Critical review of outcome research on interpersonal psychotherapy for anxiety disorders

Group interpersonal psychotherapy for generalized anxiety disorder: development process and a pilot test

BACKGROUND

Generalized Anxiety Disorder (GAD) is a common and disabling psychiatric disorder that negatively impairs patients' quality of life. Studies suggest that inadequate consideration of interpersonal problems may contribute to the poor treatment response in psychotherapy for GAD. Interpersonal Psychotherapy (IPT) is an evidence-based psychosocial intervention that focuses on symptoms by improving interpersonal functioning, and research demonstrates that IPT is efficacious in treating social anxiety and panic disorders. To date, however, there are no studies examining IPT for patients with GAD.

METHODS

The authors developed and pilot-tested an IPT manual for the treatment of GAD in groups with two cohorts of patients. Pre- and post-test measures of anxiety were collected and analyzed.

RESULTS

The authors successfully developed a treatment manual for Group IPT for Anxiety using iterative qualitative methods. Significant improvement from baseline was noted in the GAD scores for patients in both patient cohorts.

CONCLUSIONS

The results suggest that IPT can be successfully used for GAD in group formats and that future large-scale randomized trials should be warranted. The results also suggest that online group therapy is feasible and warrants further study and that it may be used to deal with access and logistical barriers faced by many patients.

Interpersonal counselling for adolescent depression delivered by youth mental health workers without core professional training: the ICALM feasibility RCT

Background

As milder cases of adolescent depression do not meet treatment thresholds for specialist mental health services, young people often receive support from non-qualified professionals in third-sector/voluntary agencies. Early psychological interventions to meet growing demand with limited resources are crucial.

Objectives

The study aimed to explore the effectiveness and cost effectiveness of interpersonal counselling for adolescents by (1) assessing the feasibility and acceptability of trial procedures; (2) exploring the delivery of, and differences between, interpersonal counselling for adolescents and treatment as usual; (3) evaluating the extent of contamination of the control arm and if it should be mitigated against in a future trial; and (4) investigating whether the interval estimate of benefit of interpersonal counselling for adolescents over treatment as usual in depression post treatment includes a clinically significant effect.

Design

This was a feasibility randomised controlled trial. Non-qualified professionals from non-specialist mental health services received interpersonal counselling for adolescent training. Participants were randomised to receive either interpersonal counselling for adolescents plus treatment as usual or treatment as usual only. Assessments occurred at baseline and were followed up at weeks 5, 10 and 23. A health economics component was included to inform the design of the economic evaluation in a future study. A process evaluation examined implementation of the intervention across settings, acceptability and contamination. Interviews, observations and focus groups were analysed using thematic analysis. Session recordings were analysed using conversation analysis.

Setting

The trial was conducted in 13 non-speicialist mental health services across Norfolk and Suffolk.

Participants

Help-seeking adolescents aged 12-18 years with mild depression as the primary difficulty were eligible to participate. Comorbid presentations were not an exclusion criterion. Of a target of 60, 16 participants were randomised, and 2 participants withdrew following study suspensions related to COVID-19. Of the remaining 14 participants, 7 received an intervention, with 3 receiving interpersonal counselling for adolescents and 4 receiving treatment as usual. The rest either disengaged, withdrew or were signposted.

Interventions

Participants were randomised to receive either interpersonal counselling for adolescents plus treatment as usual or treatment as usual only.

Main outcome measures

The primary outcome was the Revised Children's Anxiety and Depression Scale, although the proposed study was not designed to assess efficacy. The primary output of the feasibility trial was to design a subsequent full-scale trial.

Results

Feasibility outcomes did not meet the estimated progression criteria. Despite efforts to increase referrals, the 80% recruitment rate was not achieved. Interpersonal counselling for adolescents' attendance rates at 10 weeks were less than the 70% progression criteria estimation, impacting intervention feasibility. Retention was high, with 85.7% of participants reaching 23-week follow-up. The health economic measures appeared to perform well and were completed. Implementation and theoretical fidelity of interpersonal counselling for adolescents were analysed from four participant recordings. Adherence to the principles of interpersonal counselling for adolescents was identified, with 100% satisfactory fidelity and no indication of contamination in the control arm. The two interventions were clinically non-significant due to the study being underpowered.

Limitations

The feasibility of the randomised controlled trial was impacted by COVID-19. Services had to change standard practices, disrupting trial procedures. Challenges were identified when implementing a randomised controlled trial in non-specialist services.

Conclusions

Findings indicate a randomised controlled trial of interpersonal counselling for adolescents in non-specialist services is not feasible, yet the data collection and outcome measures were suitable. COVID-19 challenges, sites' lack of familiarity with research procedures and the research team's unfamiliarity with how different early intervention services operate led to challenges. High staff shortages, turnover and inconsistent training could have been considered. This study demonstrated the difficulties in conducting a randomised controlled trial in this service setting. Further work is needed to improve the feasibility of conducting such trials before they are attempted in future.

Trial registration

This trial is registered as ISRCTN82180413.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/112/16) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 48. See the NIHR Funding and Awards website for further award information.

