life
change rather than self-understanding; its medical model; and its avoidance of inter
preting dreams and the transference (Markowitz et al. 1998b). No one technique or
tactic makes IPT a unique and coherent approach; its overall strategies do.
Each of the four IPT interpersonal problem areas has discrete, if overlapping, goals
for the therapist and patient to pursue. The therapist repeatedly helps the patient re
late life events to mood and other symptoms. In each session after the first one, an
opening question elicits an interval history of mood and events and focuses treatment
on them. Other techniques include
-
-
-
-
-
• Communication analysis—the reconstruction and evaluation of recent affectively
charged interpersonal encounters.
• Exploration of the patient’s wishes and options—to pursue these in interpersonal situ-
ations.
423 Interpersonal Psychotherapy for Depressive Disorders
https://t.me/med1917
• Decision analysis—to help the patient choose among options.
• Role-playing—to help patients rehearse tactics for real life.
IPT focuses on current interpersonal relationships in the patient’s immediate social
context. The IPT therapist attempts to intervene in symptom formation and social
dysfunction associated with depression rather than aspects of personality. Personal
ity is difficult to accurately assess during an episode of a major psychiatric disorder
such as depression (Hirschfeld et al. 1983; Markowitz et al. 2015). IPT does help the
patient build new social skills (Weissman et al. 1974, 1981), which may be as valuable
as changing personality traits.
Phases of Treatment
As an acute treatment, IPT has three phases (Table 24–1) (Weissman et al. 2018). The
early phase, lasting no more than three sessions, sets the stage for what follows. The
therapist reviews symptoms, diagnoses depression by standard criteria (American
Psychiatric Association 2013), and gives the patient the sick role. The psychiatric history includes an “interpersonal inventory,” a careful cataloging of the patient’s past
and current social functioning and close relationships, including their patterns and
mutual expectations. Initial sessions elucidate changes in relationships proximal to
the onset of symptoms—for example, death of a loved one, children leaving home,
worsening marital strife, or isolation from a confidant. The therapist looks for mean
ingful life events such as a career change or onset of a medical illness. This review provides a framework for understanding the social and interpersonal context of the
depressive symptoms, and this framework becomes the basis of a treatment focus.
In clinical practice, the therapist assesses the need for medication on the basis of
symptom severity, illness history and response to treatment, and patient preference.
The therapist then educates the patient about the constellation of symptoms that de
fine MDD, their psychosocial concomitants, and what the patient may expect from
treatment. A formulation links the depressive syndrome to the patient’s interpersonal
situation (Markowitz and Swartz 2007), centered on one of four interpersonal prob
lem areas: 1) grief, 2) interpersonal role disputes, 3) role transitions, or 4) interpersonal deficits (Table 24–2). With the patient’s explicit acceptance of this formulation
as the treatment focus, therapy enters the middle phase.
Any formulation perforce simplifies a patient’s complex life story. Although many
patients present with multiple interpersonal problems, the formulation isolates one
or at most two salient problems related to the patient’s mood disorder, either as precipitants or as consequences, and weaves them into an organizing fiction. More than
two foci in a brief psychotherapy means no focus at all. Choice of focal problem area
depends on clinical acumen, although research has shown that IPT therapists agree
on the chosen areas (Markowitz et al. 2000a). Patients seem to find the foci credible.
In the middle phase, the IPT therapist pursues strategies appropriate to the focal inter-
personal problem area (Weissman et al. 2018). To address grief (complicated bereavement after the death of a loved one), the therapist facilitates the catharsis of mourning
and helps the patient to find new activities and relationships to compensate for the loss.
For role disputes (conflicts with a spouse, other family member, boss, coworker, or
friend), the therapist helps the patient to explore the relationship, the nature of the dis-
-
-
-
-
424 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
TABLE 24–1. Phases of interpersonal psychotherapy (IPT)
Early phase
Deal with the depression.
