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Developing interpersonal psychotherapy.pdf

Developing Interpersonal Psychotherapy (IPT) in Gloucestershire

Introduction

This paper describes IPT; its evidence base and uses. It also explains how IPT has
been developed in Gloucestershire so far and sets out a vision for the future.
What is IPT?

IPT is a short to medium term, manualised psychological therapy that was originally
devised for the treatment of depression within randomised controlled trials of anti-
depressants versus psychotherapy1. It focuses on changing current interpersonal
relationship problems. The therapy consists of 3 phases conducted weekly over 12-16
sessions.
Phase 1

Phase 1 is essentially a period of assessment and formulation, but IPT for depression
permits education of the patient regarding depression and its effects, as well as initial
advice about management of symptoms and anti-depressant medication. The patient is
orientated to the treatment, given the “sick role” and then a thorough inventory of
their relationships is undertaken. Interpersonal problems are related to periods of
depression and the therapist negotiates that a small number of difficulties become the
focus of the remaining therapy.
IPT conceptualises interpersonal problems in one of four ways:
Grief – unresolved grief following the loss of an important person.
Interpersonal Disputes – conflicts between individuals regarding differing
expectations, either overt or covert.
Role Transition – difficulties experienced adapting to changes in role throughout the
stages of life. This could include divorce, cha nge of job, home etc.
Social Deficit – the absence of any socially supportive relationships.
Phase 2

During phase 1, the therapist asks a series of questions to elicit information. In phase
2, the emphasis is on the patient to take the lead discussing the agreed problem areas.
The therapist is active in encouraging the patient to explore issues in detail and to
consider alternative ways to bring about change. The therapist style is non-directive,
but actively maintains the focus on the agreed topics.
Phase 3
Consists of the final 3 sessions, which are spaced at fortnightly intervals. Progress is reviewed, and relapse prevention discussed. Has IPT been adapted for other conditions?

IPT has been adapted for several other conditions including bulimia nervosa, binge
eating disorder, anorexia nervosa, social phobia, anxiety disorders, borderline
personality disorder and substance abuse2, 3. Although IPT was originally intended for
the treatment of acute depression, it has also been developed with specific populations
i.e. depressed adolescents, depressed older people, bi-polar disorder and as a
maintenance treatment for people with chronic relapsing depression2, 3.

What evidence is there for its effectiveness?

Depression – IPT has been shown to be an effective treatment for major depressive
disorder, equalling the effects of CBT4.

Bulimia nervosa –
IPT is an effective treatment for bulimia nervosa. It acts less
rapidly than CBT, but achieves similar effects at one- year outcome5.
Binge eating disorder – IPT achieves similar results to CBT5.

Why is IPT relevant to Gloucestershire mental health services?

A report on psychological services within the NHS supported the use of IPT for
depression and bulimia nervosa6. NICE are currently looking at eating disorders and
will be considering depression later this year7, 8. Given the evidence base for IPT for
these two disorders, it is highly likely that NICE will recommend that IPT should be
available within mental health services.

What would be the advantages of supporting the development of IPT?
IPT is an effective therapy for interpersonal problems and as such has the capacity to
be used for a range of psychiatric disorders. Unlike CBT, the adaptations are minor
and once trained, therapists could treat a range of disorders without needing further
training.
IPT has been successfully used with adolescent, working age adult and elderly
populations. It offers the opportunity to clinicians from these care groups to share
clinical supervision utilising the same therapeutic model.
The training is relatively short as the skills base required to practise IPT incorporates
usual good clinical practice. The discipline involved in learning to follow a
manualised approach can have positive beneficial effects on clinicians’ wider practise.
IPT has already been proposed as a sensible choice for psychotherapy training for
trainee psychiatrists9.
What impact would there be on current service delivery?
Patients who require some form of psychological therapy as well as medication and
review are already being treated using other eclectic therapeutic approaches or
therapies with little or no evidence base (excluding CBT). IPT is flexible enough to be
practised by both psychological therapy teams and CMHTs. The number of sessions
can be tailored to the needs of the patient, as there is no set programme to deliver once
phase 2 has begun.
Clinicians would need time to attend the initial training and supervision course and
would then need to be able to attend regular group supervision in Gloucestershire for
a couple of hours each month.
What IPT training and therapy is already available in Gloucestershire?

