Interpersonal Psychotherapy (IPT)

Overview

The International Society of Interpersonal Psychotherapy defines interpersonal psychotherapy (IPT) as a time-limited, well-studied, manualized treatment for major depression and other psychiatric disorders.[1] According to Markowitz & Weissman (2004), IPT is one of two psychotherapies, including cognitive behavioral therapy (CBT), that is an empirically-based psychotherapeutic intervention. IPT is aligned with the central paradigm of psychotherapy in which the therapist empathically engages the patient to help the patient feel understood, then presents a clear rationale and treatment ritual for the patient which often yields successful experiences.[2]

IPT is traditionally a 12-16 week, once-weekly therapy used primarily for treatment of major depressive disorders. The basic structure of IPT has three phases. The initial phase focuses on the therapist creating an interpersonal inventory for the patient, then identifying one of four key problem areas that is the root for the patient’s depression, and finally working collaboratively to develop and implement solutions to the problem.[3] This general structure has been adapted to treat depression in various groups including young children, adolescents, and postpartum mothers in areas where treatment access is limited. Additionally, current research is examining IPT as an adjunctive treatment for those with eating disorders, bipolar disorder, PTSD, and social anxiety disorders.[4] Because of its proven efficacy and adaptability, there have been more than 250 randomized controlled studies of IPT published around the world since 1974.[5]

History & Developments

In 1970, psychopharmacologist and psychotherapist Dr. Gerald Klerman led a maintenance study of the treatment of depression and carried out the first recorded clinical IPT trial. As the head of the Connecticut Mental Health Center and faculty at the Yale School of Medicine at the time, he was joined by Dr. Eugene Paykel, a London-trained psychiatrist, to design a study to test the relative efficacy of a tricyclic antidepressant (both with and without psychotherapy) as maintenance treatment for ambulatory non bipolar depression. Around the same time period, a manual for cognitive-behavioral therapy (CBT) was under development by psychiatrist Aaron Beck. Dr. Klerman was inspired and influenced by the work being conducted by Beck, however, both IPT and CBT drew much skepticism at the time due to the novel aspect of time-limitation and therapies being written into procedural manuals.

Nevertheless, Klerman believed there was a strong rationale for IPT in clinical trial use. Many patients received both psychotherapy and medication, either together or in sequence, however no positive clinical trials of psychotherapy had been conducted. In fact, previous trials that examined patients receiving psychotherapy lacked the design necessary to draw any conclusion. The research group’s goal was to use randomized controlled clinical trials to establish the efficacy of psychotherapy with antidepressant use, develop and administer standardized assessments to measure outcomes including quality of life and social functioning, and replicate their results outside of the original study. In initial studies, the research group found that IPT was more effective than a placebo. In combination with medication it fared better than either treatment alone; furthermore, on one-year follow-up, IPT helped patients to build social skills, which medication did not. In 1984, after the efficacy of IPT had been demonstrated outside of the research group, the first IPT manual was published.[6]

Treatment

Interpersonal therapy is a manual-based treatment, which means the therapist strictly adheres to a treatment process whose effectiveness is supported by evidence. The rationale behind IPT is that depression occurs within an interpersonal context and affects relationships and the roles of people within those relationships. By addressing interpersonal issues, interpersonal therapy for depression puts emphasis on the way symptoms are related to a person's relationships, including family and peers.[7]

IPT follows a simple paradigm by first explaining to the patient that their problems are treatable medical conditions and linking their state of affective distress to their interpersonal situations. One important tenet in IPT for treating depression is that depression does not occur due to an individual's fault and it can affect anyone.[8] Another IPT specific characteristic is: rather than focusing on symptoms in therapy sessions, the number of problems addressed are intentionally limited to one or two in order to focus on making specific adjustments in regard to interpersonal situations that may help reduce symptoms of depression.

IPT addresses four key problem areas:[9,10]

Grief or Complicated Bereavement: Grief is the experience of loss through death and becomes an issue when it becomes excessive so that it interferes with one’s daily life and functioning (e.g., the death of a loved one)
Role Dispute: These types of disputes occur in marital, family, social, school, or work settings. The disputes emerge from differing expectations of a situation and can cause severe distress (e.g., a struggle with a significant other)
Role Transition: This problem often occurs from changing circumstances and life upheaval, whether from work, social, or geographic contexts, and are felt as losses when one is unable to adapt to the change (e.g., the beginning or ending of a marriage).
Interpersonal Deficits: This refers to the patient reporting "impoverished" personal relationships either in number or in quality (e.g., individuals lacking close relations, those having difficulty sustaining relationships, or those who fear social relationships/social phobia fall in this group).