1. Review depressive symptoms.
2. Name the syndrome: formal diagnosis.
3. Provide psychoeducation about depression and its treatment.
4. Give the patient the “sick role.”
5. Evaluate the need for medication.
Relate depression to interpersonal context: interpersonal inventory.
1. Determine the nature of interaction with significant persons.
2. Identify reciprocal expectations of the patient and significant others and whether these
were fulfilled.
3. Discuss satisfying and unsatisfying aspects of relationships.
4. Detect recent changes in key relationships.
5. Determine changes the patient desires in his or her relationships.
Identify the major problem area.
1. Determine problem area related to current episode and set treatment goals.
2. Identify which relationship is related to the episode and what might change in it.
Explain IPT concepts and contract.
1. Outline the therapist’s understanding of the problem: formulation.
2. Agree on treatment goals (focal problem area):
a. Brief treatment (time limit)
b. Target of improving depression (not character)
3. Describe IPT procedures: here-and-now focus, need to discuss important concerns, review
of current interpersonal relationships, discussion of practical aspects of treatment.
Middle phase
Use specific strategies for treating grief, role disputes, role transitions, or interpersonal deficits.
Termination phase
Consolidate gains.
Foster independence.
Address guilt (and blame the therapy) if the patient’s symptoms did not respond.
Review risk of relapse and recurrence.
Recontract for continuation or maintenance treatment if appropriate.
pute, whether it has reached an impasse, and available options to resolve it. If these options fail, the therapist and patient may conclude that the relationship has reached an
impasse and consider ways to change the impasse or to end the relationship.
A role transition is a change in life status: beginning or ending a relationship or career, moving, being promoted, retiring, graduating, or receiving a diagnosis of a medical illness. The patient learns to manage the change by mourning the loss of the old
role while recognizing positive and negative aspects of the new role he or she is assuming and taking steps to master it. The residual fourth IPT problem area, interpersonal deficits, comprises patients who lack all of the first three problem areas (i.e.,
have no recent life events). This least-defined focus, an anomalous non-life-event-
425 Interpersonal Psychotherapy for Depressive Disorders
https://t.me/med1917
TABLE 24–2. Interpersonal psychotherapy problem areas
Problem area Definition
Grief (complicated bereavement) Death of a significant other
Role disputes Struggle with a significant other
Role transitions Life event that changes perceived social role
Interpersonal deficits No life events; social isolation (used only if none of
the above are appropriate)
based category for a life-event-based therapy, defines the patient as lacking the social
skills to initiate or sustain relationships. Its goal is to help the patient develop new re
lationships and skills. Some patients who appear to fit this category may have DSMIV (American Psychiatric Association 1994) dysthymic disorder, for which other IPT
strategies have been developed (Markowitz 1998).
IPT sessions address current, here-and-now problems. Sessions open with the
question “How have things been since we last met?” This orients the patient to recent
interpersonal events and recent mood, which the therapist helps the patient to link.
Therapists sympathize with patients’ suffering and validate their emotions while taking an active, supportive, and hopeful stance to counter the depressed patient’s pessimism. They elicit and emphasize the options for change in the patient’s life, options
that the depressive episode often has kept the patient from seeing or exploring fully.
Understanding the situation does not suffice; therapists stress the need for patients to
test these options to improve their lives and simultaneously treat their depressive epi
sodes. Enacting a practical solution to the patient’s focal interpersonal crisis within
the envelope of the time-limited treatment is the implicit homework of IPT.
The termination phase of IPT, the last few sessions of acute treatment or last months
of maintenance treatment, supports the patient’s newly regained sense of competence
by recognizing and consolidating therapeutic gains. The therapist enhances the patient’s self-esteem and independence by underscoring that the patient’s depressive
episode has improved through the patient’s interpersonal actions in changing a life
situation. Moreover, the patient achieved this at a time when he or she had felt weakest. The therapist also helps the patient to anticipate triggers for and responses to depressive symptoms that might arise in the future. Relative to psychodynamic therapy,
IPT deemphasizes termination: it is a graduation from successful treatment, a role
transition that, like most, is bittersweet. The sadness of separation is distinguished
from depressive feelings. If the patient has not improved, the therapist emphasizes
that the treatment has failed, not the patient, and that alternative effective treatment
options exist. Patients with multiple prior depressive episodes or significant residual
symptoms who successfully complete acute treatment but remain at high risk for recurrence may contract for maintenance therapy as acute treatment draws to a close.