How Emotional Intelligence Influences Students' Life Satisfaction During University Lockdown: The Chain Mediating Effect of Interpersonal Competence and Anxiety

Students' life satisfaction is an essential reflection of their well-being, particularly during challenging times. The COVID-19 pandemic, a global catastrophe, has had an immeasurably negative impact on individuals' daily lives. It has also provided an opportunity to investigate the factors contributing to students' life satisfaction during such difficult times. Considering the unique characteristics of these university students, the current study examines the impact of emotional intelligence (EI) on students' life satisfaction, as well as the direct and sequential mediating effects of interpersonal competence and anxiety on this relationship. A total of 297 university students in Shanghai, China, participated in the study. All participants were recruited online during the early phase of the COVID-19 pandemic in 2022. Four well-established questionnaires were utilized to assess students' trait emotional intelligence, interpersonal competence, anxiety, and life satisfaction. The findings indicate that interpersonal competence significantly mediates the relationship between EI and life satisfaction. Although anxiety does not significantly mediate this relationship, it plays a notable role in the sequential mediating effect involving interpersonal competence and anxiety. The study reveals that nurturing students' EI can significantly enhance their interpersonal competence, which can reduce anxiety and ultimately increase their self-reported life satisfaction.

Interpersonal Psychotherapy: A Review of Theory, History, and Evidence of Efficacy

Interpersonal psychotherapy (IPT) is an empirically validated treatment for mood disorders, anxiety disorders, eating disorders, and trauma. IPT is based on the concept of "relational frame"-that an individual's experience of psychological distress impacts those around them, and that their social support network impacts the distressed individual. This concept, along with the specific techniques and tools that flow from it and the theoretical bases of IPT (attachment and interpersonal theory) make IPT unique. In this article we review the theoretical bases of IPT (attachment and communication) and provide a brief history of IPT, as well as the evidence supporting its use for a variety of disorders. We also describe its application to groups, adolescents, and other diverse populations. Future directions for research and treatment development are proposed, particularly research in the area of combining IPT with other psychotherapeutic modalities.

A systematic review of brief respiratory, embodiment, cognitive, and mindfulness interventions to reduce state anxiety

Introduction

Anxiety is one of the most prevalent mental health conditions worldwide, and psychotherapeutic techniques can be employed to help manage and mitigate symptoms. While the available therapies are numerous, key strategies often involve cognitive and/or embodiment techniques. Within body-centered methods, breathing-oriented approaches are particularly prevalent, using either attention towards or active control of breathing. As the perception of body states (i.e., interoception) is thought to be an integral component of emotion generation, these embodiment and breathing techniques may be key in addressing the miscommunication between the brain and body that is thought to exist with anxiety. Therefore, we conducted a systematic review and meta-analysis to assess the effects of acute administration of psychological interventions for state anxiety.

Results

This systematic review was conducted in accordance with the PRISMA statement and registered prospectively in PROSPERO. A literature search for randomized controlled trials was conducted in PubMed, PsycINFO, and Scopus. We considered interventions that focused on cognitive, embodiment or breathing strategies, or a combination of these techniques. Twelve studies met our inclusion criteria, and study characteristics, quality and effect sizes were assessed. A single cognitive study was found to produce a moderate reduction in state anxiety, while moderate to large effects were found across studies assessing embodiment practices. In contrast, studies which utilized breathing-based interventions alone produced inconsistent results, with both attention towards and active control of breathing producing large to no effects depending on the technique employed. Finally, consistent moderate effects were found with combination techniques that involved passive attention (e.g., towards cognitions, body and/or breathing), with active combination techniques producing inconsistent results.

Discussion

While study numbers are limited regarding brief interventions, cognitive and embodiment techniques are consistently helpful for reducing state anxiety, while breathing-based exercises need to consider the specific technique employed, and how successful this may be for each individual. Furthermore, combined practices such as mindfulness can also be successful, although care must be taken when introducing an active change to one or more elements.

PROSPERO Systematic Review Registration Number

CRD42024507585 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024507585.

A Systematic Review of Psychotherapy Approaches for Anxiety in Parkinson's Disease

OBJECTIVES

Anxiety is common in Parkinson's disease (PD), negatively impacting daily functioning and quality of life in PD patients and their families. This systematic review evaluates the effectiveness of different psychotherapeutic approaches for reducing anxiety in PD and provides recommendations for clinical practise.

METHODS

Following PRISMA guidelines, 36 studies were included and risk of bias was evaluated.

RESULTS

We identified cognitive behavioral therapy (CBT), mindfulness-based therapies, acceptance and commitment therapy, and psychodrama psychotherapies. There is good evidence-base for anxiety reduction using CBT approaches, but with mixed results for mindfulness-based therapies. Other therapeutic approaches were under researched. Most randomized control trials examined anxiety as a secondary measure. There was a paucity of interventions for anxiety subtypes. Secondarily, studies revealed the consistent exclusion of PD patients with cognitive concerns, an importance of care partner involvement, and a growing interest in remote delivery of psychotherapy interventions.

