Interpersonal Psychotherapy for Older Adults
Summary and Keywords
In clinical practice with older adults, depression is a common presenting problem and is usually interwoven with one or more life problems. These problems are often the focus of psychotherapy. Interpersonal Psychotherapy (IPT) is a highly researched and effective treatment for depression in adults and older adults. IPT is time-limited, and as an individual psychotherapy it is usually conducted over 16 sessions. IPT focuses on one or two of four interpersonally relevant problems that may be a cause or consequence of depression. These include: role transitions (life change), interpersonal role disputes (conflict with another person), grief (complicated bereavement), and interpersonal deficits (social isolation and loneliness). The four IPT problem areas reflect issues that are frequently seen in psychotherapy with depressed older people.
In outpatient mental health settings that serve older adults, depression is one of the most frequent presenting problems. When compared to older people without depression, older adults with depression take longer to recover from medical problems, and they have higher rates of death (Snowdon & Almeida, 2013). Especially in the oldest old (85 years of age and older), the interaction among life circumstances, health, and mental health becomes increasingly complex and requires sophisticated clinical diagnostic acumen and a holistic approach to engagement and treatment of older individuals (Hinrichsen, 2016).
For both older and younger adults with depression, psychotropic medication and psychotherapy are the primary therapeutic modalities. Most older adults prefer psychotherapy to medication for depression (Arean, Alvidrez, Barrera, Robinson, & Hicks, 2002). In studies of mixed-age adults, psychotropic medication and psychotherapy generally have been found to have comparable efficacy (Cuijpers & Gentili, 2017). Some medical professionals may be reluctant to prescribe an antidepressant to an older person with complex medical problems because the patient is already taking numerous medications and the interactions among those medications may yield unfavorable side effects (“polypharmacy,” see Arnold, 2008). Almost four decades of well-designed clinical trials have found that a number of psychotherapies are effective in the treatment of depression (and other mental disorders) in late life (Scogin & Shah, 2012). Among these evidence-based psychotherapies is Interpersonal Psychotherapy for Depression (IPT).
Overview of Interpersonal Psychotherapy
IPT was developed in the 1970s by Gerald Klerman, Myrna Weissman, and their colleagues. Earlier versions of IPT were used in initial clinical trials of the treatment of depression in samples of mixed-age adults at Yale University (Klerman, Dimascio, Weissman, Prusoff, & Paykel, 1974). IPT was one of two psychotherapeutic treatment modalities (the other was cognitive behavioral therapy [CBT]) used in the large, multisite treatment study in the 1980s called the NIMH Treatment of Depression Collaborative Research Program. The Collaborative Research Program addressed a fundamental question: Do medication, psychotherapy, or a combination of the two work in the treatment of major depression? The general answer was yes, and also that IPT was effective in the treatment of depression (Elkin et al., 1989). The success of IPT in the treatment of depression built interest and enthusiasm among depression researchers in using IPT in other clinical trials. Forty years of research consistently has found that IPT is an effective treatment for depression in varied age groups. Meta-analyses have concluded that IPT and other psychotherapies are powerful interventions that decrease depression and enhance people’s ability to contend with life problems associated with the depression (Cuijpers et al., 2011).
The implementation procedures of IPT used in the NIMH Collaborative Research Program were summarized in the original IPT treatment manual, Interpersonal Psychotherapy of Depression (Klerman, Weissman, Rounsaville, & Chevron, 1984). This was updated by Comprehensive Guide to Interpersonal Psychotherapy (Weissman, Markowitz, & Klerman, 2000). The most current summary and statement of IPT is The Guide to Interpersonal Psychotherapy: Updated and Expanded Edition (Weissman, Markowitz, & Klerman, 2017). Other IPT books and treatment manuals exist. The history of IPT is extraordinary since there have been many adaptations of this therapy that generally have demonstrated meaningful clinical efficacy (Weissman, 2006). The foundation of IPT rests on its original format, which is as an individual therapy. Over the years, IPT has been adapted to other forms including marital/dyadic and group. Its length has been adapted from the original 16-week version to briefer versions and a monthly “maintenance” version was developed that is delivered after the initial “acute” treatment of 16 weeks. It has been used in the treatment of mental disorders other than depression including bipolar disorder, eating disorders, personality disorder, and posttraumatic stress disorder. IPT has been studied in specific populations including adolescents, adults, older adults, HIV-positive individuals, military service veterans, post- and perinatal depression, primary care, and other medical groups. Perhaps most intriguing is that IPT has been used successfully in the treatment of depression in other cultures and countries including the first randomized controlled clinical trial in Africa in the 1990s (Bolton et al., 2003). International studies of IPT have been conducted in Asia, Africa, Australia/New Zealand, Europe, and the Middle East with clinical outcomes that support its efficacy. In clinical treatment guidelines, IPT is recommended as a treatment for depression in the United States (American Psychiatric Association, 2000), the United Kingdom (National Institute for Health and Clinical Excellence, 2004), and New Zealand/Australia (Ellis, 2004).
