IPT: From Humble Origins as ‘High Contact Therapy’ to International Adoption

Abstract

Back to table of contents Previous article Next article Clinical & ResearchFull AccessIPT: From Humble Origins as ‘High Contact Therapy’ to International AdoptionMyrna Weissman, Ph.D.Myrna WeissmanSearch for more papers by this author, Ph.D.Published Online:27 Apr 2021https://doi.org/10.1176/appi.pn.2021.5.4AbstractNow used worldwide, interpersonal psychotherapy is being adapted for treatment of mental disorders related to the stresses and losses associated with the global COVID-19 pandemic.Interpersonal psychotherapy (IPT) had a very humble origin in the 1970s, when it was known colloquially as “high contact” psychotherapy. The evidence for psychotherapy as a treatment rested largely on surmise. There were no psychotherapy manuals for training to conduct clinical trials and, therefore, no clinical trial and no demonstrated efficacy. Psychotropic medications were having great success with demonstrated efficacy and FDA approval.Nevertheless, the most common treatment for major nonpsychotic depression was psychotherapy, so it was a time of cognitive dissonance. Psychotherapists thought that medication might undo the effects of the transference. Pharmacologists thought that psychotherapy would upset the patient and interfere with the reduction of symptoms. Many believed that psychotherapy could not be subjected to clinical trials as every relationship was unique.It was against this background that Gerald Klerman, M.D., a psychiatrist at Yale University, decided to test the efficacy of medication as maintenance treatment for depression. There was good evidence for the efficacy of tricyclic antidepressants for acute treatment of depression, but how long to maintain patients on medication to prevent relapse was unclear.Some psychotherapy had to be included as a milieu effect, if only because most patients were receiving some form of psychotherapy. But which psychotherapy? It had to be what was commonly used in ambulatory psychiatric practice. Dr. Klerman admired the development of a manual for cognitive-behavioral therapy (CBT) by Aaron Beck, M.D., but it was not commonly used in clinics where medication was prescribed. Another alternative, psychoanalysis, also was usually not given with medication treatment.Finally, supportive psychotherapy emerged as the most likely candidate. However, there were no manuals for supportive psychotherapy with sufficient detail to guide the therapy or the training of therapists. Dr. Klerman engaged me to work with him to specify a psychotherapy that likely could be practiced in a psychopharmacology clinic. This became weekly “high contact” psychotherapy. The content focused on the effects of recent life events on the onset of depression and other common disorders. The systematic study of life events showed that a break in attachment through deaths, disputes, life changes, or the absence of attachments and loneliness were clearly present before the onset of depressive episodes. In other cases, the patient’s depression triggered these events.The life events research later formed the basis of IPT. Our experience of beginning medication trials with a diagnostic evaluation and a medical and psychosocial history also determined the manual content and the therapist training that followed.The maintenance trial, to our surprise, demonstrated the efficacy of high contact psychotherapy. Medication prevented relapse, and psychotherapy enhanced social functioning, and patients on combined treatment improved the most. This high contact therapy was then renamed interpersonal psychotherapy.A Growing IPT Database EmergesAround the same time, Dr. Beck also published his clinical trials of CBT, and the field of evidence-based psychotherapy was launched. Dr. Klerman’s untimely death in 1992 slowed the early flow of training and trials of IPT, but now the field is catching up, especially with the adaptation of IPT in low-income countries.In 2019, psychiatrist Paula Ravitz, M.D., and colleagues published in the Harvard Review of Psychiatry a review of interpersonal psychotherapy covering from 1974 to 2017. They found 1,119 English language articles and 133 randomized, controlled clinical trials of IPT for depression, as well as for eating disorders, bipolar disorder, anxiety, posttraumatic stress disorder (PTSD), substance use, and comorbid medical illness in adults. Since this review was completed, a number of clinical trials, including implementation studies, were launched, and another update should be forthcoming.In 2018, John Markowitz, M.D., and I published an update of the IPT manual, adaptations, and clinical trials. IPT is now a part of recommended treatment guidelines in the United States, United Kingdom, Canada, and Australia. In February 2019, the U.S. Preventive Services Task Force recommended IPT and CBT for the treatment and prevention of depression during pregnancy.IPT has been adapted for groups, brief formats, and web-based guided self-help and translated into several languages. There are numerous training programs outside of universities or medical schools.Adapting to the PandemicThe most unexpected development has been the use and adaptation of IPT in low-income countries. In 2003, Helena Verdeli, Ph.D., M.Sc., and I were invited to participate in a study on the treatment of depression in Uganda. The civil war, social upheaval, HIV, and famine had left its citizens depleted. The village leaders and traditional healers asked for help in treating individuals with depression. Medication was not possible, given the shortage of medical personnel and cost. The community leaders were interested in psychotherapy in groups since people in Uganda saw themselves as part of a family or group and did not trust individual treatment. The sexes had to be separate. We simplified the language of the IPT manual, and as we engaged with local community leaders and learned more about the people and region, we made changes in the manual. The problem areas that IPT addressed—grief, death of a loved one, role disputes or disagreement, role transitions or life changes, and loneliness or social isolation—fit in well with community experience. Helena Verdeli and Kathleen Clougherty, L.C.S.W., went to Uganda to train trainers who would then train and supervise local community health workers. A clinical trial led by Paul Bolton, M.B.B.S., at Johns Hopkins University using our manual and trainees was undertaken. The trial showed the efficacy of group IPT when compared with treatment as usual for depression and functioning improvement both at trial completion and at six-month follow-up in 284 patients. The results were published in the June 18, 2003, issue of