CONCLUSIONS

Person-centered anxiety interventions tailored for PD patients, including those with cognitive concerns, and trials exploring modalities other than CBT, warrant future investigations.

CLINICAL IMPLICATIONS

Practitioners should consider PD-specific anxiety symptoms and cognitive concerns when treating anxiety. Key distinctions between therapeutic modalities, therapy settings and delivery methods should guide treatment planning.

A Comprehensive Review of the Generalized Anxiety Disorder

Excessive, uncontrollable, and usually unjustified worry about certain things is a sign of the mental and behavioral disease known as generalized anxiety disorder (GAD). Genetic research suggests that numerous genes are likely implicated in the development of GAD, even if much is yet unclear about this. As a result, if someone in a family has GAD, there is a high likelihood that someone else will also suffer from the illness, as well as another anxiety disorder. Individuals with GAD are frequently overly bothered about workaday affairs like health, assets, demise, family, accord issues, or effort challenges. Worry frequently interferes with daily functioning. Excessive concern, restlessness, difficulty sleeping, tiredness, irritability, sweating, and trembling are a few symptoms that may be present. For a formal diagnosis of GAD, symptoms must be persistent for at least six months and consistent. Conversion in the amygdala's utilitarian congruence and how it processes fear and anxiety have been linked to generalized anxiety disorder. Neurotransmitters, and particularly the gamma-aminobutyric acid (GABA) variant, have long been known to cause GAD through dysregulating amygdala activity in the brain. Anxiety, concern, or physical symptoms must significantly hinder social, academic, or occupational functioning in order to qualify for a GAD diagnosis. The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) provides explicit ethos to aid doctors in identifying this disorder. Psychological therapy based on cognitive behavioral therapy (CBT) principles is effective in reducing anxiety symptoms for short-term treatment of GAD. In this, the patient's thinking ability and methods are focused. The main principle behind CBT is that your thought patterns affect your feelings, which in turn can affect your behavior. Drugs like antidepressants, buspirone, benzodiazepines, and can all be worn to goody GAD. Outside of therapy, patients with anxiety can learn to manage it by practicing relaxation methods, reframing unfavorable ideas, and adopting stress-relieving adjustments. Being socially active and setting aside time for proper self-care are crucial components of managing generalized anxiety disorder.

Efficacy of interpersonal psychotherapy in mainland China: a systematic review and meta-analysis

Objective

Interpersonal Psychotherapy (IPT) is an evidence-based therapy. There have been increasing demand and training opportunities of IPT in China. Reviewing current evidence on its use in Chinese patients can help us understand the applicability of IPT in China and identify knowledge gaps to encourage and better future research in this field.

Method

We did a comprehensive search of three major electronic databases: PubMed (English), Chinese National Knowledge Infrastructure (CNKI) and WanFang Data (Chinese). We examined overall study design, outcome measures, data analyses and other parameters. We only selected articles of Randomized Clinical Trials (RCT) for this review. All study findings were grouped and summarized per psychiatric diagnoses. The meta-analysis and forest plots were performed whereas studies could be combined.

Results

After a full text review of 132 articles, 40 were selected for the final review. Comparing with control groups, evidences supported the efficacy of IPT in Chinese patients with Major Depressive Disorder (MDD), Postpartum depression, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, Post Stress Traumatic Disorder (PTSD), and Post-psychotic Depression. It was also beneficial to college students and Chinese first-time mothers. Meta-analysis using a random-effects model consistently yielded significant score differences between the IPT and control groups (p < 0.0001) on MDD.

Conclusion

This systematic review has identified the current best evidence for IPT efficacy in Chinese population. The findings support IPT as an effective treatment in Chinese with certain psychiatric conditions, consistent with those from many other studies throughout the world.

Feasibility and Acceptability of Internet-based Interpersonal Psychotherapy for Stress, Anxiety, and Depression in Prenatal Women: Thematic Analysis Abstract (Preprint)

Background

Prenatal mental health is a global health concern. Despite the far-reaching impact of prenatal mental health issues, many women do not receive the psychological care they require. Women in their childbearing years are frequent users of the internet and smartphone apps. Prenatal women are prime candidates for internet-based support for mental health care.

Objective

This study aimed to examine the feasibility and acceptability of internet-based interpersonal psychotherapy (IPT) for prenatal women.

Methods

Semistructured interviews were conducted with women who had received internet-based IPT modules with guided support as a component of a randomized controlled trial evaluating the scale-up implementation of a digital mental health platform (The Healthy Outcomes of Pregnancy and Postpartum Experiences digital platform) for pregnant women. Qualitative thematic analysis was used to explore and describe women’s experiences. Data were analyzed for emerging themes, which were identified and coded.

Results

A total of 15 prenatal women were interviewed to examine their experiences and views on the feasibility and acceptability of internet-based IPT modules. Participants found the content informative and appreciated the ways in which the digital mental health platform made the IPT modules accessible to users. Participants voiced some differing requirements regarding the depth and the way information was presented and accessed on the digital mental health platform. The important areas for improvement that were identified were acknowledging greater depth and clarity of content, the need for sociability and relationships, and refinement of the digital mental health platform to a smartphone app.

