Interpersonal Psychotherapy

Dr Paul Wilkinson
University Lecturer and Consultant
Child & Adolescent Psychiatrist
IPT-UK Accredited IPT Therapist
University of Cambridge
IPT Why?
A NICE-recommended treatment for
moderate to severe depression

1
st
line for adolescents
2
nd
line for adults
Contents
1. What is IPT?

2. What is the evidence?

3. Brief case example

4. How to become an IPT therapist
1. What is IPT?
History
A manualised synthesis of what was
thought to be good 1:1 therapy for
depressed individuals
Not based on complex theory

Key people
Gerald Klerman
Myrna Weissman
John Markowitz
Laura Mufson (adolescents)

IPT The Basics
1:1 psychological therapy
Often uses parental support

Short-term
16 sessions for adults
12 sessions for adolescents

Designed for depression
Used in bulimia, bipolar disorder, PTSD,
borderline personality, HIV, dementia..
Not CBT

Not counselling

Not a placebo
Negative
Automatic
Thoughts
Emotions
Physiological
Symptoms
Behaviours
Dysfunctional Conditional
Assumptions
Core Beliefs
Cognitive
Behavioural
Therapy
Interpersonal Therapy
Emotions / Affect
Interpersonal
Relationships
IPT - Structure
1. Initial Phase
Interpersonal Inventory
Choose a problem area

2. Middle Phase
Intensive work on the problem area

3. Termination Phase
1. Initial Phase
Confirm diagnosis of depression

Psychoeducation, sick role

Life event details
Interpersonal Inventory
Intensive exploration of interpersonal network
Important people
Details of relationship
Frequency, quality, type of contact
Emotional support (confiding)
Social companionship (fun)
Practical support (help)
How satisfied is each member?
Expectations
Reciprocity
Agree a Problem Area
Grief
Role transition
Interpersonal disputes
Interpersonal sensitivity (deficits)
(Single parent family)

Set clear collaborative goals
2. Middle Phase
Use specific strategies to help the patient
negotiate their interpersonal difficulties
more successfully

Within problem area(s)

Interpersonal Therapy
Emotions / Affect
Interpersonal
Relationships
Specific Techniques 1
Depend on the problems
Recognise emotions and affect
And express them
Communication skills
Communication analysis
Express their unhappiness with situation
Clarify expectations
Deal with disputes
Specific Techniques 2
Form balanced view of past and future
Develop a positive future
Problem solving
Role play
Modelling
Some use of transference

3. Termination Phase
Review useful strategies from middle
phase
Encourage mastery of the new skills
Think about warning signs for relapse
Identify techniques to deal with these
Explicitly discuss feelings about ending
Contrast grief with depression
Ending
Explicit contract at start
IPT is the learning of new techniques,
designed to persist after ending
Can discharge after the final session
?Reviews to check still not depressed
Booster IPT sessions
Eg after 1 and 3 months
Establish focus in advance
Maintenance IPT
Eg every 2 months for 1 year
Commonly needed if IP Sensitivities
To consolidate improvement
Discuss how problems were dealt with,
and think of ways to do so differently in
future (if necessary)
A positive move: Taking the armbands off
IPT vs CBT
IPT is simpler

So cannot be used in as many situations
OCD, anxiety, psychosis.

Some patients find CBT quite difficult, and
find IPT easier to understand
2. What is the Evidence?
Adults
1. Boston-New Haven Study, 1979
81 adults
16 weeks
Randomised to:
IPT alone
Amitriptyline alone
IPT plus amitriptyline
Nonscheduled control
DiMascio et al, 1979
Arch Gen Psych 36: 1450-6
Results
No difference between IPT and AMI
IPT and AMI each better than control
Combined treatment better than
monotherapy

At 1 year, psychosocial functioning better
in IPT groups than other groups
2. NIMH TDCRP Study, 1989
250 depressed adults
16 weeks
Randomised to:
IPT
CBT
Imipramine
Placebo
Elkin et al, 1989
Arch Gen Psych 46: 971-82
Results
No difference for mild depression
HAM-D <20

For moderate-severe depression
Imipramine the most superior to placebo
IPT better than placebo
CBT not significantly better than placebo
No significant difference between IPT and
CBT
3. Systematic Review, 2005
IPT superior to placebo (9 studies)

IPT plus medication not superior to
medication alone
Acute, maintenance or prophylactic

IPT significantly better than CBT

De Mello et al, 2005
Eur Arch Psychiatry Clin Neurosci 255: 75
4. Most Recent CBT vs IPT, 2007
177 depressed adults
Randomised to CBT or IPT

No difference for mild-moderate
depression
MADRS < 39
CBT better for severe depression
CBT better if personality disorder
Luty et al; Joyce et al, 2007
BJPsych 190: 496-502 & 503-508
Adolescents
1. Mufson et al, 1999
48 adolescents, New York, MDD
No OCD, active suicidality, substance
use, CD
Random allocation to:
12 sessions weekly IPT
Clinical monitoring every 2-4 weeks
IPT better than clinical monitoring

