Evidence-Based Reviews

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

Current Psychiatry. 2014 April;13(4):33-41B

References

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IPT-M for preventing recurrence
A second way to understand recurrence prevention is to examine the efficacy of a treatment’s maintenance protocol added to an acute treatment phase. IPT has been adapted as a maintenance treatment (IPT-M), with emphasis on keeping patients well. With this revised focus, IPT-M differs somewhat from acute IPT. Although treatment continues to center on interpersonal functioning, IPT-M favors:
• vigilance for possible triggers of new depressive episodes
• longer-term contact with a therapist
• reinforcing skills learned
• addressing an expanded number of interpersonal problem areas (given that such problems can be addressed more efficiently relative to acute treatment).

Efficacy of IPT-M. In the initial trial, Frank et al²³ compared the efficacy of IPT-M with that of pharmacotherapy (imipramine) in preventing depressive relapse among patients with recurrent depression who had responded to ≥16 sessions of acute IPT and imipramine and remained well during a 17- week continuation phase. For maintenance, patients were assigned to IPT-M alone, imipramine alone, placebo alone, IPT-M plus imipramine, or IPT-M plus placebo. Maintenance imipramine was continued at the acute dosage (target 200 mg/d; up to 400 mg/d was allowed). Maintenance IPT was monthly sessions. Patients remained in the trial for 3 years or until depression recurred.

On its own, IPT-M showed some efficacy in preventing recurrence, as the mean time to recurrence was 82 weeks for IPT-M alone and 74 weeks for IPT-M plus placebo. The prophylactic effect of imipramine was stronger, however. The mean time to recurrence for imipramine with IPT was 131 weeks, and the mean time to recurrence for imipramine without IPT was 124 weeks. Therefore, whereas monthly IPT-M can certainly help prolong wellness and delay recurrence, IPT maintenance treatment with acute doses of imipramine might be even more effective— if the patient is willing to take medication. These findings must be considered with caution because of the inherent inequity between imipramine and IPT-M in regard to maintenance dosage strength.

Frequency of treatment. In another trial, Frank et al²⁴ examined whether the frequency of maintenance IPT sessions played a role in its prophylactic effect. Adult women who had achieved depression remission with acute IPT (alone or in combination with SSRI pharmacotherapy) were randomized to weekly, bi-weekly, or monthly IPT-M alone for 2 years or until recurrence. Depression recurred during IPT-M in:
• 26% of patients who had received acute IPT alone
• 50% of those who had received acute IPT plus an SSRI.

Frequency of IPT-M sessions did not affect time to recurrence. Thus, for women who can achieve remission with IPT alone, varied frequencies of IPT-M can be good prophylaxis. For women who need an SSRI to augment acute IPT, IPT-M alone at varied dosages is less effective in preventing depression recurrence. Therefore, acute treatment response patterns can inform maintenance plans, with the most prudent maintenance strategy being to maintain the acute treatment strategy over a longer period.

IPT-M for late-life depression. A trial by Reynolds et al25 examined the efficacy of maintenance nortriptyline and IPT-M in preventing depression recurrence in patients age ≥59 who initially recovered after combined acute and continuation IPT plus nortriptyline. The 4 conditions (with their recurrence rates) were:
• monthly IPT-M with nortriptyline (20%)
• monthly IPT-M with placebo (64%)
• nortriptyline plus medication visits (43%)
• placebo plus medication visits (90%).

Clearly, the combined active treatments outperformed placebo and antidepressant alone in terms of delaying or preventing recurrence, which suggests an optimal maintenance strategy with this population.

IPT-M for later life. Another trial by the same group²⁶ enrolled patients age ≥70 with MDD that responded to acute IPT plus paroxetine. The maintenance treatments to which they were randomly assigned (and recurrence rates within 2 years) were:
• paroxetine plus IPT-M (35%)
• placebo plus IPT-M (68%)
• paroxetine plus clinical management (37%)
• placebo plus clinical management (58%).

Recurrence rates were the same for patients receiving medication plus IPT-M and medication plus clinical management, and depression was 2.4 times more likely to recur in patients receiving placebo vs active medication. Therefore, for later life depression, the optimal maintenance strategy was the SSRI.

Secondary analyses of data from these seminal trials of IPT-M point to other predictors of how and for whom maintenance IPT may work (Table 4). For example:
• Greater variability of depression symptoms during all forms of maintenance treatment is related to a greater risk of recurrence.
• Persistent insomnia is related to greater risk of recurrent depression.
• High interpersonal focus in IPT-M sessions is related to longer time to recurrence.

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

References

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