The Structure, Goals, Techniques, and Ethos of IPT
IPT is a time-limited treatment for depression. As noted earlier in this introduction, the original format of IPT was as an individual psychotherapy delivered over 16 weekly sessions. The overall purpose of IPT is to improve the patient’s depression and improve capacity to contend with interpersonally relevant life events that appear to have triggered the depression or that followed the depression. IPT is delivered in three phases: The initial sessions (weeks 1–3), the intermediate sessions (weeks 4–13), and termination (weeks 14–16) (Weissman et al., 2000). Within the intermediate sessions, treatment focuses on one or two of the IPT problem areas: role transitions (life changes), interpersonal role disputes (conflicts with a significant other), grief (complicated bereavement), and interpersonal deficits (social isolation and loneliness). Goals and strategies are outlined for each of the four IPT problem areas. The therapist uses a variety of therapeutic techniques in service of achieving the goals and strategies for each of the IPT problem areas.
The Initial Sessions (1–3)
The initial sessions are the assessment phase of the treatment during which a number of tasks are completed.
Assessment and Education About Depression
The patient’s depression is assessed using clinical interviewing and often standardized depression assessment instruments. The depression is characterized within the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) psychiatric nomenclatures. The therapist reviews the symptoms with the patient, explains that they are part of depression, and may provide the patient with the formal name of the depressive syndrome and meaning of scores obtained from a depression rating scale. The status of the depression is evaluated throughout the course of IPT. Information is provided about usual treatments for depression (i.e., psychotherapy, medication, or a combination of the two), the fact that depression is a treatable condition (i.e., the patient should be hopeful about the likelihood of improvement), and an initial discussion of whether the patient might be interested in antidepressant medication if not currently taking it. The patient is educated about the functional impact of depression (i.e., that it impairs ability to function), and a discussion is undertaken about whether the patient could temporarily reduce some responsibilities or get assistance from others until feeling less depressed. The latter is called “giving the sick role” in IPT. The notion of sick role comes from the sociological literature that has documented that it is normative to give individuals suffering from health problems (e.g., broken arm, suffers from influenza) temporary reprieve from daily responsibilities until they are better. The intent of this sick role discussion is to convey that depression is an illness and to reduce self-blame for poor functioning, convey an appreciation to the patient for efforts made to function despite having depression, and reduce some daily stress.
Likely Trigger(s) to Depression
Gaining a rough chronology of the onset of the depression and possible trigger(s) helps the therapist begin to think about the IPT problem area(s) that will be the focus of treatment. Sometimes individuals feel they have been depressed for a “long time”; however, with assistance from the therapist they can usually identify when the depression worsened.
The Interpersonal Inventory
The interpersonal inventory is a broad and brief review of past and current important relationships in the person’s life. The inventory is typically conducted in the second IPT session and often completed in the third session. The therapist is interested in positive and negative aspects of the relationship, things the individual would like to change about the relationship, and whether the relationship might be tied to the current depression. Usually, the therapist spends no more than 10 minutes on each individual. The inventory helps to clarify interpersonal strengths and weaknesses, a possible pattern of conflict across relationships, whether the patient has a dispute with a given individual who is tied to the depression, and if that dispute might be an IPT problem area during treatment.