-
-
Indications and Contraindications
Research on psychotherapy outcome has lacked the resources available to pharmaceutical companies, whose products are accordingly better studied. Nonetheless, a
426 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
series of RCTs comparing IPT with control conditions have defined the efficacy of IPT
for patients with mood disorders. Indications for IPT thus have been determined not
by random application but by RCTs. For some patient subgroups, IPT has been
adapted in separate treatment manuals (e.g., Markowitz 1998; Mufson et al. 2011).
Still more interesting are comparative trials of IPT with CBT and medication, which
have provided some data on differential therapeutics. No absolute contraindications
exist for using IPT with nondelusional depressed outpatients, yet no treatment is ideal
for all patients. Given a choice between two treatments of already established efficacy,
the clinician must determine which factors may predict a better outcome for patients
with a given diagnosis (Frances et al. 1984). The following section documents the ef
ficacy of IPT for patients with unipolar, nondelusional mood disorders, first addressing acute and then chronic forms of depression (Table 24–3).
Acute Treatment of Major Depressive Disorder
IPT was first studied as an acute antidepressant treatment in a four-cell, 16-week randomized trial comparing IPT, amitriptyline, their combination, and a nonscheduled
control treatment for 81 outpatients with MDD (DiMascio et al. 1979; Weissman et al.
1979). Amitriptyline worked more quickly, but IPT and amitriptyline did not significantly differ in symptom reduction at the end of treatment. Each reduced symptoms
more efficaciously than did the control treatment, and combined amitriptyline-IPT
was more efficacious than either active monotherapy. Not surprisingly, patients with
psychotic depression who received IPT alone fared poorly. On naturalistic follow-up
at 1 year, many patients had sustained improvement from the brief IPT intervention,
and IPT patients had developed significantly better psychosocial functioning regardless of whether they had received medication. This effect on social function was not
found for amitriptyline alone, nor had it been evident for IPT immediately after the
16-week trial (Weissman et al. 1981).
In the ambitious, multisite NIMH Treatment of Depression Collaborative Research
Program (Elkin et al. 1989), investigators randomly assigned 250 outpatients with
MDD to 16 weeks of IPT, CBT, or clinical management with either imipramine or pill
placebo. Most subjects completed at least 15 weeks or 12 treatment sessions. More
mildly depressed patients (defined as baseline 17-item HAM-D score<20) improved
equally in all treatments. Among more severely depressed patients (HAM-D score
≥20), imipramine worked fastest and most consistently outperformed placebo. IPT
was comparable to imipramine on several outcome measures, including HAM-D
score, and superior to placebo for the more depressed patients. CBT was not superior
to placebo among the more depressed patients.
Klein and Ross (1993) reanalyzed the NIMH Treatment of Depression Collaborative
Research Program data with the Johnson-Neyman technique and found that medication outperformed the psychotherapies, which were superior to placebo, especially
among more impaired patients. The authors found CBT inferior to IPT for patients
with BDI scores greater than 30, a score demarcating the boundary between moderate
and severe depression.
