Psychodynamic and Interpersonal Psychotherapies
Abstract and Keywords
This chapter focuses on two widely used treatments for depression: dynamic therapy (DT) and interpersonal therapy (IPT). Although each has its unique theoretical conceptualization of depression and offers relatively distinct techniques to facilitate change within depressed patients, both center on adverse and disruptive interpersonal relationships with underlying maladaptive repetitive patterns and interpersonal schemas as main contributors to depression. In this chapter, we describe how each orientation conceptualizes depression, elaborate on specific techniques each treatment orientation offers, and summarize the available research on the efficacy of each paradigm for bringing about therapeutic change in depressed patients. We also review the literature on moderators of, and candidate mechanisms underlying, these documented effects. Finally, we discuss what is known and what is yet to be learned about DT and IPT for depression.
In the beginning, there was psychoanalysis! Slowly therapists began to develop less intense forms of therapy, that is, ones in which patients were seen less often. Such approaches are now called psychoanalytically or psychodynamically inspired psychotherapies. In modern times, psychotherapy researchers began investigating the efficacy of such psychotherapies, including manualized, time-limited ones.
There have also been tests of interpersonal psychotherapies, most prominently Klerman, Weissman, Rounsaville, and Chevron’s (1984) interpersonal psychotherapy (IPT). One of the first systematic attempts to test the efficacy of IPT was the famous NIMH Treatments for Depression Collaborative Research Program (TDCRP) of Elkin et al. (1989). This study investigated the efficacy of manualized cognitive therapy versus IPT. One of the reasons Elkin, Parloff, Hadley, and Audry (1985) introduced IPT was because it represented a manualized psychotherapy that can be considered dynamically inspired, especially with its focus on interpersonal relatedness and conflicts. Moreover, dynamic therapies (DTs) and IPT each differ from cognitive and behavioral models, which have garnered the most research attention in recent times. It is perhaps for these reasons that these two therapies, though quite distinct from each other, are often grouped together as they are in this volume. Like many other authors, we recognize that DT and IPT are different, and we discuss them in this vein in two different sections of this chapter.
There is no one unified theory of DT, but rather a variety of theories that have developed throughout more than a century. Nonetheless, it is possible to delineate fundamental principles across different DT theories. Most DTs recognize that people are not always aware of all of the reasons for their behavior, that facilitating the awareness of unconscious motivation is important in order to increase (p. 448) choices in life, and that this increased awareness can be facilitated through dynamic techniques, such as exploration and interpretation of avoided distressing thoughts, feelings, and fantasies (Barber, Muran, McCarthy, & Keefe, 2013; Summers & Barber, 2010). These principles are in line with the psychodynamic view of human beings as complex creatures whose experiences and actions are motivated by both conscious and unconscious motivations (Safran, 2012).
Like other therapists, dynamically oriented therapists are not only interested in alleviating the specific presenting symptoms; they also aim to work on the underlying roots of the patient’s current suffering in order to bring sustained change. In DT, these roots are conceptualized as originating in the tendencies through which individuals experience and view the world, which have been formed throughout their life by relationships with significant others (formative experiences). Some aspects of these relationships lie outside of the patient’s awareness, but can be delineated and explored through current relationships, especially through the relationship with the therapist, which may reflect the patient’s representations of significant others. The latter process is known as transference.
The Evolution of the Conceptualization of Depression from a Dynamic Perspective
Throughout the past century, many psychodynamic conceptualizations of depression have been offered. Freud (1917) focused on fantasized or actual loss and guilt over the loss, along with low self-esteem and failures in the attempt to restore self-esteem. Karl Abraham (1924) argued that those who suffered from low self-esteem in childhood were at risk of becoming depressed as adults when facing a new loss or disappointment. Other conceptualizations of depression focused on the role of internal mental processes and early infantile experiences of love and frustration that are projected onto the mother and then introjected (internalized) back onto the self. Kernberg (1992) described a punitive set of internal values that leads to unconsciously motivated self-defeating behaviors that result in suffering, the aim of which is to relieve feelings of guilt.