The Interpersonal Formulation and Plan for Treatment
Typically in the third session the therapist provides an understanding of the patient’s issues and recommends a plan for treatment. The therapist reviews the current presenting depressive symptoms and reminds the patient that depression is treatable and the patient should be hopeful about the outcome of treatment. The apparent precipitant/consequence of the depression is reviewed. The IPT problem area or area(s) then is identified and a rationale provided to the patient about why it will be a treatment focus (i.e., tied to the depression). The patient is asked whether there is concurrence with the formulation. If the patient concurs, then the therapist outlines the plan for the remaining treatment including its goals, structure, expectations about attendance and other administrative matters, and number of remaining sessions. If the patient does not concur, further discussion is warranted to clarify concerns or questions. Some patients might prefer a treatment modality different than IPT.
The Intermediate Sessions (Weeks 4–13)
During the intermediate sessions the therapist continues to evaluate the status of the depression and focuses sessions on the identified problem area(s) that have been agreed upon. Therapeutic goals and strategies are outlined for each of the IPT problem areas. The broad therapeutic goals for each of the IPT problem areas are given below.
The IPT Problem Areas
Everyone experiences life transitions and, for some, they result in an episode of depression. For an adolescent a role transition may include going to college, for an adult it may be having a child, and for an older adult it might be retirement. The IPT goals for role transitions include coming to emotional terms with changed life circumstances and building skills to better manage demands of the new role.
Interpersonal Role Disputes
Relationship problems are a common focus of psychotherapy in outpatient mental health settings. Common role disputes for older adults include those with spouse/partner, adult child, and siblings. Sometimes role disputes are with an organization such as a health or supportive care setting. IPT goals include clarifying the issues in the dispute and whether the patient’s expectations about the other party are realistic. The patient then is encouraged to change expectations and/or acquire the skills to improve the relationship.
Most individuals go through a process of grieving the death of an important person that involves emotionally and practically contending with the loss. For some, the process of grieving is more difficult than for others—sometimes called “complicated bereavement.” Some individuals with complicated bereavement have symptoms of depression mixed with those of grief (although demarcating symptoms of grief from depression may be challenging). The IPT goals for grief include facilitation of the grieving process and reestablishment of a life pattern that is more meaningful and satisfying. In the treatment of grief, a common focus of IPT with adults is loss of parent, spouse/partner, child, or sibling.
Interpersonal deficits (which some IPT therapists call “social isolation/loneliness”) are evident among individuals who would like interpersonal connections but who find it difficult to initiate or sustain them. The goals of IPT include reduction in the patient’s social isolation and encouragement of the formation of some new relationships.
The IPT treatment manual outlines a wide variety of therapeutic techniques that can be used by the therapist in service of achieving treatment goals and strategies. These techniques are not unique to IPT and are used in other therapies, too. Commonly used techniques in IPT include the following.
Some Commonly Used IPT Techniques
The patient is asked by the therapist to describe, in detail, a recent interaction with another person which is usually tied to the depression. For example, the therapist would want to know what preceded the interaction, what each party said to the other, how the patient was feeling during the interaction, what was the other person’s position understood to be, what was hoped to have been achieved in the interaction, and what could have been done differently.
The therapist encourages the patient to clarify a problem, generate options to address it, identify advantages and disadvantages of different options, and then choose one or more options.
Interpersonal Skills Building
Some individuals lack fundamental skills to address interpersonal problems. Skills building may include identifying the desired outcome of a conversation, finding the right time to talk, using productive ways to engage the other person in a conversation, managing one’s own emotions during the conversation, and being prepared to constructively respond to the different ways the conversation could go (e.g., the other party gets angry).
The technique of role play engages the patient in enactment or reenactment of a conversation. The patient may play himself (or herself), the party to a dispute, or both. Role play may help the patient practice an important conversation in advance as well as get feedback and guidance from the therapist.
These are between session efforts to take steps to address some aspect of the identified problem area. An example of these techniques for a patient with interpersonal role disputes is the following: The patient talks in detail about a recent argument with his wife (communication analysis). He then thinks about ways to address conflict with his wife, which includes a decision to talk with her about differences (decision analysis). The therapist talks with the patient about potentially productive ways to go about having a conversation with his wife (interpersonal skills building). Then the patient practices what he wants to say to the other person in conjunction with the therapist (role play). The patient then has the planned conversation with his wife (work-at-home) and returns to discuss the outcome with the therapist in the next session.