In a naturalistic follow-up study of Treatment of Depression Collaborative Research Program subjects at 18 months posttreatment, Shea et al. (1992) found no significant difference across treatments in recovery among patients whose symptoms
-
427 Interpersonal Psychotherapy for Depressive Disorders
https://t.me/med1917
TABLE 24–3. Empirically based indications for interpersonal psychotherapy
Acute major depressive disorder
Geriatric patients
Adolescent patients
HIV-positive patients
Primary care patients
Antepartum and postpartum depressed women
Patients with marital disputes (conjoint therapy)
Recurrent major depressive disorder (maintenance prophylaxis)
Persistent depressive disorder (dysthymia)
Bipolar disorder (adjunctive treatment)
Interpersonal counseling for subsyndromal depression
a
Preliminary results are encouraging.
b
See Chapter 26 (“Psychotherapeutic Approaches to Bipolar Disorder”) in this volume.
a
a,b
had remitted (i.e., those who had minimal or no symptoms after treatment and sustained this improvement during follow-up). Thirty percent of CBT, 26% of IPT, 20%
of placebo, and 19% of imipramine subjects whose symptoms had acutely remitted
remained in remission during that time span. Of the subjects whose symptoms had
acutely remitted, relapse rates over the 18 months were 36% for CBT, 33% for IPT, 50%
for imipramine (albeit medication had been stopped at 16 weeks), and 33% for placebo. The authors concluded that for many patients, 16 weeks of treatment was insufficient to achieve lasting recovery (Shea et al. 1992).
IPT works outside the United States as well. In a trial in the Hague, the Nether-
lands, Blom et al. (1996) first undertook a pilot trial and then completed a randomized
trial of IPT, nefazodone, and their combination for 191 subjects with MDD (Blom et
al. 2004). Results suggested that all three treatments had similar benefit. Subsequent
trials have validated the efficacy of IPT for depression in many other countries
(Weissman et al. 2018).
Depressed Geriatric Patients
IPT was first used with 30 depressed geriatric patients to enhance compliance in a 6week pharmacotherapy trial and to enhance the pill placebo control group (Rothblum
et al. 1982; Sholomskas et al. 1983). The investigators noted grief and role transitions
as the modal treatment foci. They suggested modifications of IPT for older depressed
patients, including a flexible duration of sessions, more practical advice and concrete
support (e.g., arranging transportation, calling physicians), and increased recognition
that major role changes may be impractical and detrimental (e.g., divorce at age 75
years). A 6-week trial comparing IPT with nortriptyline in depressed elderly patients
showed some advantages for IPT, largely because of higher attrition in the medication
group because of nortriptyline’s side effects (Sloane et al. 1985).
Depressed Adolescents
Mufson et al. (1993) modified IPT to incorporate adolescent developmental issues.
The researchers conducted an open feasibility and follow-up trial and then a con-
428 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
trolled 12-week clinical trial comparing IPT for depressed adolescents (IPT-A) and
clinical monitoring in 48 clinic-referred adolescents, ages 12–18, whose symptoms
met DSM-III-R (American Psychiatric Association 1987) criteria for MDD. Patients
were rated biweekly by a blinded independent evaluator to assess symptomatology,
social functioning, and social problem-solving skills. Of the 48 patients, 32 (21 IPT-A,
11 control) completed the protocol.
Patients receiving IPT-A reported significantly greater improvement in depressive
symptoms and social functioning, including functioning with friends and problemsolving skills. In the intent-to-treat sample, 75% of the IPT-A patients met the recov
ery criterion (HAM-D score ≤6), compared with 46% of the control subjects. The findings support the feasibility, patient acceptance, and efficacy of 12 weeks of IPT-A with
acutely depressed adolescents in reducing depressive symptomatology and improv
ing social functioning and interpersonal problem-solving skills (Mufson et al. 1999).
Mufson et al. (2004a) subsequently tested IPT-A in a large-scale effectiveness study
in New York City school-based clinics; a 12-session course of IPT-A delivered by
school counselors was compared with treatment as usual over 16 weeks. Adolescents
with mood disorders who received IPT-A (N=63) again showed greater improve
ments than did those receiving usual treatment on independent, clinician, and selfreport ratings of symptoms and social functioning. Thus, IPT-A has shown benefits
in both efficacy and effectiveness trials. Mufson et al. (2004b) also have developed a
group format for depressed adolescents, which might have economic benefits and
take advantage of teenage peer support.