Conclusions

This study provides useful evidence regarding treatment format and content preferences, which may inform future development. It also provides research data on the feasibility and acceptability of web-based applications for prenatal mental health care.

Trial Registration

ClinicalTrials.gov NCT01901796; https://clinicaltrials.gov/ct2/show/NCT01901796

Group autonomy enhancing treatment versus cognitive behavioral therapy for anxiety disorders: A cluster-randomized clinical trial

BACKGROUND

Although cognitive behavioral therapy (CBT) is effective in the treatment of anxiety disorders, few evidence-based alternatives exist. Autonomy enhancing treatment (AET) aims to decrease the vulnerability for anxiety disorders by targeting underlying autonomy deficits and may therefore have similar effects on anxiety as CBT, but yield broader effects.

METHODS

A multicenter cluster-randomized clinical trial was conducted including 129 patients with DSM-5 anxiety disorders, on average 33.66 years of age (SD = 12.57), 91 (70.5%) female, and most (92.2%) born in the Netherlands. Participants were randomized over 15-week groupwise AET or groupwise CBT and completed questionnaires on anxiety, general psychopathology, depression, quality of life, autonomy-connectedness and self-esteem, pre-, mid-, and posttreatment, and after 3, 6, and 12 months (six measurements).

RESULTS

Contrary to the hypotheses, effects on the broader outcome measures did not differ between AET and CBT (d = .16 or smaller at post-test). Anxiety reduction was similar across conditions (d = .059 at post-test) and neither therapy was superior on long term.

CONCLUSION

This was the first clinical randomized trial comparing AET to CBT. The added value of AET does not seem to lie in enhanced effectiveness on broader outcome measures or on long term compared to CBT. However, the study supports the effectiveness of AET and thereby contributes to extended treatment options for anxiety disorders.

Mediators in Psychological Treatments for Anxiety and Depression in Adolescents and Young People: A Protocol of a Systematic Review

Introduction

Anxiety and depressive disorders are a significant problem that starts in childhood or adolescence and should be addressed early to avoid chronic mental conditions. There is strong evidence to demonstrate that psychological treatments are effective for these disorders, however, little is known on mediators and mechanisms of change of psychological treatment in adolescents and young adults. Understanding the pathways through which psychological treatments operate will facilitate more effective treatments.

Aim

We aim to conduct a systematic review, exploring the available evidence on mediators of psychological treatments for anxiety and depression in adolescents and young adults.

Methods

A systematic search has been performed on PubMed and PsycINFO databases to identify studies from inception to 23rd February 2020. Eligible studies include randomized controlled trials and trials (quasi-experimental) designs that have enrolled adolescents and young adults presenting with depression and/or anxiety and that have examined mediators of psychological treatments. A group of 20 reviewers from the COST-Action TREATme (CA16102) divided into 10 pairs independently screen studies for inclusion, extract information from the included studies, and assess the methodological quality of the included studies and the requirements for mediators. The methodological quality will be assessed by The Mixed Methods Appraisal Tool. Extracted data from the included studies will be collected and presented using a narrative approach.

Discussion

This systematic review will summarize and provide a comprehensive overview of the current evidence on mediators of psychological treatments for anxiety and depression for adolescents and young adults. Results will allow the identification of strategies to optimize intervention to enhance clinical outcomes.

Ethics and dissemination

Ethics approval is not required. Findings from this systematic review will be published in a peer-reviewed journal and disseminated at conferences and meetings. PROSPERO registration number: CRD42021234641.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Interpersonal Sensitivity Mediates the Effects of Childhood Maltreatment on the Evaluation of Life Events and Anxiety States in Adult Community Volunteers

BACKGROUND

Childhood maltreatment has long-lasting psychological effects, which often manifest in adulthood. Previous studies have suggested that the effects of childhood maltreatment are not only direct but also indirect, being mediated by other factors. In this study, we hypothesized that the effects of childhood maltreatment on state anxiety in adulthood are mediated by interpersonal sensitivity and the evaluation of life events, and investigated this possibility by covariance structure analysis.

SUBJECTS AND METHODS

Self-administered questionnaires (Child Abuse and Trauma Scale, State-Trait Anxiety Inventory Form Y, Life Experiences Survey, and Interpersonal Sensitivity Measure) were distributed to adult community volunteers in Japan, and 404 eligible responses were collected. A structural equation model was constructed to analyze the direct and indirect effects of childhood maltreatment on state anxiety, with interpersonal sensitivity and the evaluation of life events as potential mediators.

RESULTS

Our model showed that childhood maltreatment increases state anxiety in adulthood both directly and indirectly via interpersonal sensitivity. In addition, interpersonal sensitivity mediated the effects of childhood maltreatment on the negative evaluation of life events, and the negative evaluation of life events mediated the effects of interpersonal sensitivity on anxiety symptoms.