Termination is discussed from the beginning of therapy, since the patient is told that the treatment is time limited. The therapist periodically reminds the patient of the number of remaining sessions. The last three IPT sessions are devoted to termination although for many patients two sessions are sufficient. (1) Feelings about ending. The end of therapy is explicitly discussed along with feelings the patient may have about ending (e.g., relief, disappointment, fear). (2) Status of the depression and problem area. The degree to which the patient’s depressive symptoms have changed during the course of treatment is reviewed often by examining the accumulation of depression rating scales that are used throughout the therapy. For example, the patient’s Patient Health Questionnaire (PHQ-9; scores range from 0–27) depression rating scale score was initially 21 (severe depression) and is now 5 (mild depression). Furthermore, the patient no longer meets criteria for a major depressive episode. The extent to which the patient feels progress has been made in the identified problem area(a) is discussed along with the therapist’s assessment. (3) Future problems and warning signs of onset of depression. The therapist engages the patient in a discussion of potential future problems and how they may be addressed with skills that have been acquired during the course of IPT. The therapist also helps the patient to identify the characteristic initial symptoms of depression for that individual (e.g., “I lose interest in bowling,” “I get irritable with my spouse”). Options to address the onset of depressive symptoms in the future are explored (e.g., alert my primary care provider, call the therapist for a follow-up appointment). (4) Non- or partial response and possible additional treatment. Some patients do not respond to IPT. That is, depression did not significantly improve, substantive progress has not been made in the identified problem area, or both. Or there is only partial improvement. Lack of or partial response is explicitly discussed, and the patient is then engaged in a discussion of other therapeutic options (e.g., extend the number of sessions of IPT, try a different therapeutic modality, change therapists, start an antidepressant medication). Also, as noted earlier, there is a monthly “maintenance” version of IPT that has been shown to reduce the risk of depressive relapse. Maintenance IPT, following the initial course of IPT, may be an especially good option for individuals with recurrent depression.
The IPT Therapeutic Ethos and Stance
Throughout the treatment, the therapist continues to monitor and discuss the depression along with current and past life circumstances associated with it. In one sense, the depression is a third party in the therapeutic room. The therapeutic ethos of IPT is: (1) There are always options to deal with life circumstances (versus the hopelessness and helplessness often part of depression). (2) “That’s your depression talking” (versus believing who you “are” is the depression). The stance of the therapist includes: (1) Active collaboration with the patient; (2) conveyance of hope that things will improve (based on solid research that treatment for depression works for most people); (3) continual education about the connection between depression and interpersonally relevant life events; and (4) ongoing encouragement to address life problems tied to the depression.
Interpersonal Psychotherapy for Depressed Older Adults
Early in the history of IPT, some noted that it seemed particularly well suited to address problems seen in clinical practice with depressed older adults (Sholomskas, Chevron, Prusoff, & Berry, 1983). Clinical experience and subsequent research support that view. IPT’s collaborative and active engagement with the patient as well as its focus on problem solving are generally consistent with recommendations for doing psychotherapy with older adults (Knight, 2004). The IPT problem areas are also consistent with the field of gerontology’s historical concerns about later life role loss, widowhood, functional decline, and associated social isolation. IPT does not require much adaption when used with older people (Hinrichsen, 2008). However, those who provide clinical services to older adults should possess the attitude, knowledge, and skills relevant to this population that are obtained in a substantive fashion (see e.g., American Psychological Association’s Guidelines for Psychological Practice with Older Adults [APA, 2014] and the Pikes Peak Model for Training in Professional Psychology [Knight, Karel, Hinrichsen, Qualls, & Duffy, 2009]). In clinical practice, IPT outcomes appear comparable to those found in research studies (Hinrichsen & Clougherty, 2006). IPT is included among evidence-based treatments that are recommended for use with depressed older adults by the Substance Abuse and Mental Health Services Administration (2011). IPT has been adapted for cognitively impaired older adults (Miller, 2009).