Rosselló and Bernal (1999) at the University of Puerto Rico compared IPT (n=22),
CBT (n=25), and a wait-list control condition (n=24) in a 12-week RCT for adolescents
(ages 13–18 years) whose symptoms met DSM-III-R criteria for MDD, dysthymia, or
both. The investigators did not use Mufson and colleagues’ IPT-A adaptation. Both
IPT and CBT were more efficacious than the wait-list condition in reducing adolescents’ self-rated depressive symptoms. IPT was more efficacious than CBT in increasing self-esteem and social adaptation. Effect sizes for improvement were 0.73 for IPT
and 0.43 for CBT.
Mufson and colleagues have since adapted IPT-A as a group intervention, as a preventive intervention, and as an intervention for preadolescents (Weissman et al. 2018).
-
-
-
Depressed HIV-Positive Patients
Markowitz et al. (1992) modified IPT for depressed individuals with HIV (IPT-HIV)
in the early years of the epidemic, when AIDS appeared to be an acute and lethal illness rather than the chronic disease it has now become. The adaptation emphasized
common concerns among this population about illness and death, grief, and role tran
sitions. A 16-week randomized trial in 101 subjects compared IPT-HIV, CBT, supportive psychotherapy, and imipramine plus supportive psychotherapy (Markowitz et al.
1998a). As with the subset of more severely depressed individuals in the Treatment of
Depression Collaborative Research Program study (Elkin et al. 1989), all treatments
were associated with symptom reduction, but IPT and imipramine plus supportive
psychotherapy produced significantly greater symptomatic and functional improvement than CBT or supportive psychotherapy alone. Many patients reported improvement in neurovegetative symptoms that they had mistakenly attributed to HIV
infection.
-
429 Interpersonal Psychotherapy for Depressive Disorders
https://t.me/med1917
More recently, Heckman et al. (2017) successfully used telephone IPT to treat iso-
lated rural patients with comorbid depression and HIV infection.
Depressed Primary Care Patients
Schulberg et al. (1996) compared IPT with pharmacotherapy for depressed primary
care medical patients. The investigators integrated IPT into the primary care center.
Not only did nurses take vital signs before sessions, but primary care patients re
ceived treatment for MDD without having to go to a “shrink”: the mental health care
came to them. If patients were medically hospitalized, attempts were made to con
tinue IPT in the hospital.
Patients with MDD (N=276) were randomly assigned to receive IPT, nortriptyline,
or their primary care physicians’ usual care. IPT was given weekly for 16 weeks and
then monthly for 4 months (Schulberg et al. 1996). Depressive symptoms declined
more rapidly with either nortriptyline or IPT than with usual care. About 70% of
those who completed the trial who had received nortriptyline or IPT, but only 20% of
those who had received usual care, had recovered after 8 months. Subjects with a history of comorbid panic disorder had a poorer response across treatments than did
those without a panic history (C. Brown et al. 1996), a finding subsequently corrobo
rated by Frank et al. (2000).
Patients With Antepartum and Postpartum Depression
Pregnancy and nursing are key role transitions for women of childbearing age, who
are prime candidates for depressive episodes (see
Women,” in this volume). Even though most antidepressant medications may carry
little risk of teratogenesis and not all are detectable in breast milk, physicians are re
luctant to prescribe medication, and patients are reluctant to accept it, during pregnancy and nursing. Thus, peripartum depression is an ideal target for IPT.
Spinelli (1997) at Columbia University tested IPT in women with antepartum depression. She added “complicated pregnancy” as a fifth interpersonal problem area.
Timing and duration of sessions were adjusted in response to bed rest, delivery, ob
stetrical complications, and childcare. As with depressed HIV-positive and primary
care patients, telephone sessions and hospital visits were sometimes necessary (Spi
nelli 1997). In a 16-week trial, Spinelli et al. (2016) found that IPT had greater efficacy
than a control parenting education condition in treating women of generally low so
cioeconomic status with moderately severe depression.