LIMITATIONS

There may be possible recall bias owing to the self-administration of the questionnaire. In addition, this study had a cross-sectional design, and hence the results should be validated by a prospective study.

CONCLUSION

The effects of childhood maltreatment on the state anxiety of adult volunteers are not only direct but are also mediated by interpersonal sensitivity. Our results suggest that assessing interpersonal sensitivity may help to determine optimal treatments for patients with anxiety who experienced maltreatment in childhood.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017)

BACKGROUND

Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders.

METHODS

English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research.

RESULTS

IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment.

CONCLUSION

Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Separation anxiety in PTSD: A pilot study of mechanisms in patients undergoing IPT

INTRODUCTION

Separation anxiety disorder (SAD) comprises one aspect of attachment dysregulation or insecurity. Although SAD aggravates posttraumatic stress disorder (PTSD) risk, no clinical research has tracked how many patients with PTSD have SAD, its clinical associations, or its response to PTSD treatment. Our open trial of interpersonal psychotherapy (IPT) for veterans with PTSD assessed these SAD domains.

METHODS

Twenty-nine veterans diagnosed with chronic PTSD on the Clinician-Administered PTSD Scale were assessed for SAD using the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and for Symptom-Specific Reflective Function (SSRF), another dysregulated-attachment marker capturing patients' emotional understanding of their symptoms. Patients received 14 IPT sessions for PTSD with assessments at baseline, Week 4 (SCI-SAS and SSRF), and termination for SAD, PTSD, and depression.

RESULTS

At baseline, 69% of patients met SAD criteria. Separation anxiety did not correlate with baseline PTSD severity, depressive severity, or age when traumatized; patients with and without SAD had comparable PTSD and depression severity. Patients with baseline comorbid SAD who completed IPT (N = 17) reported significantly improved adult separation anxiety (p = .009). Adult SAD improvements predicted depressive improvement (p = .049). Patients with SAD showed a stronger relationship between early SSRF gains and subsequent adult SAD improvement (p = .021) compared with patients without SAD.

DISCUSSION

This first exploration of dysregulated/insecure attachment features among patients with PTSD found high SAD comorbidity and adult SAD improvement among patients with SAD following IPT. Highly impaired attachment patients normalized attachment posttreatment: 14-session IPT improved attachment dysregulation. This small study requires replication but begins to broaden clinical understanding of separation anxiety, attachment dysregulation, and PTSD.

Efficacy of interpersonal psychotherapy for post-traumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Evidence for the efficacy of treatments for post-traumatic stress disorder (PTSD) is urgently required. This systematic review and meta-analysis examines the efficacy of interpersonal psychotherapy (IPT) in reducing the symptoms of PTSD.

METHODS

Five databases were searched from inception until November 2018 to identify randomized controlled trials (RCTs) that assessed the efficacy of IPT in patients with PTSD symptoms. The reference lists of included studies were also hand searched. A random effects model was used to estimate changes in a clinician-administered PTSD scale, or self-reported symptoms.

RESULTS

Of 509 screened abstracts, ten clinical trials (11 study arms) involving 755 patients with PTSD symptoms were included. Nine studies (10 study arms) were included in the meta-analysis. The overall standardized mean difference was -0.44 (CI: -0.69, -0.19), p = 0.0005. This represents a change in the clinically administrated PTSD Scale (CAPS) of approximately 12 points. IPT was not superior to other active controls, such as medication and non-IPT psychotherapies, but was significantly superior to passive controls, such as waiting list and educational pamphlets.

LIMITATIONS

Most studies modified the IPT protocol and did not comprehensively assess clinician fidelity to the protocol. The included studies generally had small sample sizes and were of limited quality.

CONCLUSIONS

IPT may be an effective treatment for PTSD, but clinical trials with larger sample sizes and improved methodology are required to confirm effects.

Internet-based interpersonal psychotherapy for stress, anxiety, and depression in prenatal women: study protocol for a pilot randomized controlled trial

BACKGROUND

Psychological distress, defined as depression, anxiety and perceived stress, during pregnancy is common, with 15-25% of women experiencing clinically significant levels of such distress. Despite the far-reaching impact of prenatal psychological distress on mothers and their children, and that women are receptive to screening, few providers routinely screen for prenatal psychological distress and less than one in five women will receive the mental health care that they require. There is a lack of certainty regarding the most effective treatments for prenatal psychological distress. No online interpersonal psychotherapy (IPT) trials have been conducted that focus on improving psychological distress in prenatal women. The purpose of this pilot randomized controlled trial is to evaluate the perspectives of pregnant women on the feasibility and acceptability of online IPT (e-IPT) delivered during pregnancy.

