Am J Geriatr Psychiatry 11:97-102, February 2003
© 2003 American Association for Geriatric Psychiatry
The Value of Maintenance Interpersonal Psychotherapy (IPT) in Older Adults With Different IPT Foci
Mark D. Miller, M.D.,
Ellen Frank, Ph.D.,
Cleon Cornes, M.D.,
Patricia R. Houck, M.S., and
Charles F. Reynolds III, M.D.
Received March 29, 2002; revised June 19, July 17, 2002; accepted July 19, 2002. From the Intervention Research Center for Late-Life Mood Disorders, University of Pittsburgh School of Medicine, Pittsburgh, PA. Address correspondence to Dr. Miller, University of Pittsburgh, 742 Bellefield Towers, Pittsburgh, PA 15213. e-mail: millermd{at}msx.upmc.edu
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ABSTRACT
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Objective/METHODS: The authors examined recurrence rates of major depression in elderly subjects with different foci of interpersonal psychotherapy (IPT), who were treated for up to 3 years with either monthly maintenance IPT and pill placebo or with monthly clinical management and pill placebo. RESULTS: Among subjects with an IPT focus on role conflict, a greater proportion of those treated with maintenance-IPT survived for 3 years without recurrence than those treated with placebo/clinical management. Median time to recurrence was 68.9 weeks in IPT-treated patients versus 16.3 weeks for patients in clinical management. Subjects with an IPT focus on abnormal grief or role transition demonstrated no effect differential for maintenance IPT and pill-placebo on recurrence prevention over supportive clinical management and pill-placebo. CONCLUSION: If replicated in a larger sample, these findings have important implications for ongoing case-management decisions.
Key Words: Interpersonal Therapy • Depression • Drug–Placebo Comparisons
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INTRODUCTION
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Interpersonal psychotherapy (IPT) is a manual-based, short-term (12–16 weeks) therapy in which the therapist plays the active role of advocate and educator. Depression is viewed as a state of illness that plays itself out in the interpersonal sphere of the patient regardless of whether it stems from a biological or genetic vulnerability or from psychological or psychosocial stressors.
The underpinnings of IPT stem from the pragmatic approach of social casework developed by Klerman and colleagues1 along theoretical grounds articulated by Adolph Meyer2 and Henry Stack Sullivan,3 among others. Specifically, interpersonal relationships are regarded as the stage upon which the nidus for depression is formed, modulated, or played out, and from which the IPT therapist can work with the patient to develop better understanding, but more importantly, better coping strategies in the here-and-now.
The goals of the initial sessions of IPT include building rapport, taking a thorough history, educating about depression, consideration of the concomitant use of antidepressant medication, and taking a thorough inventory of all pertinent interpersonal relationships. This database, obtained during the initial sessions, is used to formulate a focus for the therapy in one of four broad areas: 1) unresolved or abnormal grief; 2) role transition; 3) role conflict, or 4) interpersonal deficit (long-standing difficulties forming and maintaining satisfying interpersonal relationships). The presenting complaints and problems are reviewed by the therapist in the context of current interpersonal relationships (or recently lost relationships, in the case of abnormal grief) in an effort to secure the patients' agreement to a specific focus for the work of IPT. During weekly 50-minute sessions, the agreed-upon focus is systematically explored according to the IPT manual guidelines with the goal of attaining symptom relief and learning better coping strategies that circumvent demoralization and continued depression.
Through empathetic statements, education, and attempts at patient advocacy, the maintenance of a positive transference and a productive working relationship is encouraged. Transference interpretations are otherwise discouraged, and intense affects are redirected for exploration and problem-solving to real-time relationships in the patient's current interpersonal sphere. For the focus of grief, the IPT manual outlines strategies for helping the patient adequately mourn the loss and pursue new sources of emotional sustenance. For role-transition, the therapist encourages the patient to mourn the loss of the previous role when appropriate and to explore ways in which new roles can be formed, tested, and maintained. For role conflict, which is usually marital, IPT seeks to assess the stage of the role conflict. The relationship may be at an impasse, where confrontation can seek to rekindle the stalemated process of satisfying interaction; renegotiation may be useful for exploring alternate coping strategies through communication analysis. If the relationship has passed the "point of no return," exploring dissolution of the relationship may be the best approach. The focus of interpersonal deficit often arises in those patients with greater degrees of character pathology. The strategy for helping these patients is to encourage greater meaningful interaction and contact with others. In this focus, the work on better interaction skills begins with the patient–therapist relationship. Better interactive strategies begun in the therapy sessions are then practiced by the patient with real-life relationships. The outcome of such practice is reviewed, with potential modification, in subsequent sessions.
