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432 The APA Publishing Textbook of Mood Disorders, Second Edition
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had psychotherapy been more intensive, recurrence rates might have declined. Because
there were no precedents for this research, the choice of a monthly dosing interval for
maintenance IPT was reasonable and indeed showed some benefit. Several studies
have since begun to test the effects of differing maintenance doses of psychotherapy.
These difficult, protracted studies have yielded exciting results. They showed that
psychotherapy not only works acutely but also can continue working to ward off the
return of a typically recurrent illness. These research trials also have contributed to
the knowledge base on differential therapeutics by assessing potential moderators of
outcome.
Persistent Depressive Disorder (Dysthymia)
Dysthymia is a syndrome, often of early onset, with high debility and comorbidity
(see
Chapter 35, “Atypical Depression, Dysthymia, and Cyclothymia,” in this volume). Because dysthymic individuals often have been ill from an early age, they tend
to accept their symptoms as part of themselves, an internal defect, and may not seek
appropriate treatment. Early onset of symptoms impedes the development of social
skills. Moreover, because these individuals often struggle through life without the
evident crisis of a major depressive episode, people around them also may accept that
they have nervous or melancholy characters and not press them to find treatment.
Thus, many dysthymic individuals become patients late in the course of chronic ill
ness and are resigned to their condition.
From an IPT perspective, dysthymic patients present an additional problem. As
the description of IPT earlier in this chapter indicates, the IPT model connects recent
life events with recent mood changes. This model nicely fits acute depression but
makes less sense for the often decades-long cases of chronic depression. Accordingly,
Markowitz (1998) modified IPT for DSM-IV dysthymic disorder (IPT-D), taking advantage of the patient’s sense that the illness was part of his or her character. IPT-D
encourages patients to reconceptualize what they consider their lifelong character
flaws as ego-dystonic, chronic mood-dependent symptoms—as a chronic but treatable state rather than an immutable trait. Therapy itself is defined as an “iatrogenic
role transition” from believing oneself flawed in personality to recognizing and treat
ing the mood disorder. Markowitz (1994, 1998) openly treated 17 pilot subjects with
16 sessions of IPT-D: none worsened, and 11 subjects had remission of symptoms.
On the basis of these pilot results, investigators at Weill Medical College of Cornell
University conducted a randomized trial comparing 16 weeks of IPT-D alone, ser
traline plus clinical management, supportive psychotherapy, and combined IPT-D
and sertraline for 86 patients with “pure” DSM-IV dysthymic disorder (i.e., no major
depressive episode within the prior 6 months). Preliminary results in this underpowered trial found improvement across cells, with no statistically significant advantages
for any condition, although post hoc analyses showed some advantages for the pharmacotherapy cells (Markowitz 2003). Other studies at Cornell University are comparing IPT with supportive psychotherapy for double depression and IPT plus Alcoholics
Anonymous (AA) meetings with supportive psychotherapy plus AA meetings for
chronically depressed patients with secondary alcohol abuse.
Browne et al. (2002) conducted one of the largest psychotherapy studies ever, treating 707 patients with DSM-IV (American Psychiatric Association 1994) dysthymic dis-
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order. Most patients (68%) were women with a mean age in the early 40s. Half had
early-onset (before age 21) dysthymic disorder, a third had current double depres
sion, and two-thirds had a history of double depression. Patients were randomly assigned to receive sertraline (50–200 mg/day) alone, IPT alone, or combined IPT plus
sertraline. The median dosage of sertraline was 100 mg/day in the sertraline-only
group and 150 mg/day in the combined treatment cell. Treatment dosage in this com
munity study was not fully balanced; IPT treatment (not adapted as described above)
consisted of up to 12 (mean=10) 1-hour sessions over 6 months, whereas sertraline
treatment usually endured for the 2 years of the study. Thus, the study compared
acute psychotherapy with acute and maintenance pharmacotherapy.
Treatment outcome considered both symptoms and economics. Response was defined as a 40% or greater decrease on the Montgomery-Åsberg Depression Rating Scale
(Montgomery and Åsberg 1979). (Many studies require a 50% decrement for response.)
Of the 586 patients completing the 6-month acute phase, 60% of the sertraline-alone,
58% of the combined treatment, and 47% of the IPT-alone patients met response criteria.