As should be clear based on the above brief examples of psychodynamic conceptualizations of depression, each psychodynamic theory for depression focuses on somewhat different aspects of the pathology, suggesting that there may be different layers of understanding as depression manifests differently across individuals. However, most DTs still share a core conceptualization of depression as originating from individual biological and temperamental factors, early attachment relationships, and significant experiences throughout life, which together influence a person’s perception of himself or herself and others. Consistent with these core psychodynamic conceptualizations of depression, Busch, Rudden, and Shapiro (2004) suggested two pathways that predispose a person to depression. In the first pathway, narcissistic vulnerability, or the tendency to react to mistakes and disappointments with a significant loss of self-esteem, results in sensitivity to perceived rejection by others. This perceived rejection triggers reactive anger toward the person who is judged to have caused the narcissistic injury. Such anger, though, results in the depressed person experiencing guilt and self-directed anger, which in turn lowers self-esteem further, thereby increasing the narcissistic vulnerability and promoting a vicious cycle that can eventually result in depression. In the second pathway the individual attempts to deal with the low self-esteem by a compensatory idealization of the self or others, which leads to disappointment when the self-imposed high standards are not met. This disappointment results in devaluation of the self and others, which decreases self-esteem further, resulting in a vicious cycle that can cause depression. This two-pathway conceptualization of depression has recently gained support in the literature, most notably with regard to the first pathway, which has been bolstered by studies showing a link between anger and depression (for a review see Busch, 2009).
Dynamic Interventions for Depression
DT interventions for depression address the vicious cycles outlined above that are thought to contribute to depression. However, the specific goals of DTs may differ according to the length of treatment. Long-term DT (LTDT) aims to change personality features that are assumed to increase the risk for depression, thereby attempting to reduce vulnerability to depression and, consequently, to prevent relapse and recurrence. Short-term dynamic therapy (STDT; usually lasting from 8 to 20 weeks) is a time-limited approach aimed at reducing specific symptoms rather than facilitating global or structural change. STDT focuses on gradually linking depressive symptoms to the core dynamics that are related to the described cycles, thereby reducing the negative consequences of the cycles (Busch et al., 2004). Although in clinical practice both LTDT and STDT are being used, most (p. 449) psychological research has studied STDT, and thus we describe it in more detail here.
Only more recently have variants of STDT been proposed that focus on specific psychiatric disorders such as depression (e.g., Busch et al., 2004; Luborsky et al., 1995; Summers & Barber, 2010). Most DT techniques can be arrayed along a continuum from “expressive” to “supportive” (Luborsky, 1984). Expressive techniques seek to facilitate patient insight and understanding of repetitive maladaptive interpersonal and intrapersonal patterns or conflicts. Expressive techniques include interpretations (linking patients’ experiences, behaviors, and thoughts to facilitate understanding of their interpersonal and intrapersonal patterns), and especially transference interpretations (aimed at facilitating patients’ understanding of their relationship patterns within the therapeutic relationship). Expressive techniques also include confrontation of self-destructive or aggressive behavior. Supportive techniques are intended to build the therapeutic alliance, and include empathic validation and affirmation, warmth, and understanding. These supportive techniques are commonly used in other, nonpsychodynamic therapeutic orientations. Other DT techniques include working with countertransference (the reactions of the clinician to the patient) as well as encouraging an attitude of curiosity and self-reflection toward one’s own train of thoughts, feelings, and behaviors, without the explicit use of homework (e.g., Busch et al., 2004; Summers & Barber, 2010).