Professor Christopher Fairburn (University of Oxford) has provided a 2-day IPT
introductory course in Gloucestershire on 3 occasions. 2 cohorts of staff have
subsequently attended the group supervision in Oxford. The supervision consists of 6
half days during which attendees share case discussions, with Professor Fairburn
providing clinical supervision regarding adherence to the model. Each attendee also
submits 3 audiotapes of clinical sessions to Professor Fairburn, who listens to them
and provides written feedback. Successful completion of the supervision course leads
to the provision of a certificate of competence from Professor Fairburn.
This training meets the requirement of IPT UK for the first level of IPT training.
An IPT supervision group has met monthly for over one year in Gloucester. Members
consist of clinicians that have completed the supervision in Oxford. This group also
meets with Professor Fairburn quarterly for supervision and development purposes.

How could IPT be developed further?

It would make sense to continue to train at least one cohort of six staff per year, to
ensure that the number of staff fully trained continues to slowly grow (bearing in
mind there will be some wastage of staff over time). This would require an adequate
number of staff to have undertaken the 2-day introduction course and funding for the
supervision course. The Regional Workforce Development Confederation has
provided funding on two previous occasions.
A provisional aim would be that IPT could become available within each care group,
followed by each PCT area and finally each local mental health team. This
programme of development would take some years to achieve.
Within the next 2-3 years, it would be likely that local clinicians would have
sufficient clinical expertise and experience of supervision within the model to provide
training locally “in- house”, and even offer training to other areas to generate income
and develop the Trust as a centre of excellence in IPT. Professor Fairburn has already
encouraged the current IPT group members to consider taking this on.
This option would require support for a few key individuals to continue to develop
skills via supervisor training courses and attendance at IPT conferences.

How much would it cost?

2003 prices:
2-Day introduction course:

£2000 plus cost of refreshments. Previous courses have had about 60 attendees and
have generated income by selling places to other areas.
Supervision course in Oxford:
£7500 plus cost of travel for 6 attendees.
Occasional supervision with Professor Fairburn
£500 per half day session.
Conclusion
IPT is an adaptable, easily learned evidence based treatment for depression and
bulimia nervosa. It is currently being tested for several other disorders. Local
development of IPT offers the opportunity to enhance the quality of service delivery
and invest relatively cheaply in multi-disciplinary staff training.
Sam Clark-Stone
Clinical Co-ordinator
Eating Disorders Project
03/03
References

1. Klerman GL, Weissman MM, Rounsaville BJ & Chevron ES (1984) Interpersonal psychotherapy of depression. New York: Basic Books. 2. Weissman MM & Markowitz JC (1998) An overview of interpersonal psychotherapy. In: Interpersonal Psychotherapy. Edited by JC Markowitz. Washington DC: American Psychiatric Press. 3. Weissman MM, Markowitz JC & Klerman GL (2000) Comprehensive guide to interpersonal psychotherapy. New York: Basic Books. 4. Craighead WE, Hart AB, Craighead LW & Ilardi SS (2002) Psychosocial treatments for major depressive disorder. In: A guide to treatments that work (2nd edition). Edited by PE Nathan & JM Gorman. London: Oxford University Press. 5. Wilson GT & Fairburn CG (2002) Treatments for eating disorders. In: A guide to treatments that work (2nd edition). Edited by PE Nathan & JM Gorman. London: Oxford University Press. 6. Parry G & Richardson A (1996) NHS psychotherapy services in England. 7. National Institute for Clinical Excellence (Expected date of publication January 2004) Eating Disorders: The management of anorexia nervosa, bulimia nervosa and binge eating disorder. 8. National Institute for Clinical Excellence (Expected date of publication February 2004) Depression: The management of depression in primary and secondary care. 9. Morris J (2002) Interpersonal psychotherapy – a trainee’s ABC? Psychiatric
Further reading, downloaded from
http://www.interpersonalpsychotherapy.org.uk/books.php

