Interpersonal Therapy for Major Depression

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Similar to CBT, Interpersonal Therapy, or IPT, is an empirically validated, time-limited form of psychotherapy (lasting between 12 and 16 sessions duration) designed to treat depression and depressive symptoms. Unlike CBT, Interpersonal Therapy is not a behavior therapy, coming instead from more psychodynamic and social-learning traditions. Instead of focusing on correcting dysfunctional thoughts, IPT focuses on understanding how personal relationships can cause someone to become depressed or make worse already existing depressive symptoms. The IPT approach shifts blame from the (typically guilt-ridden) patient onto the illness and to some degree, onto the patients' interpersonal situation.

Interpersonal therapy has three phases. In the first "formulation" phase, the therapist diagnoses depression, and determines the interpersonal context in which the depressive episode arose by examining the patient's history for the following potential problem areas:

Grief over a recent death or loss. Grief feelings can be caused by losing a person or something else important (e.g., becoming disabled or losing a house).
Role transition such as getting married or divorced, being promoted or demoted, being ill, moving to a new city, or becoming a parent.
Interpersonal disputes such as a struggle with a significant other (e.g., a spouse, family member, friend, or boss).
Interpersonal deficits (not caused by life changes) that promote social withdrawal and impairments in social and communication skills (e.g., never attending social functions for work).

Based on the therapist's conclusions, which are referred to as the "interpersonal formulation", the depressed patient and the therapist work together to reach an agreement on the causes of symptoms and the focus of subsequent treatment. While in the formulation phase, the IPT therapist focuses on the patient's recent life events and mood. IPT also includes a psycho-educational component in which the therapist educates the patient concerning the causes of depression, various treatment options, and the potential for improvements to occur. In addition, the depressed person is often encouraged to adopt a 'sick role', which involves being excused from blame for missing activities because of symptoms. At the same time, the individual is expected to be compliant with the therapist's recommendations and actively work to get better.

The individual's acceptance of the interpersonal formulation marks the beginning of the middle phase of IPT. The middle phase focuses on one (or at most, two) of the four interpersonal problem areas. Each problem area requires a particular set of strategies to overcome. The grief problem area requires catharsis (a release of pent-up emotion) over the loss, and establishing new (or resuming old) activities to fill the void of that loss. The interpersonal disputes problem area requires resolving the disagreement or, if resolution is not possible, ending the relationship and mourning its loss. The role transition problem area involves mourning the loss of an old role while recognizing the positive aspects of and gaining mastery over a new one. The interpersonal deficits problem area requires teaching depressed people new social skills in order to build new relationships.

Each IPT session begins with the question, "How have things been since we last met?" Exploring a recent event leads to a discussion of the focal problem area (e.g., grief or whatever the identified primary issue happens to be). If the patient has handled things well recently and is feeling better, the therapist highlights the connection between coping skills and mood and offers congratulations. On the other hand, if the patient remains depressed, the therapist and individual together explore interpersonal difficulties that have arisen (e.g., the inability to assert oneself or to express anger appropriately). In addition, the therapist and depressed patient explore the patient's options for handling similar situations in the future. Role-playing alternative approaches helps the patient to strengthen social skills for future situations.

The termination phase of IPT, which occurs during the last few therapy sessions, is a "graduation" that reinforces a person's sense of competence and independence. The IPT therapist points out the client's achievements during treatment, reviews the nature of depression, and discusses the risk of recurrence. If a client has not improved, the therapist notes that the therapy has failed (rather than the patient!) and discusses alternative treatment options. People with recurrent depression who have responded to IPT may be offered continuation treatment in a new treatment contract.

IPT is most useful for people who are in the midst of recent conflicts with significant others and/or have experienced difficulty adjusting to stressful life transitions. As with CBT, patients who are unable or unwilling to practice skills taught in therapy are not likely to gain significant symptom relief. Most therapists recommend that clients remain in ongoing, maintenance therapy if that is possible. Maintenance IPT (IPT-M) is often used following termination of the short-term phase of therapy. Recent research suggests that IPT-M may prevent future episodes of depression, particularly in women.

In clinical trials, both CBT and IPT have been found to be effective treatments for depression. There is no certain way to know up front (without actually trying them) whether one form of therapy will be a better fit for patients than the other. The available studies are too small and specific to recommend a specific type of person who would benefit best from one or another type of therapy. Just as patients may need to try different types of antidepressant medication, the may also need to try different types of therapy, or even different therapists within a particular therapeutic approach to gain maximum relief.

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