Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings

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.

Working Alliance, Interpersonal Problems, and Depressive Symptoms in Tele-Interpersonal Psychotherapy for HIV-infected Rural Persons: Evidence for Indirect Effects

OBJECTIVE

Interpersonal psychotherapy (IPT) has demonstrated efficacy for the treatment of depression, yet little is known about its therapeutic mechanisms. As a specific treatment, IPT has been shown to directly reduce depressive symptoms, although it is unclear whether these reductions occur via interpersonal changes. Within IPT, the potential role of the working alliance, a common factor, as a predictor of depression and interpersonal changes is also unclear.

METHOD

Participants were 147 depressed persons living with HIV in rural communities of 28 U.S. states enrolled in a randomized clinical trial. Seventy-five patients received up to 9 sessions of telephone-administered IPT (tele-IPT) plus standard care and 72 patients received standard care only. Two models were tested; one included treatment condition (tele-IPT vs. control) and another included the working alliance as independent variables.

RESULTS

The first model found an indirect effect whereby tele-IPT reduced depression via decreased social avoidance. There was a direct effect between tele-IPT and reduced depression. In the second model, the working alliance influenced depressive symptom relief via reductions in social avoidance. Both goal and task working alliance subscales were indirectly associated with reductions in depressive symptoms, also through reductions in social avoidance. There were no direct effects involving the working alliance. Tele-IPT's influence on depressive symptom reduction was primarily through a direct effect, whereas the influence of working alliance depression was almost entirely via an indirect effect through interpersonal problems.

CONCLUSION

Study findings have implications for IPT when intervening with depressed rural people living with HIV/AIDS over the telephone.

A dimensional approach to assessing personality functioning: examining personality trait domains utilizing DSM-IV personality disorder criteria

BACKGROUND

This study compared a dimensional, trait domain approach to characterizing personality pathology with the traditional polythetic approach with respect to their associations with interpersonal functioning and personality traits from the five factor model.

METHODS

Psychiatric inpatients (N=1476) were administered the Structured Clinical Interview for DSM-IV Axis II personality disorders. Dimensional representations of trait domains were derived from reorganizing DSM-IV criteria into personality trait domains from DSM-5 Alternative Model. Dimensional scores and personality disorder (PD) total criterion scores served as independent variables in predicting interpersonal profile clusters, as well as extraversion, agreeableness conscientiousness, neuroticism and openness from the five factor model traits.

RESULTS

Trait domain scores and PD criteria totals were significantly correlated with submissive interpersonal style yet none proved significant in regression analyses. Avoidant and borderline PD total criteria were negatively associated with a normative interpersonal style. Combined trait domain of detachment and avoidant PD total criteria predicted a hostile/withdrawn interpersonal style. The trait domain of detachment was negatively associated with five factor traits of extroversion, whereas borderline PD total criteria were negatively associated with conscientiousness. Avoidant and borderline PD total criteria were positively associated with neuroticism.

CONCLUSIONS

The cross-cutting dimensional approach provided useful information in predicting a hostile/withdrawn interpersonal style as well as extroversion. Importantly, PD criterion scores and dimensional trait scores combined to predict this interpersonal style providing support to the alternative model of personality diagnosis in DSM-5. Clinicians are encouraged to assess dimensions of personality traits as these are related to interpersonal problems frequently encountered in psychiatric settings. While potentially useful, the dimensional approach articulated here did not yield substantial prediction of behavior.

Interpersonal Change Following Intensive Inpatient Treatment

OBJECTIVE

Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization.

METHODS

Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored.

RESULTS

Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition.

CONCLUSION

Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.

Mechanisms of change in interpersonal therapy (IPT)

Although interpersonal therapy (IPT) has demonstrated efficacy for mood and other disorders, little is known about how IPT works. We present interpersonal change mechanisms that we hypothesize account for symptom change in IPT. Integrating relational theory and insights based on research findings regarding stress, social support, and illness, IPT highlights contextual factors thought to precipitate and maintain psychiatric disorders. It frames therapy around a central interpersonal problem in the patient's life, a current crisis or relational predicament that is disrupting social support and increasing interpersonal stress. By mobilizing and working collaboratively with the patient to resolve this problem, IPT seeks to activate several interpersonal change mechanisms. These include: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills. We hope that articulating these mechanisms will help therapists to formulate cases and better maintain focus within an IPT framework. Here we propose interpersonal mechanisms that might explain how IPT's interpersonal focus leads to symptom change. Future work needs to specify and test candidate mediators in clinical trials. We anticipate that pursuing this more systematic strategy will lead to important refinements and improvements in IPT and enhance its application in a range of clinical populations.

Interpersonal psychotherapy: past, present and future

The authors briefly describe the origins, theory, and development of interpersonal psychotherapy: its roots in clinical outcome research, its spread from major depression to other psychiatric disorders and its increasing dissemination as an empirically validated clinical intervention included in treatment guidelines. They attempt to forecast research, organizational and training issues the growing interpersonal psychotherapy community may face in the future.