Weissman, M.M., Markowitz, J.C., & Klerman, G.L. (2000) Comprehensive Guide to Interpersonal Psychotherapy. Basic Books. Klerman, G. L., Weissman, M.M., Rounsaville, B.J. & Chevron, E.S. (1984) Interpersonal Psychotherapy of Depression. Jason Aronson Inc., Northvale, New Jersey, London. Klerman, G. L. & Weissman, M.M. (Eds) (1993) New Applications of Interpersonal Psychotherapy. Washington D.C., American Psychiatric Press,. Markowitz, J.C. (1998) Interpersonal Psychotherapy for Dysthymic Disorder Washington DC, Am. Psychiatric Press Markowitz, J.C. (Ed) (1998) Interpersonal Psychotherapy. Washington DC, American Psychiatric Press Inc. Mufson, L., Moreau, D., Weissman, W. & Klerman, G. (1993). Interpersonal Psychotherapy for Depressed Adolescents. New York, Guilford Press. Wilfley, D.E., MacKenzie, K.R., Welch, P.R., Ayres, V.E., Weissman, M.M. (2000). Interpersonal Psychotherapy for Group. Basic Books. Frank, E. , Spaner, C. (1995) Interpersonal Psychotherapy for Depression: Overview, Clinical Efficacy, and Future Directions. Clinical Psychology: Science and Clinical Psychology: Science and Practice, V2, N4, Winter. Markowitz, J.C. & Swartz, H.A. (1997). Case Formulation in Interpersonal Psychotherapy of Depression in T.D. Eells (Ed) 192-222 Handbook of Psychotherapy Case Formulation. N.Y., London, Guilford Press. New Haven-Boston Collaborative Depression Research Project Klerman G.L et al, (1974) Treatment of Depression by drugs and Psychotherapy Am J Psychiatry. 131: pp186-191 Weissman M.M et al, (Jun 1974) Treatment Effects on the Social Adjustment of Depressed Patients Arch. Gen Psych. 30, pp771-778. Paykel E.S et al (Feb 1975) Effects of Maintenance amitripteline and psychotherapy on symptoms of depression Psychological Medicine 5(1), pp67-77 DiMascio A. et al, (1979) Differential Symptom Reduction by drugs and psychotherapy in acute depression Arch. Gen. Psychiatry, 36, Dec.,pp 1450-1456 Prusoff B.A et al (Jul 1980) Research diagnostic criteria subtypes of Depression. Their role as predictors of differential response to psychotherapy and drug treatment. Arch. Gen Psychiatry, 37(7):796-801 Weissman M.M et al (1981) Depressed Outpatients: Results one year after treatment with drugs and / or interpersonal psychotherapy Arch. Gen Psychiatry, 38, Jan., pp 51-55 Klerman G.L (1990) Treatment of Recurrent Unipolar Major Depressive Disorder. Arch Gen Psychiatry, 47:1158-62 Elkin I.M (1984) The NIMH Treatment of Depression Collaborative Research Program: Where we began and where we are. In Handbook of Psychotherapy and Behaviour Change (4th ed. pp143-289) New York: Wiley. Elkin, I.M, Shea, M. T., Watkins, J.T. et al (1989) National Institute of Mental Health Treatment of Depression Collaborative Research program:general effectiveness of treatments. Archives of General Psychiatry, 46,pp 971-982. Specific variables considered:
Sotsky S.M et al (1991) Patient predictors of response to psychotherapy and pharmacotherapy: Findings in the NIMH Treatment of Depression Collaborative Research Program Am J of Psychiatry, 148: pp997-1008 Elkin I.M et al, (Oct 1995) Initial Severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of. Consulting & Clinical Psychology, Vol 63(5) ,pp 841-847 Shea M.T et al, (1990). Personality Disorders and Treatment Outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program Am J Psychiatry, 147, pp711-718 Imber S.D et al (1990) Mode-Specific Effects among three treatments for depression., Journal of Consulting & Clinical Psychology 58(3): pp352-359 Watkins J.T et al (1993) Temporal Course of