Sunday, September 24, 2017

Whatever Happened to IPT?





I  first read about the Interpersonal Psychotherapy of Depression when the book came out in 1984.  The origins were there for quite a while before the book.  Gerald Klerman, MD and Myrna Weissman, PhD were prominent in developing a model that depended heavily on psychoanalysis and previous interpersonal theorists like Harry Stack Sullivan and John Bowlby.  The theory rests on a fairly basic assumption and that is that depressions can have an interpersonal etiology as well as social and biological ones.  At the time the book came out, manualized psychotherapies were starting to peak.  A few years earlier I requested a copy of the research manual from Marsha Linehan, PhD and she sent it to me.  That original manual is quite different from the way that (dialectical behavior therapy) DBT is practiced today as a general group behavior therapy.  Beck, Ellis, and Meichenbaum were focused on cognitive-behavioral therapy or CBT at about the same time.  These authors produced texts and manuals on how to perform these therapies.  The driving force for the manuals was psychotherapy research.  A standard research protocol in any therapy was to produce a manualized version, train the research therapists in the therapy, and then monitor them at various points in the therapy to assure that they were performing the therapy according to the manual.

Clinical training at the time was not nearly as standardized. It is fair to say that the predominate training model for psychiatrists was psychoanalytically based psychodynamic psychotherapy.  The main subdivisions were insight oriented psychodynamic psychotherapy and supportive psychotherapy.  Supportive psychotherapy avoided confrontation of the patient's defenses and the therapist used many of the techniques used in CBT.  There were also some brief forms of psychodynamically based psychotherapy.  Viedermann wrote about a psychodynamic life narrative model of crisis intervention for college students in crisis.  It was designed to be delivered in just a few sessions.  The approach was interesting because it had interpersonal psychodynamic interpretations rather than transference based or interpretations based on unconscious mechanisms.

Depression is a very heterogeneous category of disorders.  The interpersonal context remains the same and it is up to the clinician to figure out what might be relevant - what might have personal meaning.   The four areas of focus noted int he above diagram can be historically recorded in just about anyone's life - but are they the cause of depression?  IPT answers the second half of that question - what can be done about it?

A good illustration is the case of the depressed person who has sustained a significant personal loss that they have not recovered from.  In clinical practice it is common to see people who are depressed and  date the onset of that depression to a point in time when a significant figure in their life died. Whether that happened 10 or 20 years ago - they have not recovered despite antidepressant maintenance or multiple antidepressant trials.  The goal for the IPT therapist is to discover of the depression is due to the loss of the meaning of the loss and facilitate completing the grief process.  In today's world, many patients with grief are referred to Eye Movement Desensitization and Reprocessing (EMDR) therapists for presumptive post traumatic stress disorder (PTSD).  I have certainly encountered people who were traumatized by the manner in which their significant other died.  The most common scenario is a surviving spouse or parent.  In the majority of cases, the patient is experiencing grief and they have not been able to complete that process.  The IPT therapist is able to recognize and treat that problem.            

There is plenty of evidence that IPT is an effective form of psychotherapy if you really need evidence.  Medline searches yield a total of 4590 references for interpersonal psychotherapy 786 reviews in that category.  For interpersonal psychotherapy depression there are a total of 1548 articles and 327 reviews.  A recent brief and excellent review article was written by Markowitz and Weissman.   It contained this description of Gerald Klerman's orientation during the initial discussions of this psychotherapy:

"Although Klerman, a psychiatrist, saw depression as basically a biological illness, he was impressed by how social and interpersonal stress exacerbated onset and relapse. Noting that ‘one of the great features of the brain is that it responds to its environment’, he felt that the interpersonal context of the onset of a depressive episode might be a target for psychotherapy." 

I would add that at the time there was active conflict between academic psychiatrists who considered themselves to be biological psychiatrists and a group who considered themselves to be psychotherapists.  Eclectic psychiatrists like Klerman existed in every department but they tended to be the silent majority.  Psychiatrists like me were fortunate to be trained by them.

There are several reasons why knowing about IPT - in addition to other psychotherapy paradigms can be useful to any psychiatrist:

1.  It is easy to learn -

There have certainly been other manualized versions of psychodynamically based psychotherapy.  The authors here have really streamlined the process and generally provide a level of analysis based on social roles/behaviors and discuss specific strategies to address problems.