Sertraline, alone or combined with IPT, was significantly more efficacious than IPT
alone. At the 2-year follow-up (N=525), IPT continued to lag in outcome, but both IPT
groups had lower health and social services costs than did the sertraline-alone group,
making the combination of IPT and sertraline most cost-effective. Concomitant IPT also
decreased the likelihood of patients discontinuing their sertraline (Browne et al. 2002).
The first of these studies was underpowered. The second was large but included no
control condition and a dosage imbalance between IPT and pharmacotherapy. The
two trials did not provide definitive evidence of the utility of IPT for chronic and per
sistent depression but suggested that its benefits may be modest (Markowitz 2003).
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Interpersonal Counseling for Subsyndromal Depression
Many primary care patients report psychiatric symptoms, but their symptoms do not
meet full criteria for a psychiatric disorder. Their symptoms can be debilitating and,
if ignored or misdiagnosed, may result in wasted use of medical procedures (Wells et
al. 1989). Interpersonal counseling is a truncated form of IPT, designed for use by medical personnel without formal psychotherapy experience to treat distressed primary
care patients whose symptoms do not meet full criteria for psychiatric syndromes. In
terpersonal counseling was initially a one- to six-session intervention for nurse practitioners. The first session lasts up to 30 minutes; subsequent sessions are briefer.
The interpersonal counseling therapist assesses the patient’s current functioning,
recent life events, occupational and familial stressors, and changes in interpersonal relationships. Such events provide the context in which emotional and bodily symptoms
presumably occur. Klerman et al. (1987) randomly assigned 128 primary care clinic pa
tients who scored 6 or higher on the Goldberg General Health Questionnaire (GHQ) to
receive either interpersonal counseling or usual care. Over an average of 3 months, interpersonal counseling subjects, often after receiving only one or two sessions, showed
significantly greater symptom relief on the GHQ than did control subjects, especially
mood improvement. Interpersonal counseling subjects subsequently used more mental health services, implying new awareness of their psychiatric symptomatology.
Mossey et al. (1996), noting that subsyndromal depressive symptoms delayed the
recovery of hospitalized elderly patients, conducted a 10-session trial of interpersonal
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counseling for elderly hospitalized medical patients with minor depression. Patients
were seen for hour-long sessions flexibly adjusted to the patient’s medical status. Sev
enty-six hospitalized patients older than 60 years who had depressive symptoms on
two consecutive assessments but whose symptoms did not meet full criteria for MDD
were randomly assigned to receive either interpersonal counseling or usual care. Re
searchers also monitored a euthymic, untreated geriatric control group. Patients found
interpersonal counseling feasible and tolerable. After 3 months, assessments showed
nonsignificantly greater improvement on all outcome variables for interpersonal
counseling relative to usual care, whereas control subjects showed a slight symptomatic worsening. Rehospitalization rates were virtually identical (11%–15%) for the interpersonal counseling and euthymic control groups and significantly less than those
for the cohort in usual care (50%). Differences between interpersonal counseling and
usual care groups reached statistical significance at 6 months on depressive symptom
reduction and self-rated health but not physical or social functioning. The investiga
tors thought that 10 sessions was insufficient for some patients and that maintenance
interpersonal counseling might have been useful. Weissman et al. (2014) summarize
the interpersonal counseling literature.
In a fascinating study in an area of Uganda ravaged by poverty, HIV, and depression, Bolton et al. (2003) used a dilute version of group IPT to treat depressed women.
For lack of mental health professionals, treatment was conducted by local college
graduates trained in what might be considered a form of interpersonal counseling.
Researchers randomized assignment to either the interpersonal intervention or usual
care by village rather than by depressed individual. Despite potential cultural differ
ences, the interpersonal counseling group had a huge benefit relative to usual care,
which was apparently minimal treatment. That the treatment had benefits for the vil
lage as a whole, even for villagers who had not participated in groups, is impressive.
IPT proved transportable to this very different culture presumably because of its
practical, present-focused emphasis on interpersonal relationships and problems,
and because there was no need to teach what would have been an alien theory of cognition or unconscious drives, for example. This study sparked the application of interpersonal counseling for populations in other low-income countries.