Change of Depression. Journal of Consulting & Clinical Psychology, 61(5), pp858-864 Shea M.T et al, (1992) Course of Depressive Symptoms over follow-up: Findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program Archives Gen Psychiatry 49:, pp782-789) Stewart J.W et al (Dec 1998) Atypical Features and treatment response in the National Institute of Mental Health Treatment of Depression Collaborative Research Program Journal of Clin Psychopharmacology 18(6) pp 429-434) Ablon J.S & Jones E.E, (1999) Psychotherapy Process in the National Institute of Mental Health Treatment of Depression Collaborative Research Program Journal of Consulting & Clinical Psychology 67(1) pp 64-75 Kung W.W & Elkin I.E (2000) Marital Adjustment as a predictor of Outcome in Individual Treatment of Depression Psychoterapy Research 10 (3), pp267-78) Reanalysis
Klein D.F(July 1990) NIMH collaborative research on treatment of depression (comment) Archives of General Psychiatry 47(7), pp 682-688 Klein D.F & Ross D.C (1993) Reanalysis of the National Institute of Mental Health Treatment of Depression Collaborative Research Program General Effectiveness Report Neuropsychpharmacology, 8(3), pp241-51. Gibbons R.D et al (Sept 1993) Some Conceptual and Statistical Issues in analysis of longitudinal psychiatric data. Application to the NIMH treatment of depression Collaborative Research Program dataset Archives of General Psychiatry, 50(9) pp739-50 Elkin I.M et al (1996) Response to reanalysis J Cons & Clin Psychol., 64(1),pp92 103 Recurrent Depression
Frank, E. et al (1990): Three Year Outcomes for maintenance Therapies in Recurrent Depression Arch Gen Psych 47, Dec: pp1093-1099 ) Frank, E. et al (1991) Efficacy of Interpersonal Psychotherapy as a Maintenance Treatment of Recurrent Depression. Arch Gen Psych 48, pp 1053-1059 Kupfer D et al (1989) Advantage of EarlyTreatment Intervention in Recurrent Depression. Arch Gen Psych 46 ,pp771-775 Spanier C. et al (May 1996) The prophylaxis of depressive episodes in recurrent depression following discontinuation of drug therapy: integrating psychological and biological factors. Psychological Medicine 26(3) pp 461-75 Frank E et al (Jan 2000) Interpersonal Psychotherapy and antidepressant medication: evaluation of a sequential treatment strategy in women with recurrent major depression. Journal of Clincal Psychiatry61 (1), pp51-57 Dysthymia
Markowitz J.C et al (1992b) Interpersonal Psychotherapy of Depressed HIV - seropositive outpatients. Hospital & Community Psychiatry 43: pp 885-890 Mason B.J et al (1993) IPT for Dysthymic Disorder. In New Applications of Interpersonal Therapy ed. GL Klerman and MM Weissman 225-364 Washington DC: American Psychiatric Press Markowitz J.C (1993b) Psychotherapy of the post-dysthymic patient. Journal of Psychotherapy Practice and Research 2: 157 - 163 Markowtiz J.C (1994) Psychotherapy of Dysthymia. American Journal of Psychiatry 151: 1114- 1121 Adolescent Depression
Moreau, D. et al (1991) Interpersonal Psychotherapy for adolescent depression: Description of modification and preliminary application J Am Acad Child & Adol Psychiatry. 30: 4, pp642-651 Mufson, L. et al (1993) Interpersonal Psychotherapy for depressed adolescents. New York: Guilford Mufson, L . (1994) Modifications of interpersonal psychotherapy with depressed adolescents (IPT-A): Phase I and II Studies (J Am Acad Ch & Adol Psych. 33(5), pp 695-705 Mufson L. (1996) Interpersonal psychotherapy for depressed adolescents: A 1 year naturalistic follow-up study. J Am Acad Child & Adol Psych. 