2.  It facilitates thinking about a formulation (if you do that) - 

When it comes to assessment and diagnosis - I have a lot of details on this blog supporting the basic framework that a psychiatric diagnosis is really not enough when it comes to a psychiatric assessment.  There needs to be an overall formulation of what the patient's problems are and how they came about.  A diagnosis or diagnostic code is a poor substitute.  Considering two 50 year old men with severe depression - it probably matters if one of them got depressed as a result of being fired and the other became spontaneously depressed and could not work because of that disability.  That fact alone creates more relevant information for the diagnosis and treatment planning that all of the diagnostic codes and modifiers.

3.  The therapy can be delivered rapidly in the context of psychiatric appointments -

Once the formulation is in your notes, you can pull it up at subsequent visits and discuss what is relevant to the patient.  Many of the interventions are very focused and can be discussed over the span of 15 or 20 minutes.  Instead of just reviewing medication related symptoms and side effects, the discussion can include a therapy that is effective for depression and may either enhance or replace the medication effects.

4.  It provides a formulation that the patient understands and improves empathic communication - 

I have had people ask me at the end of the interview to "Tell me what you think the problem is." They may add other sentences for emphasis like: "I've done all of the talking here - you're the doctor - tell me what the problem is."  Listening for a thread in addition to the usual description of symptoms allows for a formulation based on interpersonal of social contexts and how that relates to diagnosis and treatment.  It should not be too hard to believe that most people find that a DSM theoretical formulation falls flat.

5.  IPT can reveal unaddressed problems - 

If the IPT therapist is talking with a patient who dates their depression back to the loss of someone who they were emotionally attached to and that has never been addressed, that provides some diagnostic and therapeutic insight in the same session.  In some cases it can also lead to cost effective therapy for the patient if there are grief counseling clinics or a clergy person who does grief counseling.  One of the glaring errors I have noticed with a lot of current therapy is that it is trauma based.  To me that means that a person has experienced trauma at the level that it could cause post traumatic stress disorder or similar problems.  I see many people with grief diagnosed as having a trauma disorder and treated with exposure therapy for grief.  Grief counseling or an IPT approach is a preferable option.  

6.  IPT adds a needed non-medicine dimension to psychiatric treatment - 

The term psychopharmacologist is often mentioned by people who I assess.  I ask myself what does a psychopharmacologist do when the patient is experiencing a chronic stressor that is either environmental of interpersonal in nature.  Does the medication just go up to the point that the person is numb to the stress?  As a psychopharmacologist myself, there is an obligation to let people know that at some point - the stressors in life will overcome the effects of medicine and that there is no medicine that will overcome chronic stress - at least without sedating them to the point that it will be difficult to function.  At that point the therapeutic alliance needs to focus on resolving the environmental or interpersonal stress.  It is extremely important at that point in time to be able to associate the patients problem with the therapy models and discuss these paradigms as a way to resolve the problem.  In this case - hopefully all psychiatrists have been trained in the non-medicine dimension before they start seeing patients.  

Those are some of my thoughts about IPT.  I have always considered it to be an effective and pragmatic form of psychotherapy.  Back when I was learning about psychotherapy, I had supervisors of every stripe ranging from Rogerian therapy to psychodynamic to existential psychotherapy.  The paradoxical  aspect of my psychotherapy supervision was that they all advocated for picking one style of therapy and sticking to it.

I really don't think that is a good idea.  Strictly in terms of psychodynamic therapy, one of the key aspects of the assessment was to determine if the patient was psychologically minded enough to engage in the constant clarification, confrontation, and interpretation that goes on in that format.  If not they were considered candidates for supportive psychotherapy.  To someone trained in my era, CBT, IPT, and DBT and their equivalents would all be considered supportive psychotherapies.

I think that provides a good rationale for knowing these therapies and being able to apply them to situations where they might be the best approach.    



George Dawson, MD, DFAPA


References:

1: Viederman M. The Psychodynamic Life Narrative. Psychiatry. 1983 Aug;46(3):236-246. PubMed PMID: 27719516.

2:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression.  Basic Books, Inc; New York; 1984: 255 pp.

3: Markowitz JC, Weissman MM. Interpersonal psychotherapy: past, present and future. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105. doi: 10.1002/cpp.1774. Epub 2012 Feb 14. PubMed PMID: 22331561.


6 comments:

  1. The short answer is there was not enough money in it.

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    1. Another good example of the government and managed care companies putting psychotherapy out of business.

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  2. We are still taught it during our third year, but that may be location specific. Do you think this is something that 1st and 2nd year residents ought to try and pick up on their own for inpatient use? (If picking it up on your own is even possible?)