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Other Formats
Wilfley et al. (2000) have defined group IPT as a treatment format. Swartz et al. (2004)
have tested IPT in a briefer, eight-session format for MDD with promising results.
Weissman (1995) has developed a handbook of IPT for patients that includes psychoeducation and worksheets. Its utility has not been formally researched.
Differential Therapeutics
If two treatments have shown efficacy in treating depression, for which patients will
one treatment likely yield a better outcome than the other? Outcome studies comparing
such treatments are beginning to identify factors that moderate, or predict, treatment
outcome (Table 24–4). The NIMH Treatment of Depression Collaborative Research Program, which compared IPT, CBT, and imipramine, suggested such moderating factors.
TABLE 24–4. Comparison of interpersonal psychotherapy (IPT) and cognitive-
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behavioral therapy (CBT)
Similarities
Common factors of psychotherapy
1. Sense of feeling understood (Relationship)
2. Framework for understanding (Rationale)
3. Hope and optimism (Remoralization)
4. Psychoeducation (Recognition)
5. Technique for getting better (Ritual)
6. Success experiences (Recovering control)
Common features of brief antidepressant psychotherapies
1. Manualized
2. Active
3. Time-limited (with comparable time courses)
4. Structured (CBT>IPT)
5. Here-and-now, current focus
6. Goals of self-assertion, mastery
7. Ultimate goal of new skills for prophylaxis
8. Can be combined with antidepressant medication
Technical similarities
1. Mobilizing patient to greater activity
2. Linking mood to activities and reactions to events, albeit with different emphases
3. Problem solving: “exploring options” vs. “empirical hypothesis testing”
4. Addressing “expectations” vs. “assumptions” about others
5. Role-playing
435 Interpersonal Psychotherapy for Depressive Disorders
Differences
IPT: medical model
CBT: homework
Focus on affect (IPT) vs. thoughts→affect (CBT); hence, more external vs. more intrapsychic
approach
Differential therapeutics of major depressive disorder: which works better for whom?
Predictor IPT if predictor is... CBT if predictor is...
Life events Present Absent
Social dysfunction (baseline) Low Very
Symptom severity (baseline) Higher Lower
Personality traits Obsessive Avoidant
Sotsky et al. (1991) found that Treatment of Depression Collaborative Research Program depressed patients with low baseline levels of social dysfunction responded well
to IPT, whereas those with severe social deficits (probably falling into the “interpersonal deficits” problem area) responded less well. In contrast, patients with greater
symptom severity and difficulty in concentrating responded poorly to CBT. Initial
greater severity of MDD and of impaired functioning predicted superior response to
high (interpersonal deficits)
436 The APA Publishing Textbook of Mood Disorders, Second Edition
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IPT and to imipramine. Imipramine worked most efficaciously for patients with difficulty functioning at work, likely 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).
In the trial of HIV-positive patients with depressive symptoms, IPT yielded a better
outcome than CBT (Markowitz et al. 1998a). This finding was not explainable by ther
apist adherence or competence, which was excellent for all treatments. Rather, IPT appeared to be a good “fit” for depressed HIV-positive patients, who had many of the
upsetting life events that IPT addresses. In contrast, CBT therapists were in the rela
tively difficult position of cautioning patients against “catastrophizing” despite the fact
that these patients faced catastrophic situations. Thus, the context of particular patients
may favor one therapy over another: patients without life events might fare better in
CBT than in IPT. Barber and Muenz (1996) studied patients who completed the Treatment of Depression Collaborative Research Program and found that IPT was more efficacious than CBT for patients with obsessive personality traits, whereas CBT worked
better for avoidant patients. These findings did not hold for all subjects entered in the
study (i.e., the intention-to-treat sample). Biological factors also may affect outcome:
abnormal electroencephalogram sleep profiles predicted significantly poorer response
to IPT than did normal sleep parameters (Thase et al. 1997). Frank et al. (1991) found
that psychotherapist adherence to a focused IPT approach may enhance outcome. The
replication and further elaboration of these predictive factors deserve ongoing study.