35(9), pp1145-1155 Mufson, L. (1999) Efficacy of interpersonal psychotherapy for depressed adolescents Arch Gen Psych. 56, pp573-579) Rossello, J. & Bernal, G. (1996) Adapting cognitive-behavioural and interpersonal treatment for depressed Puerto Rican Adolescents. In Psychological Treatments forChild and Adolescent Disorders: Empirically based strategies for Clinical Practice, ed ED Hibbs and PS Jensen pp 157-185 Washington DC: American Psychlogical Association Fombonne, E. (1998) IPT-A (Child Psych & Psychi Review, 3:4,pp169-175) Depression In Older Adults
Rothblum, E.D et al (1982) Issues in clinical trials with the depressed elderly. J Amer Geriatrics Society 30: pp 694-699 Reynolds, C. et al (1992) Combined Pharmacotherapy and Psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: A Preliminary Report Am J Psych 149: 12, Dec, pp1687-1692 Reynolds, C. et al (1994) Treatment of consecutive episodes of major depression in the elderly Am J Psych 151:12, Dec, pp1740-1743 Reynolds, C. et al (1996a) Treatment outcome in recurrent major depression: A post-hoc comparison of Elderly and Midlife patients Am J Psych 153:10, Oct, pp1288-1292) Reynolds, C. et al (1997) Which elderly patients with remitted depression remain well with continued interpersonal psychotherapy after discontinuation of anti-depressant medication? Am J Psych 154:7, July, pp958-962 Reynolds, C. et al (1998): Effects of age at onset of first lifetime episode of recurrent major depression on treatment response and illness course in elderly patients American Journal of Psychiatry 155(6) June, pp795-799 Reynolds, C. et al (1999): treatment of Bereavement-Related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. American Journal of Psychiatry 156(2) Feb, pp202-208 Reynolds, C. et al (1999): Treatment of 70(+) -year-olds with recurrent major depression. Excellent short-term but brittle long-term response. American Journal of Geriatric Psychiatry, 7(1), pp64-69 Reynolds, C. et al (1999): Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than fifty-nine years JAMA, 281 (1), pp39-45 Miller, M. D. et al (1994) Applying interpersonal psychotherapy to bereavement-related depression following loss of a spouse in late life J Psychotherapy Practice & Research, 3, pp 149-162 Miller, M.D & Silberman, R.L (1996) Using interpersonal psychotherapy with depressed elders. In A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage context, Ed. SH Zarit and BG Knight American Psychological Association, pp83-99. Miller, M.D. et al (1998)Using Interpersonal Psychotherapy (IPT) in a combined psychotherapy / medication research protocol with depressed elders J Psychotherapy Practice & Research, 7(1), pp 47-55 Prigerson, H.G. et al (1995) Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. Am J Psych. 152, pp22-30) Dew, M.A. et al (1997) : Temporal Profiles of the course of Depression during Treatment Archives of General Psychiatry, 54( No v. pp 1016-1024 Wolfson, L. et al (1997): Foci of interpersonal psychotherapy (IPT) in depressed elders: Clinical and outcome correlates in a combined IPT / nortriptyline protocol Psychotherapy Research 7:1, pp45-55 Hinrichsen, G.A (1997) Interpersonal psychotherapy for depressed older adults. Journal of Geriatric Psychiatry 30: pp 239-257 Bauer (1997) German. Application with Alzheimers. Little, J.T. et al (Aug 1998): How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 155(8), pp1035-1038) Frank, E. et al (1997). Inducing lifestyle regularity in recovering bipolar disorder patients: Results from the maintenance therapies in bipolar disorder protocol. Biol