The Efficacy of Dynamic Therapy for Depression
Although widely practiced, DT for depression has been less extensively studied than other psychotherapies, such as cognitive–behavioral therapies (CBT; Cuijpers, van Straten, Andersson, & van Oppen, 2008) but there is emerging research supporting its efficacy for a variety of disorders (Barber et al., 2013; Leichsenring et al. 2015). Currently, DT for depression has not met full, formal American Psychological Association (APA) criteria for a well-established empirically supported treatment, because there has not been a replication by a separate research group of any effective, manualized form of DT for depression (Connolly-Gibbons, Crits-Christoph, & Hearon, 2008). A recently proposed protocol has been developed that unifies the different psychodynamic approaches that have been studied in the treatment of depression (Leichsenring & Schauenburg, 2014). A test of this protocol could provide the basis for future replication. The available empirical literature on individual DT for depression (mainly STDT), as summarized in several recent meta-analyses, suggests individual DT is equivalent to other psychological treatments (e.g., CBT, antidepressants) in its effects on depressive symptoms and is superior to control conditions (Barber et al., 2013; Driessen et al., 2015; Leichsenring et al., 2015; Leichsenring & Rabung, 2011). Barber et al. (2013) further showed that the meta-analytic findings regarding the equivalence of DT to other active treatments was not moderated by the type of alternative treatment, number of sessions of DT, treatment duration, whether treatment was based on a manual, or age of the depressed population. Moreover, they found support, though based on only three studies, for the claim that combined DT and pharmacotherapy is more efficacious than pharmacotherapy alone. In sum, the existing literature suggests that individual DT is more efficacious than control conditions and does not differ in efficacy compared to alternative treatments. In addition, pending replication, Barber, Barrett, Gallop, Rynn, and Rickels (2012) showed that STDT was more effective than medication for ethnic minority men, though no differences were observed in women or in white men.
The Efficacy of Dynamic Techniques for Depression
Perhaps no less important than comparisons of treatment packages is research that aims to identify specific DT techniques that are associated with therapeutic change. Much of the research to date has focused on expressive techniques, whereas supportive techniques have received less attention, with the exception of the therapeutic alliance if this may be called a technique. Studies of expressive techniques suggest that they are beneficial when used competently (Barber, Crits-Christoph, & Luborsky, 1996), especially when interpretations are accurate and consistent with the patient’s dynamics (Crits-Christoph et al., 2013). In their comprehensive summary of the literature, Crits-Christoph, Connolly Gibbons, and Mukherjee (2013) suggested that the use of dynamic interpretations is related to positive therapeutic effects in DT, but that the use of transference interpretations at high levels is not therapeutic for certain patients. Some additional DT techniques, such as the exploration of affect (Slavin-Mulford, Hilsenroth, Weinberger, & Gold, 2011), have also received support.
(p. 450) Candidate Mechanisms of Change Underlying Dynamic Therapies
Mechanisms of change are actions that occur during therapy or changes that occur within patients that cause symptom reduction. The strongest evidence for a mechanism would involve demonstrations of a causal effect through manipulation. However, if researchers can establish temporal precedence and an association between changes in a candidate mechanism and subsequent changes in outcome, this would provide evidence of the importance of the candidate mechanism.
We cover four core candidate mechanisms of change in DT that have been examined in studies involving mostly depressed patients (e.g., Barber et al., 2013; Crits-Christoph et al., 2013; Safran, 2012). The first putative mechanism is related to the fostering of insight, or self-understanding, into unconscious conflict through the therapist’s interpretations and through the patient’s and therapist’s experiences in their here-and-now relationship. Studies suggest that changes in insight act as mechanisms of change in DTs. Specifically, increases in insight have been found to occur over the course of DT (e.g., Connolly Gibbons et al., 1999) and have been shown to relate to subsequent symptomatic change (e.g., Kivlighan, Multon, & Patton, 2000). One operationalization of the curative elements of insight emphasizes patients’ increased reflective functioning (the capacity to recognize and understand mental processes; Bateman & Fonagy, 2003). However, there is a need to explore further the conceptualization of this proposed mechanism of change in depression.
The second candidate mechanism is a patient’s increase in the flexible use of less dysfunctional and more adaptive psychological defenses (against anxiety in the internal world of the individual), and the use of better coping styles (against anxiety in the external world; Summers & Barber, 2010). Studies have revealed a decrease in the use of dysfunctional defenses and an increase in the use of adaptive defenses over the course of DT (e.g., Roy, Perry, Luborsky, & Banon, 2009), and these changes have been related to symptomatic change (e.g., Johansen, Krebs, Svartberg, Stiles, & Holen, 2011). A review of existing studies suggests that for patients with more severe Axis I disorders and/or personality disorders this second proposed mechanism may be more important in bringing about therapeutic change than in other populations (Crits-Christoph et al., 2013).
