From the Editor

What’s new in psychotherapy?

If there is one area of psychiatry that seems to have been transformed in recent years, it’s psychotherapy. Not surprisingly, then, past Readings have looked at the expanded role of short-term, evidenced-based therapies – in particular, Cognitive Behavioural Therapy, or CBT.

Today’s psychotherapy: a long way from Freud

Over the next two weeks, we’ll look in more detail at new developments in psychotherapy.

This week. A major new review of IPT.

Next week. An overview of psychotherapy developments.

This week, we consider a new paper published in The American Journal of Psychiatry on Interpersonal Therapy, or IPT. This paper is clear, lucid, and worth reading.

Is there evidence for IPT? Yes – and more than just for depression.

DG

 

Review of IPT

“Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis”

Pim Cuijpers, Tara Donker, Myrna M. Weissman, Paula Ravitz, Ioana A. Cristea

The American Journal of Psychiatry, 1 July 2016

http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2015.15091141

Interpersonal psychotherapy (IPT) is a structured, time-limited psychological intervention that was developed for the treatment of major depression in the 1970s. Since then, numerous randomized controlled trials have shown that IPT is indeed effective in the treatment of depression, that it may be more effective than other psychotherapies for depression, that it may prevent relapse after successful treatment of depression, that it may prevent the onset of major depressive disorders in those with subthreshold depression, and that it is also effective in specific target groups, such as adolescents, older adults, and patients with a somatic disorder.

IPT focuses on stressful life events of grief, interpersonal disputes, life transitions, or social isolation or deficits that are associated with the onset, exacerbation, or perpetuation of current symptoms, while helping patients to connect with social supports and to improve the quality of their relationships. The beginning phase tasks include the forming of a therapeutic alliance, conducting a psychiatric assessment with an extended social history and interpersonal inventory, providing psychoeducation, instilling hope, and choosing an interpersonal focus. During the middle phase, interpersonal problem-specific therapeutic guidelines are applied. In the concluding phase, gains are consolidated, and adaptive interpersonal strategies and contingency plans in the event of relapse are reviewed.

Since IPT appeared to be effective in the treatment of depression, researchers and clinicians started to use it for other mental health problems, including eating disorders, substance use disorders, anxiety disorders, and several others.

Few systematic reviews examined the effects of IPT.

Pim Cuijpers

So opens a review paper by Pim Cuijpers et al., recently published in The American Journal of Psychiatry. They review the literature and draw big conclusions.

Here what they did:

· They considered IPT papers, starting with a search of four databases (PubMed, PsychInfo, Embase, and Cochrane Register) with search terms for IPT and search filters for randomized trials. Randomized trials were included for mental disorders where IPT was compared to a control condition or an alternative treatment.

· IPT needed to be based on manuals developed by Klerman and Weissman or a briefer version, called interpersonal counselling.

· Inclusion criteria: any mental health problem, any age group, any language, and studies on acute, preventive, and maintenance treatments. (!!)

· The selection of studies was conducted by two independent researchers, and used the four criteria of the Cochrane Risk of Bias Assessment Tool.

· Statistical analyses were done. “For each comparison between IPT and a control or comparison group, the effect size indicating the difference between the two groups at posttest was calculated (Hedges’ g)…”

Here what they found:

· “The 90 studies included a total of 11,434 participants (4,422 in the IPT conditions, 2,906 in the control conditions, 1,823 in the comparisons with other psychotherapies, 1,464 in the comparisons with pharmacotherapy, and 819 in the comparisons with combined treatment of IPT plus pharmacotherapy).”

· “The majority of trials (69%) were targeted at depression; eight were aimed at eating disorders, another eight at anxiety disorders, and 12 at other mental health problems.”

· Effects of IPT Compared With Control Groups as Acute-Phase Treatment of Depression – The majority of papers focused on depression and IPT. They found: “The effect size indicating the difference between IPT and control conditions at posttest was g=0.60…” That’s the equivalent of a number needed to treat of 3. (!)

· IPT and Antidepressant Medication for Acute-Phase Depression – “The combination of IPT and antidepressant medication was compared with IPT alone in seven studies… and resulted in a significant effect in favor of combined IPT and antidepressant medication (g=0.24)…”

· Preventing the Onset or Relapse of Depressive Disorders With IPT – “The combination of maintenance IPT, once-monthly, plus daily pharmacotherapy was significantly more effective in preventing relapse than pharmacotherapy alone (odds ratio=0.34… number needed to treat=7) and more effective than once-monthly maintenance IPT alone…”

· The Effect of IPT on Anxiety Disorders – IPT against alternative treatments favoured the latter. But “IPT was compared with control conditions in three studies, and this resulted in large and significant effect sizes for anxiety outcomes (g=0.89… number needed to treat=2) and depression outcomes (g=0.82… number needed to treat=2).”

· The Effect of IPT on Eating Disorders – “IPT for eating disorders was examined in eight studies… IPT was compared with another type of psychotherapy in six studies with eight comparisons. The effect size of all outcomes showed no statistically significant difference (g=–0.15… number needed to treat=12 in favor of the other psychotherapies)…” Two studies directly comparing to a control group did yield a statistically significant result.

· The Effect of IPT on Other Mental Health Disorders – “We identified 12 trials in which IPT was used to treat other mental health problems, ranging from other mental disorders to distress in patients with general medical disorders, substance abuse, and obesity risk in girls… Because these trials were singular studies, the effect sizes were not pooled and no further analyses were conducted.” That said, see table below – the pattern is clear.

They conclude:

In conclusion, IPT is one of the best-examined treatments in mental health problems, and it is effective in depression and possibly in other disorders, such as eating and anxiety disorders. It is important to have more than one treatment option for patients, since no treatment works for everyone, and IPT, with its focus on salient relational and interpersonal experiences, provides an important alternative to pharmacotherapy or CBT. IPT has the potential to be used more broadly for endemic mental health problems, as a preventative treatment, and to address the concomitant interpersonal stressors associated with the onset or worsening of disorders.

A few thoughts:

1. This is a good paper.

2. The authors do an excellent job of noting the role of IPT in the treatment of depression – but they push further, and do a more complete review of the literature.

3. I note that this paper has a Canadian connection – Dr. Paula Ravitz is an associate professor at the University of Toronto and an attending at Mount Sinai Hospital in Toronto. (She is also an excellent source of Reading suggestions.)

4. Of course, this thoughtful review begs a larger question: Have we become too CBT focused? Recent studies suggest that other short-term therapies rival CBT in efficacy for certain disorders – think, for instance, of the COBRA study published recently in The Lancet. Not surprisingly, then, the new Canadian (CANMAT) guidelines for depression in adults list CBT, IPT, and BA (Behavioural Activation) as all “level 1 evidence” in the treatment of acute illness.

Perhaps CBT holds another, and simpler, advantage: practicality. In his excellent book, Fads and Fallacies in Psychiatry, McGill’s Dr. Joel Paris argues: “Where CBT therapists have been most creative is in developing toolkits for almost every symptom seen in psychiatric practice.”

Dr. Joel Paris

We don’t necessarily need to accept Dr. Paris’ argument – but I think we can agree that IPT is underappreciated as a clinical tool, and its broad applicability is being shown in recent literature. The conclusion of Cuijpers and his co-authors in this paper is worth repeating as the conclusion to this Reading: “no treatment works for everyone, and IPT, with its focus on salient relational and interpersonal experiences, provides an important alternative to pharmacotherapy or CBT.”

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.