Psych, 41, pp1165-1173 Stuart, S. & Cole V. (1996): Treatment of depression following myocardial infarction. Annals of Clinical Psychiatry, 8(4) pp 203-206 O'Hara, M.W. et al (2000): Treatment of postpartum depression Archives of General Psychiatry 57,1039-1045) Stuart, S. & O'Hara M. (Jan 1995): Treatment of postpartum depression with interpersonal psychotherapy [letter;comment] Archives of General Psychiatry 52(1): 75 - 76 Donnelly, JM et al (Jan-Feb 2000): a pilot study of interpersonal psychotherapy by telephone with cancer patients and their partners Psycho-Oncology 9(1), pp44-56 Markowitz, J., Klerman, G. L. & Perry, S. (1992b): Interpersonal Psychotherapy of depressed HIV -seropositive outpatients. Hospital & Community Psychiatry 43:9, pp 885-890 Markowitz, J et al (1995): Individual psychotherapies for depressed HIV -seropositive outpatients American Journal of Psychiatry 152:10, pp1504-1509 Swartz, H. et al (1997) Interpersonal psychotherapy of a dysthymic, pregnant, HIV-positive woman. Journal of Psychotherapy Pracice & Research 6(2), pp165-178 Markowitz (1998): Treatment of HIV -positive patients with depressive symptoms. Archives of General Psychiatry 55, May, pp452-457 Substance Abuse
Rounsaville et al (1983) Short-term interpersonal psychotherapy in methadone-maintained opiate addicts Archives of General Psychiatry 40, pp629-636 Carroll K.M. et al (1991) A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy American Journal of Drug and Alcohol Abuse, 17:3,pp229-47 Application to other disorders:
Eating Disorders
Fairburn, C.G. et al (1986) A comparison of two psychological treatments for bulimia nervosa Behav Res Ther 24, pp629-643 Fairburn, C.G. et al (1991) Three psychological treatments for bulimia nervosa: A comparative trial. Archives of General Psychiatry 48, pp463-469 Fairburn, C.G. et al (1993) Psychotherapy and bulimia nervosa: Longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy Archives of General Psychiatry 50, pp419-428 Fairburn, C.G. et al (1995) A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments Archives of General Psychiatry 52, pp304-312 Wilfey, D. et al (1993) Group cognitive -behavioural therapy and group interpersonal therapy for the nonpurging bulimic individualJournal of Con & Clin Psychology, 61(2): pp296-305 Wilfley, D. et al (1998) Group IPT adaptation(Psychotherapy Research, 8:4, pp 361-378 Agras, W.S. et al (1999) A multisite comparison of cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT) in the treatment of bulimia nervosa. Presented at Eating Disorders '99, London April 20-22 and inArch Gen Psych 57, pp 459-466 McIntosh, V.V. et al (2000) Interpersonal Psychotherapy Therapy for Anorexia Nervosa [Review] International Journal of Eating Disorders 27(2): 125-139 Application to other disorders:
Anxiety Disorders
Brown, C. et al (1996) Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders American Journal of Psychiatry 153(10) pp1293-1300 Feske, U. et al (1998) Anxiety as a predictor of response to interpersonal psychotherapy for recurrent major depression: an exploratory investigation Depression & Anxiety, 8(4), pp 135-141 Lipsitz, J.D. et al (1999) An open trial of interpersonal psychotherapy for social phobia American Journal of Psychiatry, 101: 141-148 Frank, E. et al (2000) Influence of Panic-Agoraphobic spectrum symptoms on treatment response in patients with recurrent major depression American Journal of Psychiatry, 157(7), 1101-1107)

Source: http://www.edglos.org.uk/developingipt.pdf

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