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Integration of Psychotherapy
and Pharmacotherapy
There has been a historic tension between psychotherapists and pharmacotherapists,
whose theories of psychopathology often conflict. Such is not the case for IPT. Pharma
cotherapy and IPT are easily combined and share a medical model of illness. From its
inception, IPT has been used both in contrast to and in combination with antidepres
sant medication. IPT therapists compare mood disorders to other medical diatheses,
such as hypertension, asthma, or diabetes, syndromes for which both pharmacological
and behavioral interventions are often combined. In similar fashion, patients with
mood disorders may benefit from pharmacotherapy, which relieves symptoms faster
and provides the best-tested protection against depressive recurrence and relapse, and
from IPT, which may help patients solve current life dilemmas, reduce external stressors, and strengthen interpersonal functioning.
The literature on combined treatment of depression with pharmacotherapy and
psychotherapy does not always show advantages for combined treatment, but combined treatment never fares worse than monotherapy. Many studies have been underpowered—treating too few patients to show a difference between already efficacious
monotherapies and their combination (Hollon et al. 2002). Because treatment with either medication or IPT frequently works well enough, combined treatment probably
should be reserved for more chronic, severe, or treatment-resistant patients (Rush and
Thase 1999). Some of the studies described earlier tested IPT in comparison to and in
combination with pharmacotherapy.
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de Mello et al. (2001) in São Paolo, Brazil, randomly assigned 35 dysthymic outpatients to receive either moclobemide alone or moclobemide plus 16 weekly sessions of
IPT. Both groups improved. There was a nonsignificant trend for greater improvement
on the HAM-D and Montgomery-Åsberg Depression Rating Scale in the combined
treatment group. Given the small sample size, the lack of statistically significant differences is not surprising, but the study at least hints that combined treatment might benefit chronically depressed patients.
Hellerstein et al. (2001) developed a manual for cognitive-interpersonal group therapy for chronic depression (CIGP-CD), a group therapy for dysthymic patients. As the
name suggests, CIGP-CD combines cognitive and interpersonal strategies, as well as
psychoeducation, in a group format. The researchers tested CIGP-CD in a pilot ran
domized trial for fluoxetine responders. Twenty male and 20 female subjects with
pure, early-onset DSM-III-R dysthymia were openly treated for 8 weeks with fluox
etine 20–80 mg/day (mean dosage=38 mg/day). Subjects who had a 40% or greater
decrease in HAM-D score and a Clinical Global Impression Scale score of 1 (very much
improved) were randomly assigned to either continued medication alone or medication plus CIGP-CD for 16 weeks. CIGP-CD groups of about 10 patients met weekly for
90-minute sessions. No significant group differences were seen on depressive symp
tom measures at follow-up. However, at 24 weeks there were trends (P=0.06) for increased further gains in the augmented group therapy condition over medication
alone in terms of global functioning (measured by Global Assessment of Functioning
Scale), personality functioning (on the Inventory of Interpersonal Problems and other
measures), and overall domains. Thus, again, an interpersonally based psychotherapy
may have increased benefits when added to medication for chronic depression.
Markowitz et al. (2005) compared 16 weeks of randomly assigned IPT, brief supportive psychotherapy, sertraline, and combined IPT-sertraline in a study of 94 patients with “pure” dysthymia (i.e., patients with chronic mood disorder but no history
of MDD). This study found sertraline alone or combined with IPT to have the best out
come, and IPT alone was not significantly more efficacious than supportive therapy.
These results, along with trials of other psychotherapies in the literature, suggest that
pharmacotherapy should be part of the treatment of persistent depression, with psychotherapy often a useful adjunct in helping patients who achieve euthymia to function better in that unfamiliar state.
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Conclusion
IPT began more than 40 years ago as a treatment for outpatients with MDD. IPT has
since repeatedly shown efficacy for such patients and has expanded its indications to
particular subtypes of depression. Future research should continue to define indica
tions for and limitations of IPT and explore its differential application in relation to and
in combination with other antidepressant treatments. The increasing spread of IPT
among mental health clinicians reflects these achievements but also poses challenges.
How will a treatment that has been delivered mainly by highly trained research therapists fare in clinical practice? The growing International Society of Interpersonal Psychotherapy (www.interpersonalpsychotherapy.org
standards for IPT as it spreads around the world.
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) is attempting to organize training
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