Mufson L et al, 1999
Arch Gen Psychiatry 1999;56(6):573-9.
2. Rosello & Bernal, 1999
71 subjects, Puerto Rico
Aged 13-18
RCT of IPT vs CBT vs waiting-list control

Both CBT and IPT better than control
No sig difference between CBT and IPT

Rossello J, Bernal G., 1999
J Consult Clin Psychol 67:734
3. Mufson et al, 2004
63 adolescents, New York
MDD or dysthymia, adjustment disorder
Mean CGAS 53 (similar to TADS)
Mean age 15.1
Exclusion: active suicidal ideation,
psychosis, substance use

Mufson L, et al, 2004
Arch Gen Psychiatry 61: 577
Treatments
All treatment by mental health workers in
school clinics
IPT:
12 sessions over 16 weeks
In school
Treatment as usual
Supportive counselling
As normally given by school MHW
Results

IPT better than TAU

Greater differences between treatments in
some sub-groups:
Older (15-18) vs younger
More severe depression vs less severe
Conclusions
IPT-A better than active counselling
May be more effective if:
Depression moderate as opposed to mild
Older adolescents
Effective IPT can be delivered by trained
tier 1/2 professionals
3. A Case History
The Patient John
16 year old boy
Depressed 1 years
Gradual onset since death of aunt
No significant problems before then
Under Cambridge CAMHS 10 months,
little change
CBT
Family therapy
Brief trial of fluoxetine
The Problem Area?
Grief
Role transition
Interpersonal disputes
Interpersonal sensitivity (deficits)

Next stage?
Interpersonal Inventory
Repeated pattern of IP interaction:
When people do things he finds difficult:
Doesnt know what he feels
Doesnt know what he and the other should do
Very hard to be angry
Difficult to tell people how they have made him feel
After aunt died, some people acted in ways
he wished they hadnt
Hard to be angry
Hard to tell them
Left with difficult, unidentifiable emotions

Formulation
Lifelong maladaptive pattern of
interpersonal passivity
Poor emotional literacy
Caused no problems when life was good
When bereaved, this interfered with
normal bereavement process and he
ended up depressed
It maintained the depression
The Problem Area
Grief not an issue
Interpersonal sensitivity
Long-term maladaptive interpersonal
functioning
IP sensitivity must be addressed to get out
of depression
And decrease risk of relapse
Goals
1. John to be able to tell me how he has
felt in difficult situations regularly
2. John to feel comfortable about feeling
angry 50% of the time he feels like this
3. John to have one occasion during
therapy when he talks to someone about
something theyve done, that he finds
difficult, and feels less awkward than in
past
20 sessions
Middle Sessions
1. Tie emotions to specific interpersonal
events
Initially did it in sessions, then did at the
time
Started to recognise anger
Discussions about anger
Good vs bad
Angry feelings vs angry actions

2. Maintain interpersonal activity
Friends started 6
th
form, he didnt
Stay in touch with friends
Get a job
3. Use anger
Became comfortable with angry feeling
Tells him he has been upset by someone
Act appropriately
4. Success!
Several situations where:
People upset John
John felt angry
John told them how he felt, and what he
wanted
The other then acted better
John felt better!
People treated him better!!
Termination
Review of progress
Directly addressed feelings at termination
John tried to avoid
We used the transference
Gradually increasing confidence he can
act more assertively
Move to 2 monthly maintenance
Security blanket
Maintenance
Gradually increased support network
Used it appropriately and sensitively
Coped with major stressors without being
depressed
Recognised subtle emotions
Told people when they upset him
Able to mentalise
Increased confidence in ability to cope
4. How to be an IPT Therapist
IPT is simpler than CBT

So training is simpler

IPT Therapist
Attend initial training course
4-5 days
Leicester, Edinburgh, UCL
http://www.annafreudcentre.org/shortcourses.php?id=
115

2 intensively-supervised cases
Tape every session
Supervision after most sessions
Must be appropriate IPT case
Adult/Older adolescent with depression

Maintain skills
IPT Supervisor
8 further supervised cases
At least 2 cases from each problem area

Or 4 further intensively supervised cases

Supervisor training course
Further Information
http://www.interpersonalpsychotherapy.org/
http://www.interpersonalpsychotherapy.org.uk/

Clinicians Quick Guide to Interpersonal
Psychotherapy
Weissman et al, 2007, Oxford University Press
Interpersonal Psychotherapy for Depressed
Adolescents
Mufson, L. et al, 2004, Guilford Press, New York

Contact me: pow12@cam.ac.uk
Questions / Discussion
Summary to follow
Summary
IPT is an individual short-term
psychological treatment for depression
IPT is effective for depressed adults and
adolescents
IPT is simple
IPT looks at:
Improving interpersonal functioning
Recognising emotions