As noted in the introduction, a large corpus of studies has consistently demonstrated the efficacy of IPT in the treatment of depression and other mental disorders and varied populations. Some of these studies included “mixed age” samples with older persons. A much smaller body of work has specifically examined the efficacy of IPT in the treatment of late-life depression. Two early small pilot studies of IPT with depressed older adults indicated it was a promising treatment (Rothblum, Sholomskas, Berry, & Prusoff, 1982; Sloane, Staples, & Schneider, 1985). A subsequent study found that a brief form of IPT was efficacious in reducing depressive symptoms in older adults with medical problems (Mossey, Knott, Higgins, & Talerico, 1996). Researchers in Holland found that IPT was effective in the treatment of moderate to severe depression in older adults in primary care but not for those with mild depression (Van Schaik et al., 2006). Two “continuation/maintenance” studies were conducted at the University of Pittsburgh using IPT with older adults. In the first study, the combination of (monthly) IPT and antidepressant medication reduced the likelihood of relapse in depressed older adults (Reynolds et al., 1999). In the second study, only antidepressant medication reduced risk of relapse but not (monthly) IPT (Reynolds et al., 2006). The age of participants in the second study was much older than in the first study, which may have explained the difference in outcomes. Another relevant report is from the U.S. Department of Veterans Affairs’ (VA) national effort to train VA mental health clinicians in evidence-based treatments including IPT (Karlin & Cross, 2014). The IPT initiative included a sizeable number of older veterans (i.e., a total of 45.2% were of pre-Vietnam, Vietnam, and post-Vietnam military service eras). A program evaluation found that IPT was associated with large reductions in depression as well as improvement in quality of life among veterans, many of whom were very depressed. Further, the report found that during the course of the six-month training, the vast majority of VA clinicians demonstrated competency in conducting IPT (Stewart et al., 2014).
IPT can be successfully taught to most psychology graduate students, interns, post-licensure psychologists, and social workers with and without a substantive mental health background (Hinrichsen & Iselin, 2014). Consistent with IPT training models, the trainee attends an IPT workshop, reads the IPT training manual, conducts IPT with 2–3 patients with sessions audio or videotaped, and meets weekly with the IPT consultant who provides feedback on taped sessions and guidance to the trainee.
Common IPT Problems in Depressed Older Adults
In clinical practice, role transitions are the most common issue addressed in older adults treated with IPT (Hinrichsen, 2008; Hinrichsen & Clougherty, 2006). Common role transitions include: onset or exacerbation of health problems, care for a family member with health or cognitive difficulties, residential move, financial problems, and change in work status. The next most common IPT problem area is interpersonal role disputes. Common parties to disputes include spouse/partner, adult child, and sibling. For older adults contending with grief, death of spouse/partner, adult child, sibling, and lifelong friend are most common. Interpersonal deficits (social isolation, loneliness) are not frequently seen in clinical practice. That may be because older adults often seek mental health services at the behest of another person, and individuals with interpersonal deficits are less likely to have those facilitating relationships. The author’s colleagues who work in long-term care settings report seeing a larger number of older adults with what could be characterized as interpersonal deficits than in outpatient mental health settings. The clinical training manual for IPT with older adults is Interpersonal Psychotherapy for Depressed Older Adults (Hinrichsen & Clougherty, 2006). Also see Clinician’s Guide to Interpersonal Psychotherapy in Late Life: Helping Cognitively Impaired or Depressed Elders and their Caregivers (Miller, 2009).
A Case of IPT in the Treatment of Role Transitions in Later Life
The following is a case of a depressed older adult treated with IPT. (The names are fictitious and identifying details have been changed.)