The third candidate mechanism is related to a decrease in the rigidity and maladaptive nature of interpersonal patterns. In DTs, the patient and therapist work on facilitating awareness of rigid interpersonal patterns, as well as their accompanying dysfunction and maladaptive nature. Indeed, studies show that following DTs, patients become less rigid in their interpersonal patterns (e.g., Crits-Christoph & Luborsky, 1998) and they show less interpersonal distress and better interpersonal functioning (Zilcha-Mano, Dinger, McCarthy, Barrett, & Barber, 2014). However, the association between changes in rigidity and symptomatic change (Gross, Stasch, Schmal, Hillenbrand, & Cierpka, 2007), as well as its specificity to DTs (Zilcha-Mano et al., 2014), has received less support. It may be argued that a moderate level of rigidity may imply a sense of coherence and consistency, and therefore may promote better functioning than does a very low level (McCarthy, Gibbons, & Barber, 2008).
The fourth candidate mechanism is the therapeutic alliance. The therapeutic alliance is commonly defined as the emotional bond established in the therapeutic dyad, the agreement between therapist and patient regarding the goals of therapy, and the degree of therapist–patient concordance regarding the tasks pertinent to accomplishing these goals (Bordin, 1979). Although perceived as a common element of effective psychotherapy across disorders and treatment orientations, the alliance construct originated in the psychodynamic literature (Bordin, 1979) and for decades received attention primarily from dynamic theoreticians and researchers (Muran & Barber, 2010). The association between the alliance and symptomatic change in DTs across 39 studies was found to be moderate in size (r = .28, Barber et al., 2013; see Horvath, Del Re, Flückiger, & Symonds, 2011, for similar findings across 190 studies from a variety of treatment orientations). Researchers have been addressing the meaning of this association and trying to examine the causal role of the alliance in symptomatic improvement. In a recent study, this association was found to be significant even while accounting for temporal precedence between alliance and symptoms throughout the course of treatment (Zilcha-Mano, Dinger, McCarthy, & Barber, 2014). From a relational standpoint, Safran and Muran (2000, 2006) have argued that development of the alliance, and the resolution of ruptures within it, lies at the very essence of change.
(p. 451) Discussion
Though much remains to be learned about DT for depression, the available literature suggests that it has a rich theoretical foundation that has evolved throughout more than a century. As outlined above, studies examining the efficacy of DTs have suggested that DTs are equivalent to alternative treatment (e.g., CBT, antidepressants) and superior to control conditions at termination and follow-up. Additionally, several core candidate mechanisms of therapeutic change that are at the heart of psychodynamic literature have been found to change throughout DT and to predict therapeutic outcomes. Moreover, important empirical work exists on techniques that facilitate change in these core processes. Taken together, the studies that have been conducted so far show promising support for DT for depression.
We now turn our focus to IPT (Klerman et al., 1984), which articulates a diathesis-stress formulation of depression on the assumption that interpersonal relationships are the basis of psychological functioning. Specifically, depression involves several predisposing, precipitating, and perpetuating factors, respectively including biological and social vulnerabilities (e.g., emotional dysregulation, poor attachments), adverse interpersonal life events (e.g., loss of a loved one), and inadequate social supports (e.g., restricted access to nurturing others).
IPT conceptualizes several specific interpersonal problems: (1) loss and grief, (2) interpersonal disputes (often stemming from incompatible expectations among interactants), (3) role transitions, and (4) interpersonal and communication deficits (often connected to isolation, anxiety, awkwardness, or shyness). Coupled with dispositional vulnerability and limited social support, stressors in any of these domains can promote interpersonal problems or psychiatric syndromes, including depression (Stuart, 2012). The most salient of these observable problems or patterns become the foci of treatment, with the goals of alleviating depressive symptoms and improving functioning by working through interpersonal problems related to loss, change, conflicts, or deficits while assisting patients to better use or recruit social supports.
