The ‘sick role.’ The therapist assigned Mrs. E the “sick role” to emphasize that major depression can be a severe illness. A therapist might say: “If you had pneumonia, you wouldn’t think of trying to rake leaves. You would rest and take care of yourself to speed the healing. Persons with major depression should do the same.”
The contract. The therapist also explained to Mrs. E that contracting to meet weekly for 12 to 16 weeks is part of the treatment. A contract:
- encourages patients to commit to an IPT trial for a reasonable time
- presses patients to achieve adequate progress by the deadline
- discourages digression, avoidance of painful subjects, and dependence on the therapist.
IPT begins with a complete psychiatric evaluation, including the patient’s past, family, and social histories; alcohol and drug use; medical comorbidities; mental status exam; and sometimes blood screening to rule out metabolic abnormalities. Antidepressants are prescribed as needed to relieve vegetative symptoms and are used during IPT when indicated.
Interpersonal inventory. Each of the patient’s interpersonal relationships is then systematically reviewed. This inventory sets the stage for exploring relationships that may be linked to the depressive symptoms or offer opportunities for trying alternate coping trategies, such as learning to seek social support (Table 2).
Table 1
IPT’s understanding of depression comprises 3 component processes
| Component | Description |
|---|---|
| Symptom function | Biological or psychological causes may trigger neurovegetative signs and symptoms |
| Interpersonal and social relations | Influenced by childhood learning, social reinforcement, personal mastery, and competence |
| Personality and character problems | Enduring traits such as excess anger, guilt, impaired communication, or low self-esteem may impair patient’s ability to maintain satisfying interpersonal relationships |
| Source: References 5 and 6 | |
‘How-to’ checklist of IPT procedures
|
IPT’S FOUR FOCI
IPT’s goal is to relieve depressive symptoms by identifying and focusing on problems that may have caused or are perpetuating those symptoms. Most of the reasons depressed patients give for seeking help fall into four foci: unresolved grief, role transition, role dispute, and interpersonal deficit (Table 3).5,6 The therapist uses clarification, interpretation, confrontation, and testing of perceptions and performance to address each focus, as detailed in the IPT manual.6
The therapist acts as the patient’s advocate, and focuses treatment on interpersonal relationships in the “here and now,” not past traumas, childhood conflicts, cognitive-behavioral interventions, or intrapsychic themes. No attempt is made to restructure personality.
Progress in relieving depressive symptoms is reviewed regularly, and treatment ends within the contract’s time limits in many cases. Older patients may need additional sessions because they often take longer to respond to antidepressant trials (6 to 8 weeks, compared with 3 to 4 weeks for younger adults). We allow older patients to “catch up” with additional sessions if illness, lack of transportation, or other problems prevent them from receiving the “full dose” of IPT.
IPT does not work for all patients. Consider other types of treatment if a patient shows no discernable benefit.
Table 3
IPT’s 4 foci, specific to late-life depression
| Focus | Description |
|---|---|
| Unresolved grief | Emotional reactions to the death of another person (not the loss of a job or one’s health) |
| Role transition | Difficulty adjusting to life change (such as retirement, ceasing to drive, or moving to an apartment) |
| Role dispute | Nonreciprocal expectations between two or more persons that predispose or perpetuate depressive symptoms |
| Interpersonal deficit | History of social impoverishment or inadequate or nonsustaining interpersonal relationships |
| Source: References 5 and 6 | |
Case continued: stalled in grief
As the weeks pass, Mrs. E improves but remains hypoactive and reclusive. She seems afraid to take any action without her late husband’s approval. Thinking about making independent decisions overwhelms her, and she withdraws to her couch to hide.
Her therapist discerns that Mrs. E needs more-active confrontation to accept that her new life requires her to make choices, even though decision-making is difficult for her. They develop a game, hronicling all decisions Mrs. E has made for the first time, such as calling a repairman and planting the summer vegetable garden by herself.