To prevent depression recurrence, interpersonal psychotherapy is a first-line treatment with long-term benefits

Major depressive disorder (MDD) frequently is recur­rent, with new episodes causing substantial social and economic impairment¹ and increasing the like­lihood of future episodes.² For this reason, contemporary psychiatric practitioners think of depression treatment as long-term and plan thoughtfully for maintenance therapy.

Recognizing the importance of engaging depressed indi­viduals beyond the initial response,³ American Psychiatric Association practice guidelines conceptualize depression treatment as 3 phases:
• acute treatment, with the aim of remission (symptom removal)
• continuation treatment, with the aim of preventing re­lapse (symptom return)
• maintenance treatment, with the aim of preventing re­currence (new episodes).⁴
Interpersonal psychotherapy (IPT) is an evidence-based psychosocial treatment that adheres to this model.⁵ As a time-limited, manual-driven^6,7 approach, IPT focuses on interpersonal distresses as precipitating and perpetuating factors of depression.⁸

Acute IPT’s efficacy is well-established across >200 empirical studies—making it an evidence-based, first-line treatment for adult depression.^4,9,10 Meta-analyses show that acute IPT is superior to placebo and no-treatment con­trols, and largely comparable to antidepressant medication and other active, first-line psychotherapies, such as cogni­tive-behavioral therapy (CBT).^11,12

Although this review, as well as the liter­ature, focuses largely on adult outpatients with depression, evidence of IPT’s general efficacy exists for adolescents,¹³ chronically depressed patients,¹¹ and depressed inpa­tients.¹⁴ This article presents a case study to describe the structure of IPT when used to treat depressed adults. We also present evidence of IPT’s acute and long-term ef­ficacy in preventing depression recurrence and data to guide its use in practice.

CASE REPORT

‘Safe’ but depressed
Timothy, age 18, is a first-year college student who presents for outpatient psychotherapy to address recurrent depression. He reports general unhappiness, loss of interest in things, low energy, sleep problems, poor academic and work functioning, and low self-esteem. He experienced at least 3 similar depressive episodes while in high school.

The therapist’s diagnostic and interper­sonal assessment suggests that Timothy’s depression is interpersonally driven. Timothy longs for relational intimacy but fears he will fail or burden people with his needs. He has difficulty gauging appropriate lev­els of enmeshment with others and either becomes overdependent or stays at a dis­tance. This “safe” approach to relationships contributes to boredom, loneliness, and isolation. His recent transition to college away from home and the failure of a roman­tic relationship have compounded these experiences.

Interpersonal model of IPT
IPT conceptualizes depression as involving predisposing, precipitating, and perpetu­ating biopsychosocial factors, including:
• underlying biological and social vul­nerability, such as insecure attach­ ment (ie, tenuous and often negative views of self and others)
• current interpersonal life stressors
• inadequate social supports.^15,16

For example, poor early attachment to caregivers can give rise to despair, isolation, and low mood. In turn, this can be exacerbated by poor social and commu­nication skills that promote further rejec­tion and withdrawal of social support and thus, intensified despair, isolation, and low mood. As in Timothy’s case, this vicious cycle underscores psychosocial stressors as a causal factor, maintaining factor, and result of depression. Specifically, IPT con­ceptualizes 4 main biopsychosocial problem domains:
• grief and loss
• interpersonal disputes
• role transitions
• interpersonal/communication deficits (often connected to isolation).

Working within 1 or 2 of the most salient problem domains, IPT centers on strategies for helping patients solve interpersonal problems based on the notion that modi­fied relationships, revised interpersonal expectations, improved communications, and increased social support will lead to symptom reduction.^15-17

Many techniques are utilized in IPT (Table 1) to help patients modify their interpersonal relationships as a mechanism for decreasing their distress. IPT is prob­lem-focused, aiming to improve patients’ relationships by drawing on their assets and helping to build skills around short­comings. Therefore, IPT focuses on observ­able interpersonal patterns, as opposed to latent personality dynamics.

CASE CONTINUED

Setting goals
When the clinical explains in the non-technical terms the data supporting IPT’s efficacy for depression, including with young adults, Timothy agrees to teeatment with acute IPT. The therapist behins with consciousness-raising techniques to help Timothy adopt the “sick role” by viewing depressing as an illness to be cured. Collaboratively, they establish treatment goals that fit the IPT formulation of depression— ie, revising current relationships and expectations of them, increasing social support, improving communication skills, and solving problems within 1 or 2 of the IPT prob­lem domains.

For Timothy, the most pressing psy­chosocial problems seem to be interper­sonal deficits and role transitions. He ap­pears to be insecurely attached to others, which is a risk factor for poor facilitation of, and boundaries around, good relation­ships. A transition to a new and intimidat­ing interpersonal context—living on a college campus—compounded his vulnerabilities and increased his depression.

Acute treatment. The acute phase of IPT is time-limited—often, 12 to 16 sessions with gradual tapering toward the end (akin to a continuation phase). The time limit’s pur­pose is to focus both patient and therapist on the specific goal of removing the acute “illness” of depression. The IPT clinician takes an interpersonal inventory to learn about the patient’s most important rela­tionships and hones in on the IPT domain foci. Working collaboratively, the thera­pist might help the patient mourn a loss, reconstruct a narrative with a deceased loved one, consider ways to increase social contact, develop assertiveness, label feel­ings and needs, resolve an impasse with a significant other, and so forth.