The Initial Sessions
Assessment and Education About Depression
Bob was a 75-year-old, white, widowed, retired, gay man who had lost his husband three years earlier. The patient had several chronic illnesses and was taking three medications for them. Bob said that he felt depressed on and off since childhood. However, in the last six months his depressed mood worsened. Bob’s current symptoms of depression included anhedonia (loss of interest or pleasure), depressed mood, self-criticism, lack of energy, concentration difficulties, problems staying asleep at night, and passive suicidal ideation. The Patient Health Questionnaire (PHQ-9) was administered. The PHQ-9 is a popular screen for depression in primary care and contains the nine items associated with the DSM major depressive episode. Bob obtained 22 on this measure, which is characterized as “severe depression.” Based on history and current symptoms, Bob met criteria for DSM Persistent Depressive Disorder (formerly known as Dysthymia) as well as Major Depressive Disorder, recurrent, moderate severity. This combination of two depressive disorders is sometimes called “double depression”: in addition to ongoing “low level” depressive symptoms an individual has a discrete episode of major depression (Keller, Lavori, Endicott, Coryell, & Klerman, 1983). Using the Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, De La Fuente, & Grant, 1993). Bob scored 17 out of 40, which indicated a problem with excess alcohol use. On inquiry, Bob said that he had the equivalent of three to five standard drinks each evening.
The therapist discussed the diagnoses with Bob and the PHQ-9 score and its meaning. Bob said he was not surprised. Bob was advised that his consumption of alcohol exceeded healthy alcohol-use guidelines for older adults (i.e., 7 standard drinks per week) and that it was not uncommon for depressed people to use alcohol to feel better. In the longer run, however, depression is worsened by excess alcohol use. Bob said that he would not change his drinking pattern. Despite feeling he was prone to depression throughout his life Bob had never sought mental health treatment for it. Further education about depression was provided to Bob. That is, depression could be successfully treated with psychotherapy, antidepressant medication, or both. The therapist advised that in view of his lifelong experience with depression, it would be wise to consider obtaining a consultation about starting an antidepressant. Bob said that he did not want to do that because he already felt he was taking too many medications. The patient said that it was hard for him to function because of his depression. The therapist responded that this was part of depression and that in fact Bob functioned reasonably well despite his depression. He was asked if, in the short run, he might take some pressure off himself and reduce a few daily responsibilities (or get some help for them) until he was feeling better. In IPT this is called “giving the sick role.” He said he would think about it.
Likely Trigger(s) to Depression
Bob said that his husband Carl had died three years earlier. They had been a couple for almost 30 years and married in recent years when that became possible. Carl was increasingly ill over a period of two years during which time Bob provided care to him. Bob grieved Carl’s death: their relationship had generally been a good one. After a year, he began to wonder whether he wanted to remain on the East Coast where he and Carl had lived for many years. He had gone to college and graduate school in Chicago—and over the years he had remained in contact with friends there. He moved to Chicago where he had lived the last one and a half years. After a year, he wondered whether he had made the right decision, since Chicago seemed different than in earlier years, his friends were not as engaged in his life as he had hoped, and the house that he purchased had unexpected problems. It was at that point he began to get more depressed. He also began to drink more. To understand whether unresolved grief over Carl’s death was tied to the depression, the therapist inquired more about this issue. Bob said that Carl’s loss was difficult but that he felt he had come to terms with his death, appreciated that he had sustained a meaningful relationship in his life, and was ready to move on. However, he wondered if he had moved to the wrong place.
In the second of the initial sessions, the therapist conducted the interpersonal inventory, which is a broad and brief review of past or current relationships. Bob discussed his father, mother, brothers, Carl, and some important Chicago and East Coast friends. Bob felt that the death of his father during childhood had set the stage for his propensity for depression. He demonstrated a history of meaningful relationships with others. He expressed disappointment that his Chicago friends were not as engaged with him as he had hoped. He wished that his brothers and their families were more involved in his life, but this was a long-standing concern.