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    1. It is great to hear that it is being taught in some residency programs. I think that all psychiatrists need to work on different paradigms of talking to patients in a therapeutic way in residency and throughout their careers. Picking this up on your own possible after getting the basic interviewing skills and psychotherapy skills down.

      To cite a couple of brief examples:

      1. One of the first books I read in internship was Yalom's Existential Psychotherapy. Those concepts stayed with me through my career and I could pull them up as a framework whenever existential conflicts seemed to be the most significant problem. That included crisis situations consulting in the hospital and in the ED.

      2. I was interested very early in the psychotherapy of schizophrenia and other severe problems and read books by Arieti, Grinker, and Kernberg in addition to books on basic supportive psychotherapy. I started doing that on an inpatient basis with a cross section of inpatients in acute care settings. I found it to be extremely useful even in patients where most people thought that pharmacotherapy was the only approach. As time went on I found books being published on same type of psychotherapy that I had been doing for 20 years. Now the psychotherapy of severe disorders is an accepted form of therapy.

      This is what I mean by an intellectual approach to psychotherapy. It takes a lot of reading and a lot of study but it allows you to communicate in a relevant manner with people who have a much wider range of problems. It also enhances your thinking on mental models of these disorders - your diagnostic formulations improve tremendously.

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  3. In my residency program IPT and many other modalities are taught as well. There are lots of opportunities in academic settings as a trainee. It is just that when you go into practice, it doesn't seem like most psychiatrists are doing psychotherapy. I suppose that that they may be doing it in a subtle, unspoken way, or it may be permeating from their approach subconsciously, I don't know. But then that begs the question, what is the effectiveness of these therapies when they are given in a sparse, diluted version? As opposed to the manualized forms where the evidence base comes from? Having a psychotherapy informed practice is one thing, but what about the actual practice of psychotherapy proper? I still haven't figured out the future of that is in the psychiatric profession..

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    1. Very glad to hear about your training program as well.

      Psychiatric practices vary considerably from practice to practice. In Minnesota for example we have had decades of maximum market control by 3 large MCOs. We are also seeing an increase in private practices and small groups who are practicing in a very eclectic manner. If you check out their web sites they are very explicit that they offer a lot more than medications including psychotherapy.

      I know a lot of these psychiatrists and they also have total control over patient selection and payer source in their practices. They are not bound bound to a productivity model that is based on maximizing prescribing over the entire population.

      In those same MCOs, if you explicitly request psychotherapy - you will see a therapist on the average for 2 or 3 sessions. In other words, psychotherapy access is as controlled as "medication management" by business managers. Nobody in an MCO setting gets the recommended course of IPT or CBT based on clinical trials. They get the business modified version.

      I can tell you that patients prefer seeing a psychiatrist who talks to them rather than being poised over a prescription pad or EHR. I base that on people coming up to me who I saw 10-20 years ago and asking me: "Do you remember that conversation where you said.....?" Far fewer people say the same thing about medications - even when you clearly have come up with (by all measures) a brilliant psychopharmacology treatment plan. Understandable human communication has more meaning to the average person.

      An overlooked aspect is being able to organize your thinking about the formulation. Have you covered all possible etiologies of the patients problems? Do they agree with what you are saying? The atheoretical DSM based approach generally falls flat on the formulation side, especially when it is clear that medication effects are weak.

      The actual time delivering the therapy is not a limiting factor. I have lost count of the number of times people have told me about their usual "sounding board" therapy. They end up going to a weekly session and reciting what happened the previous week. The therapist provided minimal feedback or rote homework assignments.

      If you know what you are doing - you can do more in 10-15 minutes that years of sounding board therapy.

      My final observation is the people who can't take any medications. There are many of them and even more who have varying levels of partial response. If they are seeing you as a psychiatrist - they are fairly ill - possible disabled. Do you think that you are going to find a therapist to refer them to?

      I worked with a psychiatrist who in my estimation is legendary. He ran a very busy clozapine clinic when it first came out. He had outstanding communication skills and would typically see people in 20 minutes or if things got complicated 30 minutes. He eventually moved on to a different state. 15 years after that clinic shut down people approached me to ask if I had heard about him and how he was doing. That is not how people describe their psychiatrists to me who only prescribe medications and get through the appointment in 5 or 10 minutes.

      I would not be frustrated by people dictating how you are supposed to practice. Learn how to treat people with all of the available tools and the future of psychiatry for you is bright.

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