Tuesday, September 02, 2008

Interpersonal Therapy

By: Elizabeth Norton Lasley

Interpersonal therapy is based on the premise that depression often occurs along with the onset of a major life event involving relationships. In it, patient and therapist address depression specifically as it manifests in the patient’s life situation and relationships.

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Another form of psychotherapy was inspired by Aaron "Tim" Beck’s early efforts to hold cognitive therapy up to the same rigorous scrutiny as pharmacological interventions. In the 1970s, psychiatric epidemiologist Myrna Weissman and psychiatrist Gerald Klerman, both then at Yale University, developed what came to be known as interpersonal therapy as part of the first large-scale clinical trial using both drugs and psychotherapy to treat depression.

Interpersonal therapy is based on the premise that depression often occurs along with the onset of a major life event involving relationships—such as ongoing difficulties with a spouse, friend, co-worker or family member; the loss of a loved one; or the inability to form close attachments. In interpersonal therapy, the patient and therapist agree at the outset on an appropriate length of time for their work together—anything from a few weeks to more than a year, with a few months being typical. They then address depression specifically as it manifests in the patient’s life situation and relationships. Rather than focusing on thought processes about an event, the therapist will explore what led to the problem—disputes in job or family relationships, for example—and work out strategies to either improve the situation or move on from it. With better coping tools in place, the patient is more likely to respond to future problems in productive ways that don’t lead to depression.

Klerman strongly emphasized the need for psychotherapy to mimic clinical practice. Beck used his own not-yet-published manual, Cognitive Therapy of Depression, widely in his clinical trials. But most patients with depression received various untested therapies lumped together as “supportive therapy.” Klerman advocated describing interpersonal therapy with the same clinical rigor that Beck had used in his manual.

“We felt strongly that we had to test the efficacy of interpersonal therapy before advocating its widespread use,” says Weissman, who is now at Columbia University (Klerman died in 1992). Throughout the 1980s, she and others conducted their own clinical trials. Their manual was published in 1984 and has been revised several times; 2007 saw the publication of the Clinician’s Quick Guide to Interpersonal Psychotherapy, from Oxford University Press.

“Practitioners of interpersonal therapy share a close affiliation with Dr. Beck,” Weissman notes. “Both therapies are time-limited, although the limits can vary from a few months to several years. Both have guidelines strictly set down in manuals, have a strong diagnostic component and are designed to overcome depression.”

Cognitive therapy and interpersonal therapy remain the most widely used therapies for depression, Weissman says—and not only in affluent, industrialized countries. “We got a call one day from Paul Bolton at Johns Hopkins University, saying that World Vision International [a nongovernmental humanitarian organization] was interested in treating depression in Uganda. Dr. Bolton wanted to use interpersonal therapy,” says Weissman. “It was the most interesting request I’d had in a long time.”

Trials of interpersonal therapy in Uganda, a country ravaged by war, poverty and AIDS, have shown the approach to be remarkably effective, especially among women. Specifically, Uganda has had notable success in reducing the incidence of AIDS. Health workers there feel that combating depression is an important aspect of this success, since depressed people often engage in risky behavior. With the intensive involvement of local health workers, Bolton and Weissman, along with Helen Verdeli and Kathleen Clougherty of Columbia, tailored interpersonal therapy to a uniquely African setting—taking into account many differences in communication styles. For example: “When a woman in Uganda is angry at her husband, she doesn’t chew him out. She cooks him bad food,” says Weissman.

In an initial small clinical trial in Uganda, published in 2003 in the Journal of the American Medical Association, interpersonal therapy proved highly effective in reducing depression: after therapy only 6 percent of the treated group met the criteria for major depression, compared with more than half of the untreated control group.1

A 2007 study found similar results with another high-risk Ugandan group—teenagers displaced by war to refugee camps.2 Again, the difference was more striking among women. The reason is unclear, but Weissman suspects that alcoholism, much more prevalent in men, may play a role. She adds that interpersonal therapy and cognitive therapy are used all over the world, with texts translated into numerous languages. An international society of interpersonal therapy will be meeting in New York in March 2009.

 

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References

1.      P. Bolton, J. Bass, R. Neugebauer, H. Verdeli, K. F. Clougherty, P. Wickramaratne, L. Speelman, L. Ndgoni and M. Weissman. 2003. Group interpersonal psychotherapy for depression in rural Uganda. JAMA 289:3117–3124.

 

2.      P. Bolton, J. Bass, T. Betancourt, L. Speelman, G. Onyango, K. Clougherty, R. Neugebauer, L. Murray, and H. Verdeli. 2007. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: A randomized controlled trial. JAMA 298:519–527.



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Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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