IPT’s Treatment Processes and Techniques
IPT’s central aim is to examine relational contexts associated with the onset and maintenance of depression, as well as interpersonal challenges that may arise as a consequence of being depressed. As noted previously, it is this interpersonal focus that, for some, connects IPT to psychodynamic (PD) models (Stuart, 2012). Beyond this interpersonal foundation, though, the connections between IPT and PD treatment are less than clear, especially considering that IPT, in contrast to most DTs, is highly focused, is centered primarily on conscious processes, and does not address transference or countertransference directly. It is likely that a given IPT therapist’s training background has a large influence on how dynamic their application of IPT appears in practice. Such potential heterogeneity of IPT’s application is not surprising given that many techniques are used, and none is technically proscribed. The key to adherent IPT delivery is explicitly centering on modifying relationships as a means of ameliorating distress.
IPT’s acute phase is time limited (often 12–16 sessions) and consists of three phases. The first involves consciousness raising around the interpersonal context of one’s depression, as well as assigning the patient the “sick role” to view depression as an illness to be resolved. The second involves addressing one or two primary problem domains. A therapist might, for example, help a patient mourn or reframe a loss, increase adaptive assertiveness, or recalibrate expectations of self and others in relationships. The techniques to address these issues include analyzing distressing interpersonal incidents with communication analysis, attending to a patient’s affects to heighten motivation to change, and role-playing conflict resolution tactics. IPT is not concerned with how people defend against anxieties, but rather with interpersonal assets that can be used to improve relationships and prevent future anxiety-triggering events. Moreover, therapists help patients differentiate independent stressors over which they have no control and dependent stressors over which they have the control, responsibility, and power to change. The third IPT phase addresses termination; the patient and therapist process feelings about ending, review progress, and discuss plans to prevent relapse. This last phase may involve tapered session frequency. Following the acute phase, there is an option for patients to enter maintenance IPT (IPT-M). Although IPT-M continues to focus generally on interpersonal contexts, it specifically emphasizes possible triggers of new depressive episodes, reinforces skills learned, and allows an expanded number of interpersonal issues or domains to be addressed.
(p. 452) Acute IPT’s Efficacy
With over 200 studies demonstrating its acute efficacy, IPT is among the most robustly validated psychosocial therapies for depression. Meta-analyses reveal that acute IPT is superior to placebo and wait-list controls, and typically is comparable to antidepressant medication and other active psychotherapies, such as CBT (Cuijpers et al., 2011; Jakobsen, Hansen, Simonsen, Simonsen, & Gluud, 2012). A few studies suggest a short-term benefit of combining IPT and medication (e.g., Frank et al., 2000; Weissman, Klerman, Paykel, Prusoff, & Hanson, 1974).
Acute IPT Process Research
Despite acute-phase IPT’s general efficacy, limited data exist on factors that promote or detract from its effectiveness. Although such process research lags behind, some findings illuminate candidate characteristics of patients for whom IPT works best and potential factors that may account for the success of IPT in reducing depression.
For whom does IPT work?
Statistically, this question is addressed by examining potential moderators (baseline patient characteristics) of treatment differences in outcome. Several such moderator analyses have suggested subsets of patients for whom IPT has outperformed comparison conditions. Drawing on data from the TDCRP, IPT outperformed CBT for patients presenting with high dysfunctional attitudes that confer a risk for depression (Sotsky et al., 1991) and high levels of obsessiveness (Barber & Muenz, 1996). In a comparison of IPT and selective serotonin reuptake inhibitor (SSRI) pharmacotherapy, IPT led to more rapid remission for patients presenting with a high need for medical reassurance (Frank et al., 2011). In another study, patients who reported childhood trauma evidenced greater symptom reduction in medication treatment augmented with IPT versus medication alone (Zobel et al., 2011). Finally, patients who endured more severe life events prior to or during treatment responded more favorably to IPT or CBT than to pharmacotherapy (Bulmash, Harkness, Stewart, & Bagby, 2009).