METHODS

A pilot randomized controlled trial design with repeated measures will evaluate the feasibility and acceptability of e-IPT for pregnant women compared to routine prenatal care. Qualitative interviews with 15-30 individuals in the intervention group will provide further data on the feasibility and acceptability of the intervention. Assessment of feasibility will include the ease of accessing and completing the intervention. Women will also be asked about what barriers there were to starting and completing the e-IPT. Assessment of acceptability will inquire about the perception of women regarding the intervention and its various features. A sample size of 160 consenting pregnant women aged 18 years and older will be enrolled and randomized into the experimental (e-IPT) or control (routine care) condition. The secondary outcome measures include: depression, anxiety and stress symptoms; self-efficacy; self-mastery; self-esteem; relationship quality (spouse, immediate family members); coping; and resilience. All participants will complete the aforementioned measures at baseline during pregnancy (T1), 3 months postrandomization (T2), at 8 months of pregnancy (T3), and 3 months postpartum (T4).

DISCUSSION

The results of this pilot randomized controlled trial will provide data on the feasibility and acceptability of the intervention and identify necessary adaptations. This study will allow for optimization of full trial processes and inform the evaluation strategy, including sample size calculations for the full randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01901796. Registered on 18 December 2014.

Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder

BACKGROUND

It is not known whether common anxiety/mood comorbidities of panic disorder (PD) improve with panic-focused psychological treatment, nor whether there is differential efficacy between therapies in treating comorbidities.

METHODS

In a randomized controlled trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), symptomatic comorbidities of agoraphobia, MDD, GAD, and social anxiety disorder (SAD) were assessed pre-to-post treatment with the Anxiety Disorders Interview Schedule (ADIS). Comparative efficacy of CBT versus PFPP for treating comorbid disorders was tested at termination and 1 year's follow-up. Covariance between panic and comorbidity improvements was also analyzed.

RESULTS

Most treatment completers (n = 120) evidenced diagnostic remission of their comorbidity (range = 54-69%), which typically reflected a subclinical score on the ADIS (mean range = 1.3 to 1.8). These improvements were generally retained at follow-up. However, patients with MDD dropped out significantly more often (HR = 2.79). No significant symptom change or remission differences emerged between CBT and PFPP for any comorbidity at termination or at follow-up. Panic change was strongly related to improvements in agoraphobia (r = 0.70) and MDD (r = 0.53), moderately related for GAD (r = 0.31), and not significantly related for SAD (r = 0.20).

DISCUSSION

Patients completing panic-focused psychotherapies often experience meaningful remission for diagnoses of agoraphobia, MDD, GAD, and SAD, with no detectable differences between treatments, although sample sizes for the MDD and SAD comparisons were small. In addition, additional efforts may be needed to keep MDD-comorbid patients in treatment.

An Epidemiological Study of Substance Use Disorders Among Emerging and Young Adults

OBJECTIVES

We investigated the prevalence of substance use disorders (SUDs) among emerging adults and quantified the extent to which emerging adults, compared with young adults, have increased odds for SUDs.

METHODS

Data were from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH). Respondents were 15 to 39 y of age ( n = 9228) and were categorized as: early emerging adults (15 to 22 y); late emerging adults (23 to 29 y); and, young adults (30 to 39 y). SUDs [alcohol or drug abuse/dependence (AAD or DAD)] were measured using the WHO Composite International Diagnostic Interview 3.0. The prevalence of SUDs was compared across age groups, and odds ratios (OR) and 95% confidence intervals (CI) were computed from logistic regression models adjusting for sociodemographic and health covariates. Analyses were weighted to maintain representativeness to the Canadian population.

RESULTS

The prevalence of AAD was 8.0%, 6.6%, and 2.7% for early emerging adults, late emerging adults, and young adults, respectively. For DAD, the prevalence was 6.4%, 3.6%, and 1.3%. After covariate adjustment, early and late emerging adults had greater odds of reporting AAD (OR = 3.2, 95% CI = 2.2 to 4.9 and OR = 2.4, 95% CI = 1.6 to 3.4, respectively) or DAD (OR = 4.2, 95% CI = 2.5 to 7.0 and OR = 2.5, 95% CI = 1.6 to 4.1, respectively) compared with young adults. Differences between early and late emerging adults were not significant.

CONCLUSION

Emerging adults are at increased odds for SUDs. Lack of differences between early and late emerging adults provide evidence of the extension of emerging adulthood into the late 20s. Findings have implications for the provision of screening and treatment of SUDs during this developmental period.

Psychometric analysis of the Swedish panic disorder severity scale and its self-report version

BACKGROUND

Panic disorder, with or without agoraphobia (PDA or PD, respectively), is a major public health problem. After having established a PD diagnosis based on the DSM or the ICD systems, the Panic Disorder Severity Scale (PDSS) is the most widely used interview-based instrument for assessing disorder severity. There is also a self-report version of the instrument (PDSS-SR); both exist in a Swedish translation but their psychometric properties remain untested.

METHODS

We studied 221 patients with PD/PDA recruited to a randomized controlled preference trial of cognitive-behavioral and brief panic-focused psychodynamic psychotherapy. In addition to PDSS and PDSS-SR the participants completed self-reports including the Clinical Outcome in Routine Evaluation - Outcome Measure, Montgomery Åsberg Depression Rating Scale, Sheehan Disability Scale, Bodily Sensations Questionnaire and the Mobility Inventory for Agoraphobia.