The structure of IPT falls into three sections:[11,12]

Opening sessions: initial beginning phase of IPT focuses on identifying problem areas, discussing immediate issues, and deciding targets for the therapy. This is typically conducted during sessions 1-3. The therapist creates an interpersonal inventory by carefully listening to the patient's complaints/issues, carrying out a detailed interview, and obtaining information about the history of presenting complaints. In the session, the therapist will help the patient create a list of all the key relationships in the patient’s life, and these relationships are grouped according to the four main problem areas as outlined above. This collection of information helps to identify the diagnosis and informs the decision about the central IP focus of therapy.
Middle sessions: The middle phase is focused on resolving the chosen interpersonal problem area in order to improve mood symptoms and is typically carried out in sessions 4-14. The patient and therapist work to develop solutions to the problems, and the patient tries to implement the solutions between sessions. Throughout the middle phase it is important to maintain consistent check-ins and a therapeutic alliance. This may be achieved through the therapist sustaining a supportive emotional tone, the therapist congratulating him/her to reinforce the skills, discussing things that did not work well, and facilitating open communication about the gains achieved or summary and highlights of each session.
Final sessions: The final sessions, typically in weeks 15-16, focus on dealing with any sense of loss associated with the end of therapy as well as reviewing the issues that were identified in the interpersonal inventory and the progress made in dealing with them. If the sessions were not as successful as expected, it is important to minimize patient self-blame by blaming the treatment instead. Furthermore, alternative treatment options such as continuation of the maintenance phase and adding or changing medications are discussed with the patient.

IPT Adaptations for Other Disorders

While IPT is most often used and has been shown most effective during the acute phase of major depression, IPT has also been shown to be moderately effective amongst a range of other psychological disorders. The major adaptations of IPT include both mood disorders and non-mood disorders.[13]

Mood Disorders

Dysthymia: Johns Hopkins Medicine defines dysthymia as a milder, but long-lasting form of depression also known as persistent depressive disorder.[14] According to a review study by Markowitz (1996) dysthymic disorder offers a research challenge to psychotherapeutic efficacy because of its low placebo response rate, and roughly half of dysthymic patients do not respond to antidepressant medication.[15] Though studies are very limited in terms of long-term efficacy, Browne et al. (2002) found that Sertraline with IPT is more effective than IPT alone pointing to the potential for the effects of combining pharmacotherapy and psychotherapy.[16]
Bipolar Disorder: Bipolar disorder is characterized by instability and episodes of depression and mania or hypomania as well as the episodes propensity for recurrence. An alteration in daily routine is associated with the onset of both depressive and manic episodes, thus bipolar individuals are said to have more vulnerable circadian systems. While research has long established that psychosocial stressors may have destabilizing effects on the body's natural rhythms, this phenomenon has recently been linked to those with mood disorders. This led to the development of IP social rhythm therapy (IPSRT) for managing bipolar disorder. According to IPSRT.org, the interpersonal elements of the program are based on Interpersonal Psychotherapy (IPT) for depression. The time-limited treatment that focuses on the bidirectional relationship between mood and life events can be especially helpful for individuals struggling with bipolar disorder.[17] In assessing the efficacy of IPSRT, a study by Frank et al. (2007), found that patients who received acute IPSRT achieved significantly higher regularity of social rhythms than those individuals assigned to acute ICM and the degree of protection that IPSRT subjects received from the therapy was correlated with the extent of increase in their social routines.[18]