Interpersonal Formulation and Plan of Treatment
In the third of the initial sessions, the therapist provided feedback to Bob. “As we discussed, you’ve got what the mental health field calls a major depression along with a longstanding low grade depression with which you’ve had to contend throughout much of your life. On the rating scale that I gave you on our first meeting, you had a score of 21 which is ‘severe depression’—something that we will monitor throughout therapy. Your worsening of depression started about a year after you moved to Chicago. It was harder for you to make the transition to Chicago than you had expected: the city changed, friends were not as engaged as you had hoped, and you wondered whether you made the right choice. Once you became more depressed it was much harder to do the things that you wanted including taking care of your house problems and engaging with your friends. Does that make sense?” Bob said that it did. “Further, as you got more depressed, you began to drink more. As I told you, you’re drinking much more than is recommended and it is likely making the depression worse.” “I’m not going to reduce my drinking,” remarked Bob. “It’s your choice, but it is something I want to continue to discuss with you. One other issue I discussed with you at the beginning is an antidepressant medication. I want to restate that I think it would be useful to talk with a prescriber about the possibility of starting an antidepressant. As we discussed, both psychotherapy and antidepressant medication have been shown to be helpful in reducing depressive symptoms.” Bob said that he did not want to do that.
The therapist advised that the focus of IPT would be on helping him to deal with his new life circumstances in Chicago, since those appeared tied to the onset of his major depression. (In IPT this would be characterized as a role transition.) At the end of IPT, the therapist said he expected Bob would be able to better handle this life transition and that he would be less depressed. They would meet weekly for the remaining 13 sessions. Bob concurred with the treatment plan.
The Intermediate Sessions
The broad goals of IPT’s role transitions are: Coming to emotional terms with changed life circumstances and building skills to better manage the demands of the new role. The therapist helped Bob achieve these goals by generally keeping sessions focused on role transition–related issues (versus other topics that were not tied to depression nor the challenges of his move to Chicago). At the beginning of each of the intermediate sessions the therapist discussed with Bob the status of his depression. He did this by asking Bob to subjectively rate the severity of his depression, on average, in the prior week (1=Not at all depressed, 10=Most depressed). Some therapists ask the patient to complete the PHQ-9 or other standard rating scales in advance of the therapy sessions, which are then reviewed. I have found that the subjective rating of depression is a good gauge of changes in depressive symptoms. When symptoms change from week to week, it is helpful to clarify what was different in the last week. For example, when Bob was less engaged with other people, he felt more depressed and vice versa. This tie between mood and events helped him to better understand why making efforts to more successfully engage with others yielded emotional benefits. Although Bob did not want to reduce his use of alcohol, the therapist periodically inquired about alcohol use.
The first of the intermediate sessions were focused on his life before he moved to Chicago. He discussed his life with Carl, their friendships, their respective work lives, the advantages of living in a suburban community, and related issues. Carl was an especially gregarious person who connected easily with others. Many of his friends became “their friends” including individuals and couples. Bob often took a supportive role in social gatherings—shopping, cooking, and serving. He felt comfortable in this role while Carl took social center stage. Since Carl had a successful and lucrative career, at some point Bob changed from full- to part-time work and then retired early. This change made him even more dependent on Carl as a source of social connections. At times, however, he resented that people seemed less interested in him than Carl. In the course of these sessions, Bob became tearful, wishing he could have his “old life” back when things seemed so much easier. He wondered whether he had made the right decision to move to Chicago.
Subsequently he began to talk about his current life. Going to Chicago seemed like a good idea: He had lived there before, maintained contact with friends from that period, and he liked living in the city when he was younger. He bought a home in Chicago, but there were immediate problems with the heating, not to mention the roof leaked. Carl had always taken care of this kind of thing, and he found dealing with contractors stressful. He realized that while living in a big city may have been fun when he was young, he now found it “a bit too much.” His friends seemed happy to see him, but they were less available than he had imagined. He always had contended with depressive symptoms, but Carl helped him manage his depression with support, encouragement, and engagement with others. Now nobody played that supportive role. Bob noticed that his depression worsened. As he became increasingly depressed, he found it more difficult to reach out to his friends, which only made him feel worse. At some point he was unresponsive to some of their efforts to socialize. He began to think he had made a bad choice moving to Chicago, and eventually he experienced a major depression. And he began to drink more.