O’Hara et al. (2000) compared IPT with a wait-list control condition in 120 women
with postpartum depression in a 12-week trial with an 18-month follow-up. The research assessed both the symptom states of the postpartum mothers and their interactions with their infants (Stuart and O’Hara 1995). Of the IPT group, 38% met HAMD and 44% met BDI remission criteria, compared with 14% on each measure for the
control group. Sixty percent of IPT patients, in contrast to 16% of control subjects, re
ported more than a 50% reduction in BDI score. Mothers receiving IPT showed significantly improved social adjustment relative to the control group.
Klier et al. (2001) treated 17 women with postpartum depression in nine weekly 90minute group IPT sessions followed by an hourlong individual termination session.
Scores on the 21-item HAM-D declined from 19.7 to 8.0, suggesting the efficacy of this
approach. In an exciting study of IPT as prevention, Zlotnick et al. (2001) treated 37
Chapter 42, “Depression in
-
-
-
-
-
-
-
-
430 The APA Publishing Textbook of Mood Disorders, Second Edition
https://t.me/med1917
women at risk for postpartum depression with either four 60-minute sessions of an
IPT-based group or usual care. Six of the 18 women in usual care developed depres
sion by 3 months postpartum, compared with none of the 17 IPT group patients.
Depressed Patients With Marital Disputes (Conjoint IPT)
Stressful changes in relationships such as marital conflict, separation, and divorce can
precipitate or complicate depressive episodes (Rounsaville et al. 1979). Treating mar
ital role disputes in individual IPT often has the feel of unilateral couples therapy
(Weissman et al. 2000), so extending IPT to a couples format was not difficult. Weiss
man and Klerman (1993) developed a manual for conjoint therapy for depressed patients with marital disputes (IPT-CM). IPT-CM includes the spouse in all sessions and
focuses on the current marital dispute. Eighteen patients with MDD linked to onset
or exacerbation of marital disputes were randomly assigned to 16 weeks of either in
dividual IPT or IPT-CM. Patients showed similar reductions in depressive symptoms
in both treatments, but patients receiving IPT-CM reported significantly better mari
tal adjustment, marital affection, and sexual relationships (Foley et al. 1989). These pilot findings require replication with a larger sample and other control groups.
Maintenance Prophylaxis for Recurrent Major
Depressive Disorder
-
-
-
-
-
A significant proportion of all depressions are chronic, and this chronicity may take
two forms. First, most individuals who have a single episode of MDD have a greater
than even chance of having a second lifetime episode; the more episodes one has, the
greater the risk of subsequent episodes (Boland and Keller 2002). Patients with recurrent MDD require not only acute remission of symptoms but also prevention of relapse
and recurrence. IPT is the first psychotherapy to have been tested as a maintenance
treatment to prevent recurrence of depressive episodes. Second, many depressive episodes are chronic—either chronic MDD, milder but chronic DSM-IV dysthymic disorder, or so-called double depression (i.e., MDD superimposed on DSM-IV dysthymic
disorder); DSM-5 has reclassified all of these under the rubric of “persistent depressive
disorder (dysthymia).” Chronically depressed patients are still more hopeless and resigned than are acutely depressed patients, and the chronicity of their illness alters
treatment strategies for their acute treatment.
IPT was first tested in an 8-month, six-cell trial (Klerman et al. 1974; Paykel et al.
1976). A study of this length today would be considered a continuation treatment because the concept of long-term maintenance antidepressant treatment has lengthened.
Acutely depressed outpatient women (N=150) who had responded (with 50% or greater
symptom reduction by interviewer rating) to a 4- to 6-week acute trial of amitriptyline
were randomly assigned to 8 months of weekly IPT, amitriptyline, placebo alone, combined IPT-amitriptyline, combined IPT-placebo, or no treatment. Randomization to IPT
or a low-contact psychotherapy condition occurred at entry into the continuation phase,
whereas randomization to medication, placebo, or no treatment occurred at the end of
the second month of continuation treatment. Maintenance pharmacotherapy was found
to prevent relapse and symptom exacerbation, whereas IPT improved social functioning
(Weissman et al. 1974). The effects of IPT on social functioning required 6–8 months to
appear. Combined psychotherapy and pharmacotherapy produced the best outcomes.