RESULTS

PDSS and PDSS-SR possessed excellent psychometric properties (internal consistency, test-retest reliability) and convergent validity. A single factor structure for both versions was not confirmed. In terms of clinical utility, the PDSS had very high inter-rater reliability and correspondence with PD assessed via structured diagnostic interview. Both versions were sensitive to the effects of PD-focused treatment, although subjects scored systematically lower on the self-report version.

CONCLUSIONS

The study confirmed the reliability and validity of the Swedish versions of PDSS and PDSS-SR. Both versions were highly sensitive to the effects of two PD-focused treatments and can be used both in clinical and research settings. However, further investigation of the factor structures of both the PDSS and PDSS-SR is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01606592.

A pilot study of a stepped-care brief intervention to help psychologically-distressed women displaced by conflict in Bogotá, Colombia

BACKGROUND

Colombia's 6.5 million internally displaced persons (IDPs) have been exposed to trauma, loss, and hardships. Common mental disorders (CMDs) are prevalent in this group, yet there are few evidence-based psychosocial interventions for this population. We assessed the feasibility and acceptability of a stepped-care intervention for women IDPs in Bogota, Colombia.

METHODS

Feasibility to recruit participants for an intervention trial, to screen for CMDs and displacement-related traumas, to refer high-risk cases to professional consultation, to implement evidence-based interpersonal counseling (IPC) for women with diagnosed CMDs, to retain participants in the intervention, and to conduct follow-up assessments was assessed. Assessment instruments were validated. The intervention was delivered by trained outreach personnel. Intervention acceptability was assessed by monitoring session attendance, dropout rates, and satisfaction. Potential efficacy was evaluated with pre- and post-intervention measures of CMDs.

RESULTS

We recruited 279 women IDPs into the intervention. On screening, 177 (63.4%) had symptom levels suggesting a CMD. Participants endorsed a wide range of displacement-related exposures. Most participants receiving IPC decreased their symptom levels at follow-up. Many participants did not complete the recommended number of IPC sessions; loss to follow-up was 30%. The performance of the outreach personnel improved after the initial intervention team was replaced with community members trained to deliver the intervention. The Bogotá health system was unable to reliably accommodate emergency psychiatric referrals.

CONCLUSIONS

The IPC intervention shows promise, but significant challenges remain for improving reach, adherence, and participant retention. We identified strategies and partnerships to redress some of the main study limitations.

Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises

BACKGROUND

People living in humanitarian settings in low- and middle-income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post-traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population.

OBJECTIVES

To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post-traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes.

MAIN RESULTS

We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub-Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive-behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) -1.07, 95% confidence interval (CI) -1.34 to -0.79; 1272 participants; 16 studies; low-quality evidence). The effect is smaller at one to four months (SMD -0.49, 95% CI -0.68 to -0.31; 1660 participants; 18 studies) and at six months (SMD -0.37, 95% CI -0.61 to -0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD -0.86, 95% CI -1.06 to -0.67; 1254 participants; 14 studies; low-quality evidence). Similar to PTSD symptoms, follow-up data at one to four months showed a smaller effect on depression (SMD -0.42, 95% CI -0.63 to -0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD -0.74, 95% CI -0.98 to -0.49; 694 participants; five studies; low-quality evidence) and at one to four months' follow-up after treatment (SMD -0.53, 95% CI -0.66 to -0.39; 969 participants; seven studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD -1.56, 95% CI -3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings.

AUTHORS' CONCLUSIONS

There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow-up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow-up.

"Gold Standards," Plurality and Monocultures: The Need for Diversity in Psychotherapy

For psychotherapy of mental disorders, presently several approaches are available, such as interpersonal, humanistic, systemic, psychodynamic or cognitive behavior therapy (CBT). Pointing to the available evidence, proponents of CBT claim that CBT is the gold standard. Some authors even argue for an integrated CBT-based form of psychotherapy as the only form of psychotherapy. CBT undoubtedly has its strengths and CBT researchers have to be credited for developing and testing treatments for many mental disorders. A critical review, however, shows that the available evidence for the theoretical foundations of CBT, assumed mechanisms of change, quality of studies, and efficacy is not as robust as some researchers claim. Most important, there is no consistent evidence that CBT is more efficacious than other evidence-based approaches. These findings do not justify regarding CBT as the gold standard psychotherapy. They even provide less justification for the idea that the future of psychotherapy lies in one integrated CBT-based form of psychotherapy as the only type of psychotherapy. For the different psychotherapeutic approaches a growing body of evidence is available. These approaches have their strengths because of differences in their respective focus on interpersonal relationships, affects, cognitions, systemic perspectives, experiential, or unconscious processes. Different approaches may be suitable to different patients and therapists. As generally assumed, progress in research results from openness to new ideas and learning from diverse perspectives. Thus, different forms of evidence-based psychotherapy are required. Plurality is the future of psychotherapy, not a uniform "one fits all" approach.