Summary of Previous Efficacy Studies
A 12-week comparison of IPT and amitriptyline in non-geriatric patients showed results of IPT to be superior to those of non-scheduled support and comparable to those of drug treatment.4,5 In a multisite study comparing IPT, cognitive therapy, imipramine plus clinical management, and placebo pill plus clinical management, IPT was found to be of comparable efficacy to both cognitive therapy and imipramine at 16 weeks.6 In a study comparing IPT, nortriptyline (with documented adequate blood levels), and usual care in four urban primary-care clinics, both IPT and nortriptyline were equally effective and superior to treatment-as-usual. The nortriptyline group responded more rapidly, but the IPT-treated group "caught up" by the end of the 8-month trial.7 In geriatric patients, a 16-week trial showed IPT to be as effective as nortriptyline for protocol completers, with a higher rate of study completion for those assigned to IPT (94%) than drug treatment (55%).8 In a study of bereavement-related geriatric depression, IPT assignment showed no significant advantage over pill-placebo on remission rates, compared with nortriptyline, and no added benefit when added to nortriptyline; however, subjects receiving combined nortriptyline and IPT demonstrated the highest completion and remission rates.9 This study may not have been large enough to detect a moderate difference, and treatment failure was defined as less than 50% improvement in Hamilton Rating Scale for Depression (Ham-D) scores by 8 weeks, which may have been an inadequate trial of IPT.
The Maintenance-Therapies-in-Late-Life-Depression Study
The Maintenance-Therapies-in-Late-Life-Depression Study (MTLLD) addressed recurrence prevention in 107 elderly patients with recurrent depression.10 The study compared the efficacy of combination treatment consisting of monthly IPT sessions plus nortriptyline (NT), to NT plus clinical management (CM), IPT plus placebo, and CM plus placebo (PBO) over a 3-year follow-up period. Index episodes were treated with a combination of weekly IPT sessions and nortriptyline titrated to a blood level of 80 ng/nl–120 ng/nl for 4 months of sustained remission.10 Combination treatment was found to be the most efficacious, although both monotherapies were also superior to PBO plus CM. In the over-age-70 subgroup, only combination treatment with drug and monthly IPT showed a protective effect against recurrence.
This communication reports a post-hoc analysis of the MTLLD dataset. As reported elsewhere,10 subjects age 60 or older with recurrent major depression were successfully treated to remission and maintained for 4 months by use of a combination of weekly IPT sessions and nortriptyline. Subjects were then randomly assigned, under double-blind conditions, for 3 years of monthly follow-up, to receive either 1) combined treatment with NT and monthly maintenance IPT, 2) PBO plus IPT, 3) NT plus clinical management (CM); or 4) PBO plus CM.
As a secondary analysis, we explored whether there were any clinical or demographic differences among those who survived without a recurrence after random assignment to pill-placebo and IPT versus pill-placebo and clinical management. Specifically, we asked whether IPT focus had any effect on recurrence of major depression. For this secondary analysis, we hypothesized that those subjects with either abnormal grief or role transition would have adequately worked through their grief or role transition during the course of acute and continuation treatment, such that continued monthly IPT would not be necessary to maintain wellness. By contrast, we hypothesized that subjects with an IPT focus on role conflict would be at higher risk for a return to their previous maladaptive coping pattern in the absence of monthly IPT sessions, thus increasing their vulnerability to demoralization and leading to higher rates of recurrent depression.
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METHODS
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The focus of IPT was determined during the initial sessions of the acute-phase treatment by group consensus among research therapists and supervisors using videotaped case presentations during group supervision. In this report, recurrence rates were compared within the two placebo groups to isolate any direct effect of IPT versus clinical management on recurrence rates.
