Interpersonal therapy in the general practice setting

How did interpersonal therapy (IPT) originate?

Interpersonal therapy (IPT) was originally designed about 40 years ago in a research setting as a time-limited psychotherapy, and its effectiveness was compared with amitriptyline and ‘treatment as usual’ unstructured supportive psychotherapy. The two main investigators were Myrna Weissman, a social worker, and Gerald Klerman, a psychiatrist. They proposed a brief interpersonally-based treatment specific to each of four interpersonal domains – grief, interpersonal dispute, roles transition and interpersonal sensitivity – which, they hypothesised, precipitated and maintained depressive episodes (Table 1).¹ In the trial, the patients in the arms receiving IPT or antidepressant medication showed similar rates of improvement, but the combination of IPT and antidepressant medication had the greatest impact on acute symptom improvement and delaying further episodes. Klerman and Weissman went on to write the original textbook on IPT.²

A multicentre trial in the USA was conducted to test the efficacy of the antidepressant imipramine either with or without psychotherapy as maintenance treatment for depression.³ The two short-term psychotherapies selected for the trial were cognitive behavioural therapy (CBT) and IPT. The patients in both psychotherapy arms showed similar rates of improvement, although manifested in different ways. The imipramine plus CBT group improved in dealing with depressogenic cognitions (thoughts) whereas the imipramine plus IPT group improved in interpersonal function. The interest in IPT as an active treatment in its own right was further informed by a growing interest in attachment behaviour (an important theory underpinning IPT).

What is IPT?

IPT is a time-limited manual-based psychotherapy. It is based on the premise that depression arises in an interpersonal context and that relationship problems (such as disrupted relationships or expectations of those relationships) play a part in precipitating and maintaining depressive episodes.

Therefore, the goals of IPT in relation to depression are to:

• relieve depressive symptoms
• educate patients about the link between their symptoms and events in their relationships
• improve skills in interpersonal areas that may be contributing to or exacerbating the depression.
• The components of IPT are (see Box 1 for more details):⁴
• orientation to therapy
• treatment in selected domain(s) – material can be shown to patients to help them select their preferred domains (Table 1)
• termination of therapy
• adding a maintenance phase, where required.

A recent review of studies involving IPT, CBT and antidepressant medication investigated how IPT performed in comparison with other standardised forms of treatment for adult outpatients with a primary diagnosis of major depressive disorder.⁵ The authors undertook a systematic review of the eight identified randomised controlled trials comparing individual sole IPT with other standardised treatments for adults with major depression as the primary diagnosis.

The findings were consistent with those from previous studies, in that they reported similar efficacy for IPT and CBT, but (not surprisingly) CBT had more effect on cognitions and IPT on social function. The inclusion of antidepressant medications made a difference in some studies but not in others and varied by type; venlafaxine, imipramine and nortriptyline had more effect than selective serotonin reuptake inhibitors. Barth and colleagues noted that the outcomes suggested that several kinds of treatments are effective or efficacious for patients with depression and recommended that patients can be given a treatment that fits their personal preferences, and this in turn may may have a positive effect on the outcome.⁵

How does IPT compare with CBT?

Both IPT and CBT are intended to be time limited and instruction manuals are available to provide guidance on the content of sessions.

CBT identifies and addresses the cognitions and behaviours that precipitate and maintain depression. It implies that changes in how someone appraises situations can affect their mood and behaviour. The patient is encouraged to challenge these appraisals and replace them with more helpful ones. It works best with people who can identify their thought processes and use a questioning approach to changing their unhelpful thinking styles.

IPT focusses on stressors in the patient’s interpersonal context and how they can make changes in their relationships with others, using the four domains (Table 1). The patient is encouraged to make changes in how they relate to their significant others and social network. This can be simply listed or undertaken by construction of a closeness circle, which graphically represents the patient’s interpersonal network (Figures 1a and b). It can be useful to guide the direction of therapy and can serve as a reference for progress. It also recognises that when people are depressed and anxious, it is not always because they have dysfunctional thoughts (e.g. if dealing with a serious illness).

Early research into CBT aimed at showing when its results were equal to or better than antidepressant medication use. Indeed, a multicentre study used IPT as a different form of psychotherapy to CBT to ensure that any improvements in the CBT groups were due to the effect of psychotherapy in general.³ From the outset, studies into the effectiveness of IPT have looked at the contributions made by IPT and antidepressant medications together and separately. IPT works well as a treatment on its own and works better in combination with antidepressant medications than CBT. GPs may be more comfortable prescribing an antidepressant and using the psychotherapy together. The importance of the ‘sick role’, as part of ‘the medical model’, is consistent with this finding (Box 2).⁶

How has IPT evolved?

IPT has become a well-accepted and empirically validated treatment for a variety of psychiatric disorders.⁶ Evidence has supported its use for a variety of mood disorders, anxiety disorders and eating disorders. IPT has the most evidence for its treatment of patients with depression, second only to CBT.⁵ The use of IPT has continued to expand internationally with bodies such as the Interpersonal Psychotherapy Institute in the USA (https://iptinstitute.com) providing ongoing training and accreditation.

Although the focus of IPT was originally on depression, it has since been used for several other conditions.⁷ Some of the adaptations are listed in Box 3.

CBT is the most commonly used psychotherapy for patients with depression, but not everyone can relate to its highly structured approach and it is not always applicable. There are also specific populations going through role transitions, such as those entering retirement or diagnosed with terminal illness and others engaged in interpersonal difficulties (either as disputes or attachment issues) where an IPT approach lends itself more intuitively to the therapeutic process (Table 2). These are also cases where a CBT approach may be useful for some specific issues before or after IPT. For example, it can be useful in identifying cognitions present as part of early relapse (relapse signature).

How can IPT be used in general practice?

Having an idea of the process and domains of interpersonal problems helps GPs provide a framework for understanding problems and identifying patients who would most likely benefit from an interpersonal approach to psychotherapy (Table 3, Box 4 and Figure 2).^2,8-12 This can be implemented by the GP themselves in the form of interpersonal counselling (IPC) or by referral to nursing or allied health professionals. Additionally, identification of a specific interpersonal focus of distress should trigger the GP to consider a provider trained in IPT as an alternative to CBT.

IPT works well with the medical model used in general practice and incorporates education about ‘the sick role’ and subsequent recovery. Unlike CBT, the IPT process is comfortable with concurrent prescription of medication, which may be an important aspect of therapy. GPs can assist in commencing and titrating medications, medical interventions and lifestyle modifications alongside the therapy (Box 1).

What is interpersonal counselling?

IPC is a simplified and manual-based form of IPT.¹³ It was developed for use in primary care for patients with depression and is for healthcare professionals whose backgrounds are outside mental health. It is highly structured and provides scripts to guide clinicians through the various stages over three to six sessions, again focusing on the same four domains as IPT (Table 3). It can be implemented by GPs with relative ease after training with the aid of supportive resources. It has been used by GPs in some settings and is a good way of learning about IPT. Resources for those interested in trying an interpersonal approach themselves or engaging practice nurses are given in Box 5. Details on finding an interpersonal therapist are provided in Box 6.

Conclusion

There is now a range of effective, manual- based, short-term psychotherapies, which provide GPs and their patients with choice. The growing interest in IPT comes from evidence showing it is as effective as CBT. IPT can be used for a variety of psychiatric disorders. It incorporates the ‘sick role’ and works well for patients who are medically ill or require medication. GPs or their practice nurses could undertake IPC using a manual-based approach in its current form, whereas formal training is required for IPT. MT

Acknowledgements

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