Under other circumstances, comparison conditions have outperformed IPT. In the TDCRP, CBT outperformed IPT for patients presenting with high social dysfunction (Sotsky et al., 1991) and high levels of avoidance (Barber & Muenz, 1996). In other work, patients with severe or endogenous depression responded better to combined IPT and medication treatment versus IPT alone in one study (e.g., Prusoff, Weissman, Klerman, & Rounsaville, 1980) and to CBT versus IPT in another (Luty et al., 2007). For patients with low psychomotor agitation, SSRI treatment was more advantageous than IPT (Frank et al., 2011). In two other studies, CBT was more effective than IPT for patients with comorbid personality disorders (Carter et al., 2011; Joyce et al., 2007). In one study, there was greater symptom reduction in CBT versus IPT for patients with high attachment avoidance (McBride, Atkinson, Quilty, & Bagby, 2006). In sum, the existing literature suggests that there are certain subsets of patients for whom IPT is more or less effective than an alternative treatment. However, because such moderator studies are few in number and generally require replication, clinical translation must be made cautiously.
How does IPT work?
This question is one of mechanism. To date, no research has identified therapy actions or changes within patients as IPT mechanisms or their mediator proxies. However, some work has demonstrated correlations of during-treatment IPT processes and patient changes with outcome. As defined above, these variables are candidate mechanisms worthy of further study.
In terms of during-treatment dyadic process, a positive alliance has been related to better treatment outcome (e.g., Krupnick et al., 1996). In terms of therapist behaviors, greater warmth has been linked to a reduction in depression and improved social functioning, whereas use of exploratory interventions also was related to a reduction in depression (Rounsaville et al., 1987). In addition, adherence to and competent delivery of IPT interventions have been linked to symptom reduction (e.g., Crits-Christoph, Connolly Gibbons, Temes, Elkin, & Gallop, 2010). Regarding patient changes during therapy, one study showed a positive association between greater intimacy seeking with their therapist and outcome (Ablon & Jones, 1999). In other studies, the following changes related to positive IPT outcomes: reductions in interpersonal problems (e.g., Ravitz, Maunder, & McBride, 2008), reductions in attachment anxiety and avoidance (Ravitz et al., 2008), and improved marital adjustment (Whisman, 2001).
Other possible change mechanisms in IPT can be gleaned from research that shows that change in certain variables takes place following a course of treatment, even though the relation between the changed variable and the reduction in depression has not been reported in the literature. Examples of such variables are social adjustment (e.g., O’Hara, (p. 453) Stuart, Gorman, & Wenzel, 2000), dyadic adjustment (O’Hara et al., 2000), interpersonal communication (Weissman et al., 1974), sociability (Cyranowski et al., 2002), anxiety (Weissman et al., 1974), and self-esteem (Prusoff et al., 1980). As such, these variables are also plausible candidates for—and therefore good targets for research regarding—the mechanisms through which IPT for depression may work.
IPT’s Efficacy in Preventing Recurrence in Depression
Efficacy of acute IPT in preventing recurrence.
After IPT’s inaugural controlled trial of 4-month acute treatment (Weissman et al., 1979), the researchers conducted an uncontrolled, naturalistic 1-year follow-up (Weissman, Klerman, Prusoff, Sholomskas, & Padian, 1981). At the follow-up, depression and global clinical symptoms were comparable among patients treated acutely with IPT alone, pharmacotherapy alone (amitriptyline), combined IPT and pharmacotherapy, or uncontrolled usual care. However, patients who received IPT, either alone or in combination with medication, demonstrated better social functioning relative to patients in the other conditions.
In the TDCRP, there was an 18-month naturalistic follow-up to the 16-week acute treatment phase (Shea, Elkin, Imber, & Sotsky, 1992). Among acutely recovered patients, there were comparable relapse rates at follow-up [IPT: 33%; CBT: 36%; imipramine: 50%; placebo plus clinical management (CM): 33%]. Because follow-up was naturalistic, it is impossible to make between-group claims or causal attributions about the durability of acute treatment effects; however, the finding does suggest that 16 weeks of any of the acute treatments was insufficient for one-third or more of the patients to maintain their recovered status. There was, however, one significant between group difference at follow-up; consistent with the study of Weissman et al. (1981), IPT and CBT patients reported higher relationship quality than medication and placebo patients (Blatt, Zuroff, Bondi, & Sanislow, 2000).