Non-Mood Disorders

Eating-Disorders: IPT has mainly been used to treat patients with binge eating disorder (BED). The rationale for this is many patients have had limited experience developing and maintaining intimate relationships, partly as a result of social withdrawal that is a common feature of eating disorders. Another contributing factor may be low self-esteem which increases restrictiveness and a desire to control one’s diet, food intake, and body image.[19] In a randomized, active control efficacy trial conducted by Wilson et al. (2010), results showed that among participants at 2-year follow-up, both IPT and CBT resulted in greater remission from binge eating than BWL (behavioral weight loss therapy). IPT was found to be particularly effective for patients with low self-esteem and high eating disorder psychopathology.[20] However, it is important to note that IPT has not been proven effective for all eating disorders. In particular, it has not been effective in trials involving anorexia nervosa and hence cannot be recommended as a treatment. Moreover, there is a need for research on the use of IPT in patients with eating disorders not otherwise specified (NOS) other than BED.[21]
Social Anxiety (SAD): The APA defines SAD as excessive fear of social situations leading to significant distress and impairment in everyday functioning. In interpersonal psychotherapy (IPT) for SAD, the most common interpersonal problem is role transition, followed by role dispute. The two are also sometimes a combined focus of IPT.[22] In one randomized controlled trial examining cognitive therapy (CT) and IPT in social anxiety disorders, Stangier et al. (2011) reported that CT and IPT were both effective treatments for SAD, each being associated with significantly greater improvement compared to the control group; however, there was a significant advantage found for CT (65.8% response rate) over IPT (42.1%) on the primary outcome measure. Although IPT can be effective to treat SAD, the preferred method would be cognitive therapy until further research indicates otherwise.[23]
Post-Traumatic Stress Disorder (PTSD): One characteristic specific to PTSD is numbness which makes it difficult to interact with one’s interpersonal environment. Thus, in adapting IPT for PTSD, the early part of treatment is devoted to affective attunement, or helping patients to identify their emotions and to recognize them as helpful social signals rather than as bad or dangerous.[24] Campinini et al. (2010) identified that exposure therapies are poorly tolerated by many patients and showed high attrition, so researchers carried out a study evaluating interpersonal therapy, in a group format, adapted to PTSD (IPT-G PTSD). They found that patients who did not respond to conventional psychopharmacological treatment were much more responsive to IPT-G PTSD. This therapy was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. Moreover, it was well tolerated with few dropouts, and led to significant improvements in social adjustment and quality of life.[25]

IPT Adaptations for Specific Groups

Children: The evidence-based psychosocial intervention used for depression in adolescents is known as family-based interpersonal psychotherapy (FB-IPT). Adapted from the general structure of IPT, this specific therapy is for ages 8-12 and features structured sessions with preadolescents and their parents, guidance for parents in supporting their children, and a focus on preadolescents’ comorbid anxiety and peer relationships. The family plays an integral part in FB-IPT for preadolescents because children are usually embedded in a family context and dependent upon their parents for nurturance, support, and assistance, making parental involvement in treatment for childhood depression critical.[26] An efficacy study by Dietz et al. (2014) showed that preadolescents receiving FB-IPT were more likely to have achieved remission posttreatment than those receiving child-centered therapy (CCT) (66% vs. 31%) and evidenced greater reductions in anxiety symptoms and interpersonal impairment from pre to post treatment. Furthermore, researchers found that reducing social impairment is one mechanism by which FB-IPT may decrease preadolescents’ depressive symptoms.[27]
Adolescents: For depressed adolescents ages 12-18, a model known as IPT-A is used. IPT-A utilized a similar structure to traditional IPT with a once weekly meeting for about 12 weeks.[28] The therapist provides psychosocial education to the adolescent and helps them to recognize their feelings and think about how interpersonal events or conflicts might affect their mood. This can improve communication and problem solving skills as well as enhance social functioning and lessen stress in relationships. Additionally, the patient and therapist discuss how difficult interactions influence relationships with family members, peers, and others in his or her life.[29] In regard to efficacy, a study by Duffy (2019) showed that following IPT-A, participants experienced large improvements in depression symptoms, interpersonal difficulties, and general functioning. Thus, interpersonal psychotherapy for adolescents has been proven as an effective intervention for adolescent depression, improving a range of relevant outcomes.[30]
Postpartum Mothers: IPT use has been used to prevent postpartum depression by reducing antenatal depression. The mechanism includes targeting the specific symptoms and interpersonal problem areas, especially role transitions and interpersonal conflicts. Miniati et al. (2014) sought out to assess the efficacy of IPT for PPD in a systematic review of studies using articles within the databases of PubMed and PsycINFO published between 1995 and 2013. They found that IPT studies showed overall clinical improvement in the most commonly used depression measures in postpartum depressed women and often-full recovery in several cases of treated patients.[31]

One adaptation from traditional IPT is brief IPT which consists of 8 sessions. This is particularly applicable for treating depression in pregnant, low-income, racially and ethnically diverse women.[32] Furthermore, studies have identified that IPT can improve treatment access within marginalized communities. A recent study by Dennis et al. (2023) assigned postpartum women with major depression from several Canadian public health regions in rural and urban settings to 12 weekly 60 min nurse-delivered telephone-IPT sessions. Results showed that 10.6% of women in the IPT group vs 35% in the control group remained depressed, with the IPT group 4.5 times less likely to be clinically depressed.[33]