The therapist helped Bob understand that the transition to a new city would be stressful for most people. He was a on a bit of a downward spiral (do less, feel more depressed, do less . . .) The therapist asked Bob to engage in the technique decision analysis. What options did he currently have to improve his current situation? Bob generated a number of options and associated pros and cons of each option: (1) Move back to his former home. (Pros: it will be more familiar. I can reengage with my old friends. I like suburban living. Cons: Carl won’t be there. It won’t be like it was). (2) Sell his house and get an apartment in Chicago (Pros: I won’t have to deal with the hassle of owning a house. A superintendent takes care of things in an apartment. Cons: I won’t be able to have the space I’m used to). (3) Move to the small town he had grown up in and where his brothers and their families lived. (Pros: I will be close to my family. Cons: I’ll be the only gay person in town. I never really liked that town. I won’t be close to my Chicago friends. I like being close to cultural events in Chicago). (4) Move “somewhere else” (Pros: It might be better. Cons: It might be worse. Where would I move?). Bob found this process helpful. It facilitated emotionally coming to better terms with the fact that his life with Carl was over and that there were more advantages than disadvantages of staying in Chicago. However, he might want to move to an apartment when he was a bit older. His depression lessened, and by the eighth session his PHQ-9 was 13. He voluntarily reported that he was drinking less and was feeling better.
Many of the remaining intermediate sessions focused on ways that Bob could reengage his friends and establish a daily routine that took him out of his home. His weekly mood ratings continued to show improvement, and improvement was tied to more frequent engagement with friends and attending cultural events. He considered doing volunteer work. His friends commented he seemed more cheerful and relaxed.
Throughout treatment, the therapist reminded Bob of remaining sessions. At the end of the 14th IPT session, the therapist reminded Bob that the last two sessions would be devoted to wrapping things up. In the coming week he asked Bob to think about how things had gone during therapy, his feelings about ending, and thoughts about the future. Feelings about ending. Bob said that he felt a mixture of relief, pride, and fear about ending. He felt relief because initially he did not want to be in therapy and only did it at the urging of one of his brothers. He felt pride because he was less depressed—and also that he had substantially reduced his drinking. He was fearful because he wondered how he could manage things by himself. Status of the depression and problem area. The therapist administered the PHQ-9, which was 5 (“mild depression”). Further, Bob no longer met criteria for major depression. Bob concurred that his depression was much improved. He felt that he had a better handle on his transition to living in Chicago. He said it was helpful to take stock of his old life with Carl and then think about his options, which included leaving Chicago. “When I was depressed I just felt stuck and mad at myself for having moved to Chicago. It didn’t occur to me that there were other possibilities.” Future problems and warning signs of the onset of depression. The therapist encouraged Bob to think about things that could come up in the near future with which he would have to contend. He identified: more house problems, and less availability of his friends to socialize than he would like. Options included: asking his brother about how to better deal with contractors and following up on volunteer work to fill more of his time. Bob was advised that many people have characteristic “early warning signals” that depression is coming or worsening. Bob said that he noticed that he began to have more sleep problems when his depression worsened. If that were to happen, he said he would call the therapist—or even consider an antidepressant medication. Non- or partial response to treatment and possible additional treatment. Bob did respond to treatment. In view of his long history of depression, the therapist suggested that Bob continue for monthly “maintenance” visits with the therapist for the next six months. Bob agreed with this plan.
Almost 25 years ago this author was trained in IPT. As a geropsychologist, he had treated many cases of depression in older adults. He found that IPT was a great fit for older adults. Further, IPT provided a theoretical, research-supported, clinical framework for conceptualizing and treating late-life depression. The author believes that he improved as a therapist and obtained better clinical outcomes with IPT. He has found in clinical practice that almost all older patients complete the planned course of IPT. With substantive training and supervision, almost all the students and mental health professionals this author has worked with achieved competence in the provision of IPT.
Along with CBT, IPT is the most highly recommended psychotherapy for depression. The practical challenge is that IPT is not usually taught in psychology graduate programs nor psychology internships; and it is not commonly taught in psychiatry nor in social work programs (Weissman & Sanderson, 2002). Notwithstanding substantive efforts by the Department of Veterans Affairs to train VA clinicians in IPT and other evidence-based treatments, post-licensure mental health workers may be challenged to find venues to formally learn IPT. The International Society of Interpersonal Psychotherapy (ISIPT) is the global organization for promoting, disseminating, and researching IPT. Interested readers may want to access the ISIPT, which contains training resources.
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