Treatment-resistant panic disorder: clinical significance, concept and management

Panic disorder is commonly prevalent in the population, but the treatment response for panic disorder in clinical practice is much less effective than that in our imagination. Increasing evidence suggested existence of a chronic or remitting-relapsing clinical course in panic disorder. In this systematic review, we re-examine the definition of treatment-resistant panic disorder, and present the potential risk factors related to the treatment resistance, including the characteristics of panic disorder, other psychiatric and physical comorbidities, and psychosocial stresses. Furthermore, we summarize the potential pathophysiologies, such as genetic susceptibility, altered brain functioning, brain-derived neurotrophic factor, and long-term inflammation, to explain the treatment resistance. Finally, we conclude the current therapeutic strategies for treating treatment-resistant panic disorder from pharmacological and non-pharmacological views.

Maintaining mental health and function for the long run in cystic fibrosis

Research shows that individuals with cystic fibrosis (CF) and their families experience significant emotional morbidity. In addition to distress, worry, and grief, high rates of clinically significant symptoms of depression and anxiety have been found in both individuals with CF and parents. These disorders have a major impact on the person's functioning, and that of their family, and adversely impact the capacity to cope with the burden of CF and adhere to prescribed treatments. Despite growing recognition that mental health care is an essential component of comprehensive CF care, evidence suggests many patients and their families do not receive needed support and mental health interventions. Clinical practice guidelines for screening and treating depression and anxiety in individuals with CF have been developed by The Cystic Fibrosis Foundation and the European Cystic Fibrosis Society in response to this need. This review highlights that the optimum care for individuals with CF and their families incorporates mental health in routine CF care. Addressing mental health could substantially improve physical and mental health outcomes and the functioning of individuals with CF and their families. Pediatr Pulmonol. 2016;51:S71-S78. © 2016 Wiley Periodicals, Inc.

Treatment-refractory anxiety; definition, risk factors, and treatment challenges

A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to “pseudo-resistance” (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true “treatment resistance.” Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.

Pathways from conflict-related trauma and ongoing adversity to posttraumatic stress disorder symptoms amongst West Papuan refugees: The mediating role of anxiety and panic-like symptoms

BACKGROUND

Although the relationship involving exposure to traumatic events (TEs), conditions of adversity, and posttraumatic stress disorder (PTSD) is well established in the refugee field, the psychological factors mediating the relevant pathways are not as clearly delineated. In the present path analysis, we examined a model in which anxiety and panic-like symptoms mediated the path between conflict-related TEs, ongoing adversity, and PTS symptoms amongst 230 refugees from West Papua.

METHODS

Culturally adapted measures were applied to assess TE exposure, ongoing adversity, anxiety, panic-like, PTS, and depressive symptoms.

RESULTS

Our model identified two pathways leading from conflict-related exposure to PTS symptoms, one a direct path, the other mediated by a sequence of ongoing adversity, anxiety and panic-like symptoms. Older refugees from West Papua had higher levels of anxiety and panic-like symptoms than the younger adult generation born in PNG.

CONCLUSIONS

Our findings suggest that a focus on reducing anxiety and panic together with addressing social deprivations and threats may improve anxiety and panic amongst refugees, ultimately improving outcomes for PTS symptoms.

Treatment-refractory anxiety; definition, risk factors, and treatment challenges

A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to "pseudo-resistance" (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true "treatment resistance." Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.

Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD

OBJECTIVE

Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). The authors tested interpersonal psychotherapy (IPT), which has demonstrated antidepressant efficacy and shown promise in pilot PTSD research as a non-exposure-based non-cognitive-behavioral PTSD treatment.

METHOD

The authors conducted a randomized 14-week trial comparing IPT, prolonged exposure (an exposure-based exemplar), and relaxation therapy (an active control psychotherapy) in 110 unmedicated patients who had chronic PTSD and a score >50 on the Clinician-Administered PTSD Scale (CAPS). Randomization stratified for comorbid major depression. The authors hypothesized that IPT would be no more than minimally inferior (a difference <12.5 points in CAPS score) to prolonged exposure.

RESULTS

All therapies had large within-group effect sizes (d values, 1.32-1.88). Rates of response, defined as an improvement of >30% in CAPS score, were 63% for IPT, 47% for prolonged exposure, and 38% for relaxation therapy (not significantly different between groups). CAPS outcomes for IPT and prolonged exposure differed by 5.5 points (not significant), and the null hypothesis of more than minimal IPT inferiority was rejected (p=0.035). Patients with comorbid major depression were nine times more likely than nondepressed patients to drop out of prolonged exposure therapy. IPT and prolonged exposure improved quality of life and social functioning more than relaxation therapy.

CONCLUSIONS

This study demonstrated noninferiority of individual IPT for PTSD compared with the gold-standard treatment. IPT had (nonsignificantly) lower attrition and higher response rates than prolonged exposure. Contrary to widespread clinical belief, PTSD treatment may not require cognitive-behavioral exposure to trauma reminders. Moreover, patients with comorbid major depression may fare better with IPT than with prolonged exposure.