431 Interpersonal Psychotherapy for Depressive Disorders
https://t.me/med1917
Researchers in Pittsburgh, Pennsylvania, conducted two longer antidepressant
maintenance trials of IPT (IPT-M). Frank et al. (1990, 1991) studied 128 outpatients with
multiply and rapidly recurrent depression. Patients were given combined high-dosage
(>200 mg/day) imipramine and weekly IPT until they responded; the high-dosage
medication was continued while IPT was tapered to a monthly frequency during a
4-month continuation phase. Patients who remained in remission were then randomly
assigned to 3 years of 1) ongoing high-dosage imipramine plus clinical management,
2) high-dosage imipramine plus monthly IPT, 3) monthly IPT alone, 4) monthly IPT
plus placebo, or 5) placebo plus clinical management. High-dosage imipramine, with
or without further IPT, proved most efficacious, protecting more than 80% of the pa
tients over 3 years. Most placebo patients relapsed within the first few months. Oncemonthly IPT, although less efficacious than medication, was statistically and clinically
superior to the control condition in this high-risk patient population.
Reynolds et al. (1999) conducted a second 3-year maintenance study of geriatric
patients with recurrent depression; they used IPT and nortriptyline in a design simi
lar to that used in the Frank et al. (1990) study. The IPT manual was modified to allow
more flexibility in the length of sessions, under the assumption that some elderly pa
tients might have difficulty tolerating 50-minute sessions. The investigators found that
geriatric patients needed to address early life relationships in psychotherapy, digress
ing from the here-and-now focus of IPT. Like Sholomskas et al. (1983), Reynolds and
colleagues believed that therapists needed to help patients solve practical problems
but acknowledged that some problems might not be resolvable, such as existential
late-life issues or lifelong psychopathology (Rothblum et al. 1982). Elderly depressed
patients whose sleep quality had normalized by the early continuation phase had an
80% chance of remaining well during the first year of maintenance treatment. Response rates were similar for patients who subsequently received either nortriptyline
or IPT (Reynolds et al. 1999).
The acute treatment sample comprised 187 patients 60 years or older with recurrent MDD (Reynolds et al. 1999). These patients received combined IPT and nortriptyline. One hundred seven who had remission of symptoms and then achieved recovery
after continuation therapy were randomly assigned to one of four 3-year maintenance
conditions: 1) medication clinic with nortriptyline alone, with steady-state nortriptyline plasma levels maintained in a therapeutic window of 80–120 ng/mL; 2) medication clinic with placebo; 3) monthly maintenance IPT plus placebo; or 4) monthly
maintenance IPT plus nortriptyline. Recurrence rates were 90% for placebo, 64% for
IPT with placebo, 43% for nortriptyline alone, and 20% for combined treatment. Each
monotherapy was statistically superior to placebo, whereas combined therapy showed
superiority to IPT alone and a trend for superiority to nortriptyline alone. Patients in
their 70s were more likely to have a recurrence, and to do so more quickly, than patients
in their 60s. This study (Reynolds et al. 1999) corroborated the maintenance findings
of Frank et al. (1990, 1991), with the difference that combined treatment showed advantages over pharmacotherapy alone for the geriatric population.
In both maintenance studies, the comparison of high-dosage tricyclic antidepressants with low-dose maintenance IPT is easy to misinterpret. No previous maintenance
studies had ever used either such high dosages of medication or so low a dose of psychotherapy. Had the medication dosage been lowered comparably to the reduced psychotherapy dosage, recurrence in the medication groups might well have been greater;
-
-
-
-
Соседние файлы в папке Библиотека им академика М.И. Перельмана