Interpersonal psychotherapy (IPT) for PTSD: a case study

Interpersonal Psychotherapy (IPT), a time-limited, evidence-based treatment, has shown efficacy in treating major depressive disorder and other psychiatric conditions. Interpersonal Psychotherapy focuses on the patient's current life events and social and interpersonal functioning for understanding and treating symptoms. This case report demonstrates the novel use of IPT as treatment for posttraumatic stress disorder (PTSD). Preliminary evidence suggests IPT may relieve PTSD symptoms without focusing on exposure to trauma reminders. Thus IPT may offer an alternative for patients who refuse (or do not respond to) exposure-based approaches. Interpersonal Psychotherapy focuses on two problem areas that specifically affect patients with PTSD: interpersonal difficulties and affect dysregulation. This case report describes a pilot participant from a study comparing 14 weekly sessions of IPT to treatment with two other psychotherapies. We describe the session-by-session IPT protocol, illustrating how to formulate the case, help the patient identify and address problematic affects and interpersonal functioning, and to monitor treatment response.

Universality of interpersonal psychotherapy (IPT) problem areas in Thai depressed patients

BACKGROUND

Many studies have shown the efficacy of interpersonal psychotherapy (IPT) on depression; however, there are limited studies concerning the universality of the IPT problem areas in different countries. This study identifies whether the interpersonal problem areas defined in the IPT manual are endorsed by Thai depressed patients.

METHODS

The Thai Hamilton Rating Scale for Depression (Thai HRSD) and Thai Interpersonal Questionnaire were used to assess 90 depressed and 90 non-depressed subjects in King Chulalongkorn Memorial Hospital, during July 2007 - January 2008. The association between interpersonal problem areas/sociodemographic variables and depressive disorder were analyzed by chi-square test. A multivariable analysis was performed by using logistic regression to identify the remaining factors associated with depressive disorder.

RESULTS

Most of the subjects were young to middle-aged females living in Bangkok and the Central Provinces. All four interpersonal problem areas (grief, interpersonal role disputes, role transitions, and interpersonal deficits) were increased in the depressed subjects as compared to the non-depressed subjects, as were the sociodemographic variables (low education, unemployment, low income, and having a physical illness). Logistic regression showed that all interpersonal problem areas still remained problems associated with depression (grief: adjusted OR = 6.01, 95%CI = 1.93 - 18.69, p < 0.01; interpersonal role disputes: adjusted OR = 6.01, 95%CI = 2.18 - 16.52, p < 0.01; role transitions: adjusted OR = 26.30, 95%CI = 7.84 - 88.25, p < 0.01; and interpersonal deficits: adjusted OR = 2.92, 95%CI = 1.12 - 7.60, p < 0.05).

CONCLUSION

All four interpersonal problem areas were applicable to Thai depressed patients.

A multidisciplinary therapeutic approach for reducing the risk of psychiatric side effects in patients with chronic hepatitis C treated with pegylated interferon α and ribavirin

GOALS

To evaluate the effectiveness of psychiatric counseling in reducing the rate of development of psychiatric side effects of antiviral therapy with interferon-α and ribavirin among study participants compared with standard clinical monitoring alone.

BACKGROUND

Interferon-α is used to treat chronic hepatitis C. Interferons may induce adverse events that usually, but not always, reverse within a few days after the end of therapy.

STUDY

Two hundred eleven patients with chronic hepatitis C, genotype 1b were treated with peginterferon and ribavirin for 48 weeks in a prospective trial. Two groups were randomly created. Group A was interviewed by a team of gastroenterologists, psychiatrists, and psychologists and treated with psychotherapy once a month. Group B was monitored once a month according to a conventional protocol that did not include psychotherapy. SVR (sustained viral response), severe psychiatric symptom onset, and mood progression were assessed (P calculated using Fisher exact test, Friedman test, Dunn posttest, and Mann-Whitney U-test).

RESULTS

At baseline, there was no difference in depressive symptoms or liver histologic score between the 2 groups. The onset rate of severe psychiatric manifestations was 4.7% (Group A) and 16.1% (Group B) between the 24th and 36th weeks (P<0.01). Fifteen participants in Group A and 39 in Group B required antidepressants and benzodiazepines (P<0.05).

CONCLUSIONS

Patients can develop depressive symptoms during interferon therapy. Multidisciplinary medical treatment with psychiatric counseling provided during the treatment of chronic hepatitis C may contribute to the decrease or prevent the higher rates of depression associated with interferon treatment.

Comparative outcomes among the problem areas of interpersonal psychotherapy for depression

BACKGROUND

Although interpersonal psychotherapy (IPT) is an efficacious treatment for acute depression, the relative efficacy of treatment in each of the four IPT problem areas (grief, role transitions, role disputes, interpersonal deficits) has received little attention. We evaluated the specificity of IPT by comparing treatment success among patients whose psychotherapy focused on each problem area. Moreover, we sought to understand how the patient characteristics and interpersonal problems most closely linked to the onset of a patient's current depression contributed to IPT success.