All subjects randomly assigned to clinical management plus PBO continued to see the same therapist assigned to them during the acute and continuation phases, in order to avoid a "withdrawal-of-therapist" effect. Clinical management visits lasted 15 minutes and were focused on supportive care, encouragement, and side-effect queries. When subjects in CM revealed distressing life events, these were acknowledged as such, but no further thoughts or feelings were elicited. All maintenance sessions were audiotaped, and a random subsample of 20% of tapes was rated independently to verify the absence of IPT factors. The definition of recurrence was operationalized to require subjects to meet DSM-IV criteria for major depressive disorder with a Ham-D score of 17 or greater for 2 consecutive weeks. Also, we required an independent assessment by a research psychiatrist to verify recurrence.
We explored clinical and demographic correlates of different IPT foci that might explain any differences in maintenance treatment outcome. Because only 1 subject of 107 was deemed to have a primary IPT focus of interpersonal deficit, she was excluded from this analysis. We excluded the subjects assigned to nortriptyline so as to explore the effect of IPT specifically.
We compared the following demographic and clinical variables across IPT focus groups: gender, race, education, marital status, medical burden (Cumulative Illness Rating Scale–Geriatrics), age at first episode, episode number, duration of current episode, cognitive status (Folstein Mini-Mental State Exam [MMSE]), personality features (Personality Assessment Form), and social support (Interpersonal Support Evaluation List; ISEL).
Data Analysis
We compared the rate of recurrence and time-to-recurrence across subjects with different IPT foci, using Fisher's exact test and Kaplan-Meier survival analysis. Chi-square test for categorical data and Kruskal-Wallis for continuous measures were used to examine baseline differences in demographic and clinical variables. Post-hoc pairwise comparisons were made for significant variables that met the criterion of p at less than the 0.01 level.
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RESULTS
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As shown in Table 1, the rate of recurrences was significantly higher in subjects with role conflict who received placebo/clinical management during maintenance treatment compared with those receiving monthly IPT (Fisher's exact test; p=0.009). Median time-to-recurrence was shorter in the clinical management group than in the IPT group (16 weeks versus 69 weeks; log rank 
2[1]=7.35; p<0.01; see Figure 1). There was no difference in recurrence rate (IPT versus CM) in subjects with an IPT focus on abnormal grief or role transition. The post-hoc comparison of significant baseline measures across the three groups showed higher medical burden among subjects with abnormal grief (2[1]=6.21; p<0.05) and higher scores on the Personality Assessment Form (PAF) measure of personality dysfunction (2[1]=1,156; p<0.004) among those with role conflict (Table 2).
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FIGURE 1. Recurrence rates for major depression in subjects with role conflict: monthly maintenance interpersonal therapy (MIPT) versus clinical management (CM)
Note: Elderly subjects with interpersonal conflict survived longer without recurrence of depression if they received monthly maintenance IPT (n=11; median survival: 68.9 weeks) than if they received clinical management (CM) without IPT (n=14; median survival: 16.3 weeks); log rank 2[1]=7.35; p<0.01.
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DISCUSSION
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The reader should bear in mind that all subjects were selected for a history of recurrent unipolar major depression. The major outcomes of this study (previously reported) included a previously reported superior effect for combined treatment (NT plus IPT) and drug monotherapy (NT plus CM) over IPT plus PBO.10 All three active treatment cells prolonged recovery better than PBO plus CM. Our purpose in the current study was to undertake a post-hoc, secondary analysis of subjects randomly assigned to the placebo cells (IPT plus PBO and CM plus PBO) in order to detect any measurable effect of maintenance IPT on recurrence rates. The hypothesis that subjects with role conflict would require IPT to remain well (especially in the absence of long-term antidepressant therapy) was supported. Subjects with a primary IPT focus of role conflict (determined during the acute phase of treatment) were significantly less likely to suffer a recurrence of major depression during 3 years of monthly follow-up with IPT plus PBO, compared with CM plus PBO. In fact, 100% of subjects with role conflict experienced a recurrence without monthly IPT. Subjects with IPT foci of abnormal grief or role transition showed no differential effect of maintenance IPT on recurrence rates compared with CM plus PBO. Our finding is consistent with the positive effects of maintenance IPT on the interpersonal aspects of social adjustment in late-life depression described elsewhere.11
The finding of higher medical burden in the abnormal-grief group is consistent with the extensive literature on the physiologic stresses associated with grieving. The finding of higher degree of Axis II pathology as measured by PAF scores in the role-conflict group could be explained in at least two different ways. First, subjects with more Axis II pathology might be expected to have greater interpersonal difficulties that could lead to demoralization and depression on a frequent basis. Alternatively, frequent depressive episodes with earlier age at onset could lead to maladaptive coping and role conflicts.