In another study focused on the durability of 5-week acute IPT plus pharmacotherapy versus pharmacotherapy plus CM for depressed inpatients, IPT patients evidenced more sustained remission over a 5-year follow-up than did the CM patients (Zobel et al., 2011). These rates, though, were just 28% and 11%, respectively. Thus, these brief inpatient treatments left much to be desired in terms of long-term durability (even more so than more typical length acute IPT).
Efficacy of IPT-M in preventing recurrence.
The initial IPT-M trial centered on patients who responded to at least 16 sessions of acute IPT and imipramine, and who remained stabilized during 17 weeks of continuation (Frank et al., 1990). These patients were then randomly assigned to monthly IPT-M alone, imipramine alone (same daily dosage as acute phase), placebo alone, monthly IPT-M plus imipramine (same daily dosage as acute phase), or monthly IPT-M plus placebo. Each patient’s maintenance phase was 3 years or until recurrence of depression. Analyses of the mean time to recurrence indicated 82 weeks for IPT-M alone patients and 74 weeks for IPT-M plus placebo patients. Although this indicated a significant prophylactic effect of the psychotherapy conditions, imipramine’s significant prophylactic effects were stronger at 131 weeks with IPT-M and 124 weeks without IPT-M. The findings, however, must be interpreted cautiously given that the IPT’s maintenance dosage was reduced, whereas the imipramine dosage stayed constant. Thus, it could be argued that the maintenance phase, relative to the acute phase, was an unfair comparison that inherently favored same dosage medication versus less intense IPT.
Related to the dose question, another trial focused on whether the frequency of IPT-M sessions influenced prevention of recurrence (Frank et al., 2007). In a 12- to 24-week acute phase of this trial, women received IPT to remission; if they did not meet remission criteria, they received IPT augmented with an SSRI to remission. Those who failed to remit with combined treatment were withdrawn from the study and were referred elsewhere. Remitters who maintained this status over a continuation phase (which included discontinuation of medication for those who had required the SSRI) were then randomized to IPT-M alone at weekly, biweekly, or monthly dosages for 2 years or until a recurrence of depression occurred. For patients who received IPT only during the acute phase, there was a recurrence rate of 26% during maintenance. Notably, IPT-M frequency did not affect time to recurrence with this subgroup, suggesting that more intensive IPT-M was no more effective in maintaining remission than monthly IPT-M. For patients who needed an SSRI added to their acute IPT to achieve initial remission, there was a recurrence rate of 50% during maintenance. That half of these patients did not maintain their remission status suggests that IPT alone is not an effective strategy (p. 454) for them. It is plausible that these patients would require a maintenance strategy that mimicked their combined acute phase treatment.
In a study focused on IPT-M for late life depression, there appeared to be a benefit for combined maintenance treatments (Reynolds et al., 1999). For patients who recovered from acute and continuation IPT plus nortriptyline, relapse rates were 90% for maintenance placebo plus CM, 64% for monthly IPT-M plus placebo, 43% for maintenance nortriptyline plus CM, and 20% for monthly IPT-M plus nortriptyline (all active conditions outperformed placebo, and IPT-M plus nortriptyline was significantly more efficacious than IPT-M plus placebo and showed trend level superiority over maintenance nortriptyline plus CM). This same research group examined the comparative efficacy of four maintenance strategies for even older patients (≥70 years) who had responded to acute IPT plus paroxetine (Reynolds et al., 2006). Recurrence rates were 68% for placebo plus IPT-M, 58% for placebo plus CM, 37% for paroxetine plus CM, and 35% for paroxetine plus IPT-M (paroxetine plus IPT-M outperformed placebo plus IPT-M and placebo plus CM; paroxetine plus CM outperformed placebo plus IPT-M and to a trend level placebo plus CM). Thus, for later life depression, the evidence suggests that when IPT-M is used, medications should also be maintained.
