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Human Nature Review 2002 Volume 2: 338-339 ( 21 August )
URL of this document http://human-nature.com/nibbs/02/ipt.html
Comprehensive Guide to Interpersonal Psychotherapy
by Myrna M. Weissman, John C. Markowitz, and Gerald L. Klerman
New York, Basic Books. 2000.
Reviewed by Christopher Dowrick, Professor of Primary Medical Care, University of Liverpool, UK.
Interpersonal psychotherapy (IPT) has an impressive pedigree. Two of the authors of this text have international reputations in academic psychiatry - Myrna Weissman has a major corpus of work in the field of psychiatric epidemiology, much of it with her late husband Gerald Klerman, who wrote one of the most interesting papers it has ever been my pleasure to read 1. It is therefore exciting to see that they are also innovators in the field of therapy.
IPT is based on the premise that psychiatric syndromes such as depression usually occur in a social context: a marriage or a friendship breaks up, children leave home, a loved one dies or a job is lost. The unit of observation and intervention is the primary social group, the immediate face-to-face involvement of the individual with one or more significant others. In IPT patients learn to understand the relationship between the onset and fluctuation in their symptoms and what is currently going on in their lives - their current interpersonal problems. The therapist sets a treatment contract with the patient, in which they agreeing to focus on two or three key problem areas. The four interpersonal problem areas are grief, interpersonal role disputes, role transitions and interpersonal deficits (loneliness or social isolation). Over the course of some twelve or fourteen sessions, the patient is helped to develop new ways of dealing with their interpersonal problems, with particular emphasis on emotionally charged incidents, and thereby to reduce their depressive symptoms. Techniques include the use of opening questions geared to recent events, communication analysis, exploration of patients’ wishes and options, decision analysis or role playing.
IPT is usually offered to people suffering from depressive disorders. Modified programmes have also been devised to use with depressed adolescents, couples involved in marital disputes, and for depressed HIV-positive patients.
Interpersonal therapy was evaluated in a randomised controlled trial conducted with 250 depressed outpatients by the US National Institute of Mental Health. The trial compared the efficacy of IPT with the antidepressant drug imipramine, cognitive behavioural therapy, and placebo: all treatments were given for 16 weeks. At the end of treatment medication was found to be more effective than the two psychotherapies, while the psychotherapies were more effective than placebo, particularly among symptomatic and impaired patients 2. Eighteen months after the end of treatment there were no significant differences in recovery pattern between the four treatment groups, and over a third of those who had initially recovered subsequently relapsed 3. Monthly maintenance IPT sessions are able to delay the recurrence of depression by over a year, and longer if offered in combination with antidepressant medication 4.
IPT therefore has a genuine contribution to make to the treatment of depression. This is important to recognise at a time when the proliferation of antidepressant drug treatment appears to be endless, and when we know that many patients would prefer to receive (effective) treatments that do not involve the use of drugs. However IPT is not the only kid on the block. Cognitive behavioural therapy, problem-solving treatment and group psycho-education have all been positively evaluated in recent well conducted randomised controlled trials, and even non-directive counselling is now showing evidence of efficacy in the treatment of depression in primary care settings 5,6.
All of these interventions demonstrably confer short term benefits for patients with depressive disorders in primary care or community settings, although the evidence in favour of non-directive counselling is less comprehensive than for the other interventions. There is also health economic evidence, in most cases, at least for cost equivalence. In cases of depression the benefits appear to be as strong as for antidepressant medication. Compared with drug therapy, psychosocial interventions are less likely to produce negative side effects, although careful consideration of training and supervision of therapists is important to ensure quality standards. On the issue of which of these interventions should be offered to patients, the evidence of broadly equivalent efficacy suggests that other factors may be brought into consideration. Patient acceptability is clearly of paramount importance, and both non-directive counselling and problem solving treatment perform well on this dimension. Relative cost-effectiveness may give IPT the edge against cognitive-behavioural therapy, in terms of therapist training costs. However on this basis IPT is probably less cost-effective than problem solving treatment and group psycho-education, both of which use considerably fewer sessions.
1. Klerman G. L. The current age of youthful melancholia. British Journal of Psychiatry 1988, 152, 4-14.
2. Klein D., Ross D. Reanalysis of the National Institute of Mental Health Treatment of Depression Collaborative Research Program general effectiveness report. Neuropsychopharmacology 1993, 8, 241-251.
3. Shea M., Elkin S., Imber D. et al. Course of depressive symptoms over follow-up: findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Archives of General Psychiatry 1992, 49, 782-787.
4. Frank E. Interpersonal therapy as a maintenance treatment for patients with recurrent depression. Psychotherapy 1991, 28, 259-266.
5. Ward E., King M., Lloyd M., et al. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: Clinical effectiveness. British Medical Journal 2000, 321,1383-8.
6. Dowrick C., Dunn G., Ayuso-Mateos J., et al. Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. British Medical Journal 2000,321,1450-4.
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© Christopher Dowrick.
Dowrick, C. (2002). Review of Comprehensive Guide to Interpersonal Psychotherapy by Myrna M. Weissman, John C. Markowitz, and Gerald L. Klerman. Human Nature Review. 2: 338-339.