EFFICACY & Limitations

Overall, IPT has shown empirical success in treating major depressive disorders. A growing number of studies have shown that adequate social functioning is essential for people with depression, and IPT can be used to improve the social functioning of patients with depression. A recent meta-analysis study by Bian et al (2023) found IPT to have a significant effect on improving social functioning and reducing anxiety, though the effect on overall functioning requires further research.[34]

Another emerging topic under study is the efficacy of IPT compared to CBT for non-depressive disorders. Some researchers are interested in elucidating the rationale for why and when IPT should be used over other psychotherapies. For example, a meta-analysis study by Cuijpers et al. (2016) sought out to compare the effects of these two evidence-based psychotherapies on a wider range of mental health disorders; they examined 90 studies representing 11,343 participants. IPT had significant effects on eating disorders, but the effects were slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there was no evidence that IPT was more or less effective than CBT.[35]

Future Directions

In terms of future direction, an article by Weissman (2019) in the American Journal of Psychotherapy stated that, “the most exciting developments and areas of future progress in IPT are in globalization.” Because the predicaments of people with depression are very similar (e.g., death of a loved one or life changes that disrupt attachments) even across ethnicities, cultures, and regions, there is inherent ease in translating IPT for depression across diverse contexts. Sites where IPT has been implemented include Lebanon, Egypt, Myanmar, Ethiopia, Rwanda, and South Africa. The IPT manual has been translated into 10 languages, and adaptations have included group, conjoint, and telephone IPT. Though there are IPT training methods and guided IPT resources online that improve access within marginalized communities, more training of health workers is needed in the future to increase the labor force economically and in a way that benefits communities.[36]

If you would like to explore if IPT might benefit you, please reach out to a licensed psychologist or therapist for an appointment to learn more about your options.

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Overview of IPT | International Society of Interpersonal Psychotherapy - ISIPT. (2019). Interpersonal Psychotherapy.org. https://interpersonalpsychotherapy.org/ipt-basics/overview-of-ipt/

2 Markowitz, J. C., & Weissman, M. M. (2004). Interpersonal psychotherapy: principles and applications. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 3(3), 136–139. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414693/

3 CAMH: The Centre for Addiction and Mental Health. (2023). Interpersonal Psychotherapy IPT. CAMH. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/interpersonal-psychotherapy

4 Adaptations of IPT: What works for whom? | International Society of Interpersonal Psychotherapy - ISIPT. (n.d.). https://interpersonalpsychotherapy.org/ipt-basics/adaptations-of-ipt-what-works-for-whom/

5 Ibid.

6 Weissman, M. M. (2020). Interpersonal Psychotherapy: History and Future. American Journal of Psychotherapy, 73(1), 3–7. https://doi.org/10.1176/appi.psychotherapy.20190032

7 Saling, J. (2022, August 28). Interpersonal Therapy for Depression [Review of Interpersonal Therapy for Depression]. WebMD. https://www.webmd.com/depression/interpersonal-therapy-for-depression

8 Kumar, V., Rajhans, P., Hans, G., & Chadda, R. (2020). Interpersonal Psychotherapy for Patients with Mental Disorders. Indian Journal of Psychiatry, 62(8), 201. https://doi.org/10.4103/psychiatry.indianjpsychiatry_771_19

9 Saling (2022)

10 Markowitz & Weissman (2004)

11 CAMH: The Centre for Addiction and Mental Health (2023)

12 Kumar et al. (2020)

13 Weissman (2020)

14 John Hopkins Medicine. (2019). Dysthymia. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/dysthymia

15 Markowitz, J. C. (1996). PSYCHOTHERAPY FOR DYSTHYMIC DISORDER. Psychiatric Clinics of North America, 19(1), 133–149. https://doi.org/10.1016/s0193-953x(05)70278-1

16 Browne, G., Steiner, M., Roberts, J., Gafni, A., Byrne, C., Dunn, E., Bell, B., Mills, M., Chalklin, L., Wallik, D., & Kraemer, J. (2002). Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs. Journal of Affective Disorders, 68(2-3), 317–330. https://doi.org/10.1016/s0165-0327(01)00343-3