IPT-M Process Research
There is limited process research on IPT-M. However, some studies have implicated a few moderators and predictors. In one test of moderation, patients with a high delta sleep ratio (a marker of biological vulnerability) demonstrated a longer time to recurrence following IPT-M relative to medication maintenance alone (Kupfer, Frank, McEachran, & Grochocinski, 1990). In another test, patients with lower cognitive performance (across the domains of attention, conceptualization, construction, initiation/perseveration, and memory) had a longer time to recurrence in IPT-M versus maintenance CM (Carreira et al., 2008).
Several studies have examined patient predictors as risk factors for recurrence of depression. For example, in one study, patients with more variability in their symptoms of depression across all forms of maintenance treatment (i.e., the five conditions in the study of Frank et al., 1990) had a greater recurrence risk (Karp et al., 2004). Based on data from the IPT-M dose study of Frank et al. (2007), persistent insomnia (Dombrovski et al., 2008) and having experienced more life stressors (Lenze, Cyranowski, Thompson, Anderson, & Frank, 2008) were related to a greater recurrence risk. Drawing on the data of Reynolds et al. (2006), residual anxiety and sleep disturbance conferred a greater risk for recurrence across maintenance treatments (Dombrovski et al., 2007). One study examined how patterns of acute response predicted differential response to different maintenance treatments (Dew et al., 2001). Drawing on the data of Reynolds et al. (1999), the authors found that rapid acute responders had less recurrence risk with active treatment (i.e., IPT-M, medication, or the combination of IPT-M and medication) relative to placebo. For mixed and delayed acute responders, only combined maintenance treatment outperformed placebo. Finally, for prolonged acute nonresponders, none of the maintenance treatments proved helpful (i.e., there were no between-group differences in time to recurrence).
Several studies have examined IPT-M processes as predictors of the recurrence of depression. In one study drawing on data from Frank et al. (1990), higher interpersonal focus was related to longer time to recurrence (Frank, Kupfer, Wagner, McEachran, & Cornes, 1991). In another study using data from Reynolds et al. (1999), IPT-M was more helpful than maintenance placebo plus CM when treatment focused specifically on the interpersonal domain of role conflict (Miller, Frank, Cornes, Houck, & Reynolds, 2003).
The extant literature indicates that acute IPT is efficacious; it is a first-line psychosocial treatment that outperforms placebo and wait-list control conditions, and is comparable to treatment with antidepressant medications and other first-line psychotherapies, such as CBT. Thus, when possible, IPT can be offered to depressed patients, along with other evidence-based treatments, to facilitate informed treatment decision making in line with preferences and treatment beliefs. There is some research to suggest that IPT-M, at varied frequencies, can be used to prolong wellness and delay recurrence of depression for patients who remitted initially with IPT only. However, for patients who require medication to achieve initial remission or who are being treated for depression in later life, receiving IPT-M may not be sufficient to delay recurrence. Although much remains to be learned about the most optimal conditions under which (p. 455) IPT works, and the mechanisms responsible for its effects, some preliminary research has pointed to various efficacy moderators and predictors of response (i.e., candidate mechanisms) for both acute and maintenance IPT.
Although the results of studies on both DT and IPT have been promising, it is important for future research to examine the effectiveness of DT and IPT in large, naturalistic samples (see Barber, 2009), as well as in carefully conducted randomized trials. Moreover, additional research is required to inform clinicians of the conditions under which DT and IPT are the best alternative, specific ingredients that cause change, ways in which DT and IPT strategies can be integrated with other strategies at the most effective times, and the goodness of fit between patients and the therapists delivering these forms of treatment. Thus, substantial growth in research on DT and IPT’s moderators, mediators/mechanisms, integration, dyad matching, and training/dissemination is needed for these approaches to achieve their full potential in clinical practice.
The review of the existing theoretical or empirical literature on DTs and IPT in this chapter is not comprehensive. Additionally, it should be noted that the distinction made in this chapter between DT, IPT, and other treatments is somewhat superficial, as many treatments integrate techniques from different orientations. Nonetheless, IPT and DT each has its own unique qualities. Advancing our knowledge on the processes of DTs and IPT (and other interpersonal treatment variants) will increase our ability to further develop treatments, make them more effective, and customize them for the needs of specific individuals.
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