Interpersonal Psychotherapy for Depression: A little bit of what you want to know Dr Roslyn Law Chair IPTUK National Lead for IPT and IPT-A in IAPT 1

2 Weissman MM (2006) A Brief History of Interpersonal Psychotherapy. Psychiatric Annals, 36: 8,

Translate depressive symptoms into the interpersonal context Trigger Consequence Context Maintaining 3

IPT two main objectives 4

What is IPT? 5

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IPT: What does it do? o IPT focuses on the relationship difficulties that are often very important to people experiencing depression and that are frequently identified as key features of their depression stories o IPT is primarily interested in the current conflicts, role changes, losses and difficulties in establishing and maintaining independent and satisfying relationships that so often trigger and maintain episodes of depression 7

Diagnosis Interpersonal Inventory Interpersonal formulation Contract Monitoring symptoms Interpersonal work Specific Techniques Separation responses Review of progress Resilience planning Contingency planning Maintenance contract Prevention of relapse Initial sessions 1-4 Middle sessions 5-2 Chosen focal area: Grief Interpersonal Disputes Role Transitions Interpersonal Sensitivity/Deficits Conclusions of acute treatment Sessions Maintenance (6mo-3years) TRAJECTORY PROCESS 8

Symptoms Interpersonal Inventory Focus Selection Contract Diagnosis Weekly symptom review Assist focus selection Psycho- education Patient as expert Decision re a/d meds & review schedule Review of current resources Social model of depression Mobilize available resources Review of current difficulties Clarify mood- interpersonal link Assist focus selection Guide to symptom discussion Guide to interpersonal discussion Clarify mood- interpersonal link Clarify treatment targets/goals Clear statement of focus, goals and expectations Initial symptom relief Populate timeline of depression Inform formulation Prepare for future sessions and predictable challenges Work on ending Timeline History of depression and treatment Sick role 9 9

Role Transition Role Disputes Grief Sensitivities Weekly symptom review Link symptoms to focal area Develop current relationships and skills Weekly symptom review Link symptoms to focal area Clarify communication problems Link symptoms to focal area Weekly symptom review Link symptoms to focal area Reconstruct and evaluate lost relationship Review and evaluate social support then and now Weekly symptom review Review +/- of old and new roles Explore process of changes and affect Identify key issues and expectations Develop involvement with current network Explore parallels across relationships Clarify recurring interpersonal problems Use therapeutic relationship as a model Develop new satisfying relationships 10

Explore feelings about ending and potential loss Explicit discussion of ending Review progress and highlight competence Evaluate therapy Maintenance plan Relapse prevention plan 11

Mechanisms of change in IPT Lipsitz & Markowitz (2013) o Enhancing social support o Develop resources and context to be soothed, contained and find meaning o Decreasing interpersonal stress o Target key interpersonal stressors and ameliorate negative contextual influences o Facilitating emotional processing o Development capacity for emotional awareness and regulation as a means of engaging interpersonal resources o Improving interpersonal skills o improving or adapting interpersonal skills essential to successful resolution of the current crisis or predicament.

Training in Evidence Based Practice Research evidence Patient + values + preferences Clinician observations ++ Quantifiable results Utility for clinicians Acceptable to recipients = Frueh et al (2012) Evidence-Based Practice in Adult Mental Health. Handbook of Evidence-Based Practice in Clinical Psychology. Published online. 13

Clinical evidence for IPT AuthorNumber of participantsNumber of sessions/duration Elkin et al (1989)23916 weekly plus optional 4 extra sessions Frank et al (1990)12812 weekly, 12 fortnightly, 3 years monthly Weissman (1992)356 sessions Schulberg et al (1996)27616 weekly, 4 monthly continuation sessions Reynolds et al (1999)808 weekly, 16 fortnightly, 2 years monthly Reynolds et al (1999b)107Treat to remission, 16 fortnightly, 3 years monthly De Mello et al (2001)3516 weekly, 6 monthly Freeman et al (2002)12416 sessions Reynolds et al (2006)1652 years Van Schain et al (2006)1435 months Blom et Al (2007)19312 sessions Luty et al (2007)17716 sessions Marshall et al (2008)10216 sessions Schramm et al (2008)12415 individual plus 8 group sessions Swartz et al (2008)479 sessions 14

Outcome data sample o PHQ-9 & GAD-7 data were gathered for a intention to treat sample of IPT patients in IAPT (London) o 165 patients o 18 therapists o 10 services 15

Cut off scores for Recovery PHQ-9 : below 10 is cut-off for recovery GAD-7 : below 8 is cut off for recovery WSAS:below 8 used as cut off for recovery Response: 50% reduction from baseline scores 16

Attendance 17

Focal Areas 18

% Recovery & Response (50% reduction) at session 8 and 16 19

Combined PHQ and GAD % Response and Recovery Rates 20

Mean Pre, Mid & Post Scores on PHQ- 9, GAD-7 & WSAS 21

Grief: Mean Pre, Mid & Post Scores on PHQ-9, GAD-7 & WSAS 22

Sensitivity: Mean Pre, Mid & Post Scores on PHQ-9, GAD-7 & WSAS 23

RD: Mean Pre, Mid & Post Scores on PHQ-9, GAD-7 & WSAS 24

RT: Mean Pre, Mid & Post Scores on PHQ-9, GAD-7 & WSAS 25

Outcome data sample PHQ-9 & GAD-7 data were gathered for a intention to treat sample of IPT patients 48 patients 7 therapists 6 services 26

Mean Pre/Post Scores PHQ-9 & GAD-7 27

% Recovery & Response (50% reduction) 28

IPT in IAPT 29

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Training Figures

Case management and supervision o Supervision is a condition of practice o Access to supervision is a condition of attending training o +ve: more than doubled the number of IPTUK registered IPT trainees, practitioners and supervisors during 3 years of IAPT o Limited supervision capacity but growing. Remote supervision (telephone/Skype) remains the norm 32

Case management and supervision For accreditation – Four cases completed under supervision – Must cover at least two focal areas – All sessions are recorded and three complete sessions are reviewed per case – Self assessment throughout supervision – 15 mins supervision per case per week Minimum of monthly IPT peer supervision following accreditation Distance supervision (telephone, Skype) is the norm 33

Challenges of IAPT A practitioner does not make a service – Where possible two trainees are recruited from each partnership Service targets v evidence based practice Ensuring protected time to learn and contribute to service transformation Baseline numbers of IPT practitioners and supervisors in IAPT are very small Working across adult and CYP services 34

IPT: In summary IPT is a time limited, evidence based treatment for depression in adults and adolescents. It targets key interpersonal issues that trouble many people with depression who seek treatment and collaboratively formulates a treatment plan to focus on their primary relationship difficulties It monitors symptom reduction and progress towards interpersonal goals on a weekly basis and has been shown to achieve outcomes that are equivalent or superior to existing treatment approaches for moderate to severe depression in people IPT combined with medication has repeatedly been should to achieve better outcomes in adults than either therapy alone for moderate to severe depression 35

Questions and comments 36