17 Interpersonal and Social Rhythm Therapy | Home. (n.d.). Www.ipsrt.org. http://www.ipsrt.org/

18 Frank, E., Swartz, H. A., & Boland, E. (2007). Interpersonal and social rhythm therapy: an intervention addressing rhythm dysregulation in bipolar disorder. Dialogues in Clinical Neuroscience, 9(3), 325–332. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202498/

19 Murphy, R., Straebler, S., Basden, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal Psychotherapy for Eating Disorders. Clinical Psychology & Psychotherapy, 19(2), 150–158. https://doi.org/10.1002/cpp.1780

20 Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological Treatments of Binge Eating Disorder. Archives of General Psychiatry, 67(1), 94. https://doi.org/10.1001/archgenpsychiatry.2009.170

21 Murphy et al. (2012)

22 Lipsitz, J. D. (2012). Interpersonal Psychotherapy for Social Anxiety Disorder. Casebook of Interpersonal Psychotherapy, 169–184. https://doi.org/10.1093/med:psych/9780199746903.003.0010

23 Stangier, U. (2011). Cognitive Therapy vs Interpersonal Psychotherapy in Social Anxiety Disorder. Archives of General Psychiatry, 68(7), 692. https://doi.org/10.1001/archgenpsychiatry.2011.67

24 Adaptations of IPT: What works for whom? | International Society of Interpersonal Psychotherapy - ISIPT

25 Campanini, R. F. B., Schoedl, A. F., Pupo, M. C., Costa, A. C. H., Krupnick, J. L., & Mello, M. F. (2010). Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial. Depression and Anxiety, 27(1), 72–77. https://doi.org/10.1002/da.20610

26 Dietz, L. J. (2020). Family-Based interpersonal psychotherapy: An intervention for preadolescent depression. American Journal of Psychotherapy, 73(1), appi.psychother. https://doi.org/10.1176/appi.psychotherapy.20190028

27 Dietz, L. J., Weinberg, R. J., Brent, D. A., & Mufson, L. (2015). Family-Based Interpersonal Psychotherapy for Depressed Preadolescents: Examining Efficacy and Potential Treatment Mechanisms. Journal of the American Academy of Child & Adolescent Psychiatry, 54(3), 191–199. https://doi.org/10.1016/j.jaac.2014.12.011

28 Mufson, L., Gallagher, T., Dorta, K. P., & Young, J. F. (2004). A Group Adaptation of Interpersonal Psychotherapy for Depressed Adolescents. American Journal of Psychotherapy, 58(2), 220–237. https://doi.org/10.1176/appi.psychotherapy.2004.58.2.220

29 Reyes-Portillo, J. (2015). About Interpersonal Psychotherapy for Adolescents (IPT-A) | Columbia University | Child Psychiatry. Columbia.edu. https://childadolescentpsych.cumc.columbia.edu/articles/interpersonal-therapy-adolescents-ipta

30 Duffy, F., Sharpe, H., & Schwannauer, M. (2019). Review: The effectiveness of interpersonal psychotherapy for adolescents with depression – a systematic review and meta‐analysis. Child and Adolescent Mental Health, 24(4), 307–317. https://doi.org/10.1111/camh.12342

31 Miniati, M., Callari, A., Calugi, S., Rucci, P., Savino, M., Mauri, M., & Dell’Osso, L. (2014). Interpersonal psychotherapy for postpartum depression: a systematic review. Archives of Women’s Mental Health, 17(4), 257–268. https://doi.org/10.1007/s00737-014-0442-7

32 Adaptations of IPT: What works for whom? | International Society of Interpersonal Psychotherapy - ISIPT

33 Dennis, C.-L., Grigoriadis, S., Zupancic, J., Kiss, A., & Ravitz, P. (2020). Telephone-based nurse-delivered interpersonal psychotherapy for postpartum depression: nationwide randomised controlled trial. The British Journal of Psychiatry: The Journal of Mental Science, 216(4), 1–8. https://doi.org/10.1192/bjp.2019.275

34 Bian, C., Zhao, W.-W., Yan, S.-R., Chen, S.-Y., Cheng, Y., & Zhang, Y.-H. (2023). Effect of interpersonal psychotherapy on social functioning, overall functioning and negative emotions for depression: A meta-analysis. Journal of Affective Disorders, 320, 230–240. https://doi.org/10.1016/j.jad.2022.09.119

35 Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis. American Journal of Psychiatry, 173(7), 680–687. https://doi.org/10.1176/appi.ajp.2015.15091141

36 Weissman (2020)