The findings that no subjects with role conflict as a primary IPT focus in the placebo/clinical management cell survived without a recurrence over 3 years and that a higher proportion of subjects with role conflicts did survive without a recurrence on monthly IPT suggest that monthly IPT offered a protective effect against recurrence in this subgroup. It is clinically plausible that subjects with maladaptive coping skills and personality dysfunction would revert to their old habits without monthly "booster" IPT sessions that remind, confront, and help subjects to explore more adaptive strategies in the face of new problems.
These data should be interpreted with caution, given the small sample size of the specific IPT subgroups. Furthermore, it should be noted that this secondary analysis was not part of the design of the original study. These findings should be considered preliminary until confirmed with larger sample sizes. Nevertheless, these data are the first to show a measurable effect of maintenance IPT against a recurrence of major depression in a specific subgroup of elderly subjects (those with an IPT focus of role conflict) in a randomized, controlled trial. If confirmed in a larger sample, the clinical implication is that those elderly subjects with role conflict can have their risk for recurrence reduced by continuing monthly maintenance IPT. At the same time, IPT plus PBO was not significantly more effective than CM plus PBO in those with abnormal grief or role transition, suggesting that systematic follow-up with medication and simple care-management technique might be effective in these patients. It is also worth noting, however, that pill-placebo/clinical management could itself represent a significant psychosocial intervention that may have a stronger preventive effect than maintenance treatments (or the lack thereof) in usual care.
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ACKNOWLEDGMENTS
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The authors acknowledge with gratitude the clinical care of subjects in this study provided by Lin Ehrenpreis, LCSW; Jean Picone, LCSW; Rebecca Silberman, Ph.D.; and Lee Wolfson, M.Ed.
This work was supported by grants R37 MH43832, P30 MH52247, and R01 MH37869 from the National Institutes of Health.
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REFERENCES
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- Klerman GL, Weissman MM, Rounsaville BJ, et al: Interpersonal Psychotherapy of Depression. New York, Academic Press, Basic Books, Inc., 1984
- Meyer A: Psychobiology: A Science of Man. Springfield, IL, Charles C. Thomas, 1957
- Sullivan HS: The Interpersonal Theory of Psychiatry. New York, WW Norton, 1953
- DiMascio A, Weissman MM, Prusoff BA, et al: Differential symptom reduction by drugs and psychotherapy in acute depression. Arch Gen Psychiatry 1979; 36:1450-1456[Abstract]
- Weissman MM, Prusoff BA, DiMascio A, et al: The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am J Psychiatry 1979; 136:555-558
- Elkin I, Shea MT, Watkins JT, et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness and treatments. Arch Gen Psychiatry 1989; 46:971-983[Abstract]
- Schulberg HC, Block M, Madonia M, et al: Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53:913-919[Abstract]
- Schneider LS, Sloane RB, Staples FR, et al: Pretreatment orthostatic hypotension as a predictor of response to nortriptyline in geriatric depression. J Clin Psychopharmacol 1986; 6:172-176[Medline]
- Reynolds CF III, Miller MD, Pasternak RE, et al: Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry 1999; 156:202-208[Abstract/Free Full Text]
- Reynolds CF III, Frank E, Perel JM, et al: Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999; 281:39-45[Abstract/Free Full Text]
- Lenze EJ, Dew MA, Mazumdar S, et al: Combined pharmacotherapy and psychotherapy in maintenance treatment for late-life depression: effects on social adjustment, quality of life, and perception of health. Am J Psychiatry 2002; 159:466-468[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