METHODS

Patients meeting DSM-IV criteria for an episode of major depressive disorder (n=182) were treated with weekly IPT. Remission was defined as an average Hamilton Rating Scale for Depression 17-item score of 7 or below over 3 weeks. Personality disorders were diagnosed using the Structured Clinical Interview for DSM-IV Personality Disorders.

RESULTS

Contrary to our prediction that patients whose treatment was focused on interpersonal deficits would take longer to remit, survival analyses indicated that patients receiving treatment focused on each of the four problem areas did not differ in their times to remission. Nor were patients in the interpersonal deficits group more likely to have an Axis II diagnosis. Patients whose treatment focused on role transitions remitted faster than those whose treatment focused on role disputes, after controlling for covariates.

CONCLUSION

With skillful use of IPT strategies and tactics and with careful medication management where appropriate, patients in this study whose treatment focused on each problem area were treated with equal success by trained IPT clinicians.

Investigation of stressful life events in patients with systemic sclerosis

OBJECTIVE

To assess the occurrence of stressful life events in the year before the initiation of systemic sclerosis.

METHODS

A consecutive series of 40 patients with systemic sclerosis (mean age (56.3+/-11.9) years, mean disease duration (4.3+/-3.1) years; 32 females and 8 males), including 28 with diffuse cutaneous scleroderma and 12 with limited cutaneous scleroderma, were evaluated. A control group of 40 healthy subjects free of systemic sclerosis also was included. Socioeconomic status was investigated and Paykel's interview for recent life events (a semi-structured research interview covering 64 life events) was conducted.

RESULTS

Patients with systemic sclerosis showed higher percentages of lower education (72.5%) and working class (82.5%), and reported more stressful life events (P<0.05), such as exits (P<0.05), undesirable events (P<0.01), and uncontrolled events (P<0.001), when compared with the control. More events that had an objective negative impact (P<0.001) were also reported in systemic sclerosis patients than in the control. These results are in accordance with a multifactorial model of pathogenesis in systemic sclerosis.

CONCLUSION

We reported a strong relationship between stressful life events and the initiation of systemic sclerosis. Our findings are consistent with current understanding of the extensive links of behavioral responses to stress with neurophysiological and biochemical processes.

Interpersonelle Psychotherapie bei stationär behandelten, depressiven Patienten

Zusammenfassung. Theoretischer Hintergrund: Eine erfolgreiche Depressionsbehandlung beinhaltet neben einer Remission depressiver Symptome, die Verbesserung der psychosozialen Leistungsfähigkeit. Fragestellung: Führt eine stationäre Behandlung mit Interpersoneller Psychotherapie in Kombination mit Medikation zu ausgeprägteren psychosozialen und interpersonellen Verbesserungen im Vergleich zu einer Standardbehandlung? Methode: 105 depressive Patienten, die auf „Interpersonelle Psychotherapie plus Pharmakotherapie” oder „Pharmakotherapie plus ärztliche Kurzgespräche” randomisiert wurden, wurden nach 5 Wochen stationärer Behandlung sowie 3 und 12 Monate nach Entlassung untersucht. Ergebnisse: In der klinischen Beurteilung der allgemeinen psychosozialen Leistungsfähigkeit erwies sich die Kombinationsbehandlung der Standardbehandlung signifikant überlegen, was allerdings über eine Verbesserung der Depressivität zu erklären war. In der Selbstbeurteilung der sozialen und interpersonellen Anpassung zeigten sich keine signifikanten Unterschiede. Schlussfolgerung: Zusätzliche Psychotherapie zeigt im Rahmen einer kurzfristigen stationären Depressionsbehandlung keine Vorteile hinsichtlich der sozialen und interpersonellen Anpassung gegenüber einer psychiatrischen Standardbehandlung.

A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients

BACKGROUND

Psychotherapy of "pure" dysthymic disorder remains understudied. This article reports outcomes of an acute randomized trial of 94 subjects treated for 16 weeks with either interpersonal psychotherapy (IPT), brief supportive psychotherapy (BSP), sertraline, or sertraline plus IPT.

METHODS

Recruited by clinical referral and advertising, subjects met DSM-IV criteria for early onset dysthymic disorder, with no episode of major depression in the prior six months. They were randomly assigned to one of four 16-week treatments, with options for crossover or continuation treatment. Results were analyzed from the intention-to-treat sample by ANCOVA, controlling for baseline depressive severity.

RESULTS

Subjects improved in all conditions over time, with the cells including sertraline pharmacotherapy showing superiority over psychotherapy alone for response and remission. Response rates were 58% for sertraline alone, 57% for combined treatment, 35% for IPT, and 31% for BSP.

LIMITATIONS

The study was underpowered and may have employed too "active" a control condition. Follow-up data were unobtainable.

CONCLUSIONS

In this acute trial for "pure" dysthymic disorder, sertraline with or without IPT showed advantages relative to IPT and BSP. Methodological difficulties may have limited differential outcome findings. This study bolsters a small but growing literature on the treatment of dysthymic disorder, suggesting that pharmacotherapy may acutely benefit patients more than psychotherapy.