Evidence-Based Reviews

Late-life depression: Focused IPT eases loss and role changes

Current Psychiatry. 2005 November;4(11):40-50

References

1. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health treatment of depression collaborative research program: general effectiveness of treatments. Arch Gen Psychiatry 1989;46:971-82.

2. Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990;47;1093-9.

3. Kupfer DJ, Frank E, Perel JM, et al. Five-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1992;49:769-73.

4. Miller MD, Reynolds CF. Living longer depression free: A family guide to the recognition, treatment and prevention of depression in later life. Baltimore: Johns Hopkins University Press; 2002.

5. Klerman GL, Weissman MM, Rounsaville BJ, Chevron E. Interpersonal psychotherapy of depression. New York: Academic Press; 1984.

6. Weissman M, Markowitz JC, Klerman GL. Comprehensive guide to interpersonal psychotherapy. New York: Basic Books; 2000.

7. Miller MD, Cornes C, Frank E, et al. Interpersonal psychotherapy for late-life depression: Past, present and future. J Psychother Pract Res 2001;10(4):231-8.

8. Wolfson LK, Miller M, Houck PR, et al. Foci of interpersonal psychotherapy (IPT) in depressed elders: clinical and outcome correlates in a combined IPT/nortriptyline protocol. Psychother Res 1997;7(1):45-55.

9. Miller MD, Frank E, Cornes C, et al. Value of maintenance Interpersonal Psychotherapy (IPT) in elder adults with different IPT foci. Am J Geriatr Psychiatry 2003;11(1):97-102.-

10. Joiner T, Coyne JC. The interactional nature of depression: advances in interpersonal approaches. Washington, DC: American Psychological Association; 1999.

11. Sherrill JT, Frank E, Geary M, et al. An extension of psychoeducational family workshops to elderly patients with recurrent major depression: Description and evaluation. Psychiatr Serv 1997;48(1):76-81.

12. Reynolds CF, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999;281(1):39-45.

13. Alexopoulos GS, Meyers BS, Young RC, et al. Executive dysfunction and long-term outcomes of geriatric depression. Arch Gen Psychiatry 2000;57(3):285-90.

14. Bozoki A, Giordani B, Heidebrink JL, et al. Mild cognitive impairments predict dementia in nondemented elderly patients with memory loss. Arch Neurol 2001;58(3):411-6.

15. Hinrichsen GA, Zweig R. Family issues in late-life depression. J Long Term Home Health Care 1994;13:4-15.

16. Reischies FM, Neu P. Comorbidity of mild cognitive disorder and depression—a neuropsychological analysis. Eur Arch Psychiatry Clin Neurosci 2000;250(4):186-93.

17. Teri L. Behavior and caregiver burden: behavioral problems in patients with Alzheimer disease and its association with caregiver distress. Alzheimer Dis Assoc Disord 1997;11(suppl 4):S35-S38.

18. Wright LK, Clipp EC, George LK. Health consequences of caregiver stress. Medicine, Exercise, Nutrition, and Health 1993;2:181-95.

The therapist applauds these “firsts” and points out that Mrs. E’s depressive symptoms have improved as her list of completed decisions has grown. Mrs. E holds the power to make decisions, the therapist stresses, and bears the consequences of not taking action.

Applying ipt to late-life depression

Our group has used IPT in research protocols for 15 years. We and others^7-11 have found that IPT is well-suited for treating late-life depression because:

Older patients without psychotherapy experience or psychological sophistication can easily participate.
Persons with limited education can understand IPT’s informal explanations of depression.
Two foci of IPT—grief and role transition—address common themes of aging, such as spousal role disputes after retirement or caregiver stress when one partner becomes ill or shows signs of dementia.

In this research, median time to recurrence of major depression was 69 weeks in IPT-treated patients compared with 16 weeks in similar patients treated with monthly clinical management. Age, depression severity, or medical burden did not determine whether a patient got well with IPT plus nortriptyline.

Only minor IPT adaptations were required for older patients, such as:

shorter sessions for those who reported physical discomfort
accommodating for hearing loss, arranging transportation, and conducting sessions by telephone when patients were ill or shut in by inclement weather.

Case continued: more ‘firsts’ build confidence

Mrs. E makes slow, sometimes painful, but steady progress. Her therapist encourages her to keep trying more “firsts,”such as going back to church and attending her first social event alone, and to review her emotional reactions.

Mrs. E’s depressive symptoms wane as her confidence builds, and she readjusts her self-image to that of a widow who enjoyed a good marriage with a benevolent but overprotective husband. Her therapist links her progress to her string of successful “firsts” and to the contributing benefit of anti-depressant medication.

IPT As maintenance therapy

In the Maintenance Therapies for Late Life Depression (MTLLD) study—a randomized, double-blind, placebo-controlled trial¹²—we showed IPT to be effective as maintenance therapy for recurrent depression in patients age 60 and older. The 187 patients (mean age 67, one-third age ≥70) with nonpsychotic unipolar major depression were first treated to remission with IPT plus nortriptyline (80 to 120 ng/mL).

We then randomly assigned the 107 who achieved recovery to one of four maintenance therapies. After 3 years of monthly follow-up, relapse rates were:

20% with nortriptyline plus maintenance IPT
43% with nortriptyline plus medication clinic visits
64% with maintenance IPT plus placebo
90% with medication clinic plus placebo.

Combination therapy. Patients in all active-treatment groups, including those receiving IPT plus placebo, did statistically better than those receiving medication clinic visits plus placebo, indicating that IPT had a protective effect (though not as robust as that of medication). Based on these results, combined antidepressant/IPT therapy appears to be the optimal clinical strategy for maintaining recovery with IPT.

Further analysis showed that patients age ≥70 required combined treatment with nortriptyline and IPT to stay well, whereas those ages 60 to 69 stayed well with drug therapy alone. Patients age ≥70 also had a higher and more rapid relapse rate.

Recurrence by therapy focus. In patients who received placebo instead of nortriptyline:

Time without a new depressive episode was similar for patients with a focus on grief or role transition, whether they received IPT or medication checkups.
Recurrence rates were clearly lower in patients whose initial focus was role dispute if they received monthly maintenance IPT sessions instead of medication check visits.

We suspect the reason for this difference may be that patients more or less resolved grief and role transition issues during acute treatment, before randomization. Those with role disputes who achieved remission probably drifted back to maladaptive behaviors across 3 years. They became depressed again without monthly IPT refresher sessions to reinforce the new skills and insights they had learned.⁹

Case continued: looking ahead

As the 12- to 16-week contracted period winds down, Mrs. E admits she still longs for her husband’s protection. She said she would gladly give up her independence to have that “safe” feeling back.

The therapist acknowledges that feeling but gently reminds her that she has the tools to face her new life realistically. During therapy, Mrs. E has shown she can assess life’s many decisions, make rational choices, and live with the consequences.

Their final discussion touches on the notion that Mrs. E could imagine having some kind of friendship with another man in the future.

Wrapping up. The last IPT sessions focus on reviewing any decline in depressive symptoms that may be linked to having learned new coping skills. With successful IPT, patients learn to appraise their strengths and remaining vulnerabilities and gain skills, self-confidence, and understanding to confront remaining obstacles after therapy ends.