JAMA. This was the first clinical trial of psychotherapy in Africa.Following the Uganda success, a humanitarian effort using the people whom Helena Verdeli and Kathleen Clougherty had trained in IPT was undertaken to treat depressed women in Uganda by Sean Mayberry through an NGO called Strong Minds. Strong Minds was rated by Forbes in 2019 as one of the best nonprofit organizations to support with donations and has since treated over 11,000 women and expanded to Zambia. In 2020, the therapists converted to teletherapy because of COVID-19. Since the Uganda study, the International Society of IPT, which holds a meeting every other year, has supported global communication about IPT (see www.InterpersonalPsychotherapy.org).There have been numerous expansions of IPT in clinical trials and for humanitarian purposes. For example, IPT training for clinical use or research has been carried out in China, Haiti, India, Rwanda, South Africa, Egypt, Brazil, and Mozambique, among others. Humanitarian efforts are ongoing in Lebanon with Syrian refugees. In 2010 WHO launched the Mental Health Gap Action Programme (mhGAP) to determine how nonspecialist health care workers can treat people with mental disorders. The mhGAP developed a 100-page manual identifying priority neuropsychiatric disorders and evidence-based treatment and included IPT. In 2016, with our permission, the WHO launched the group IPT manual as part of World Mental Health Day. The manual has been translated into Arabic, Chinese, French, Russian, and Swahili.In 2017, I was invited by a WHO group in Egypt to simplify the manual for IPT for primary care patients in distress called Interpersonal Counseling (IPC). This manual, which is free, is being used in many parts of the world.COVID-19 and Lessons LearnedThe COVID-19 pandemic and reported increase in rates of depression and other psychiatric disorders have hastened the development of more economical and briefer treatments to provide access to more people. There is a flurry of international activity in response to the COVID-19 pandemic, exemplified by an experience in Mozambique. Prior to COVID-19, Milton Wainberg, M.D., and colleagues had trained 23 expert IPC national trainers who have in turn trained 15 mental health specialists and 70 primary care providers.In response to the pandemic, the Ministry of Health implemented a free telephone service in which COVID-19-positive patients were referred to the mental health line as the first point of screening for psychiatric problems. About 100 mental health professionals across 10 provinces in Mozambique have been trained virtually to deliver IPC using a tablet-based application to guide facilitation, and a clinical trial will be resumed following COVID-19 precautions.New York City was initially one of the hardest-hit cities during the first wave of the COVID-19 pandemic. Alarming rates of depression and anxiety have been reported related to fear, economic uncertainty, social isolation, and grief. At Columbia we screen COVID-19 survivors discharged from the hospital and key family members using the methods developed for Mozambique. Individuals screening positive for a common mental disorder (depression, anxiety, PTSD) may be offered IPC via telehealth, using the same tablet-assisted system.There are numerous other examples of the adaptation for the pandemic. Holly Swartz, M.D., and colleagues at the University of Pittsburgh had been conducting a clinical trial using machine learning to better understand the patient-therapist mechanism of interaction during IPT when the pandemic caused them to move to telehealth. Now they will be able to assess the differences between in-person and telehealth-based therapy. Given the likely increase in telemedicine after the pandemic ends, this will be useful information for understanding the therapeutic alliance.In response to COVID-19, Strong Minds has added educational material on anxiety disorders and pandemic-related stressors and has helped participants share their fears and identify specific life events related to lockdown. To simplify and improve training, Ravitz, Singla, and colleagues at the University of Toronto have created an online case-based, self-directed IPT training course with interactive learning exercises and captioned demonstrations of the clinical principles. It is being piloted with psychiatry residents and will eventually be accessible globally to decrease barriers to IPT training (www.LearnIPT.com).John Markowitz, M.D., has argued that IPT, which focuses on life events and social support, is an effective treatment for people adversely impacted by the pandemic, including the social and interpersonal upheaval of the lockdown, the stretching of social bonds with social distancing, the curtailing of usual pleasures, and the loss of a familiar daily structure and social supports. People under distress coming to medical clinics may receive relief from a brief guided psychosocial intervention such as IPT or IPC.Access to care and not education or culture is the barrier. IPT is scalable. The task shifting to nonspecialist health care workers who are trained and supervised can be effective. Digital technology can be implemented in low-income as well as high-income countries because nearly everyone has a cellphone. These methods are being tested and used for teletherapy, training, guided, and self-administered approaches.It is likely that IPT is acceptable to diverse cultures because of the universality of the importance of human attachment. Nonetheless, allegiance to any one therapy has no place in the care of patients as no treatment works for everyone, even with the same conditions. IPT should be seen as one of the several evidence-based psychotherapies in a clinician’s toolbox. ■ReferencesRavitz P, Watson P, Lawson A, Constantino MJ, Bernecker S, Park J, Swartz HA. Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017). Harv Rev Psychiatry. 2019 May/Jun;27(3):165-180. doi: 10.1097/HRP.0000000000000219. PMID: 30883446.Weissman MM, Markowitz JC, Klerman GL. The Guide to Interpersonal Psychotherapy: Updated and Expanded Edition. New York, NY: Oxford University Press; 2018.O’Connor E, Senger CA, Henninger ML, Coppola E, Gaynes BN. Interventions to Prevent Perinatal Depression: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2019 Feb 12;321(6):588-601. doi: 10.1001/jama.2018.20865. PMID: 30747970.Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P, Speelman L, Ndogoni L, Weissman M. Group Interpersonal Psychotherapy for Depression in Rural Uganda: A Randomized Controlled Trial. JAMA. 2003 Jun 18;289(23):3117-24. doi: 10.1001/jama.289.23.3117. PMID: 12813117.World Health Organization and Columbia University. Group Interpersonal Therapy (IPT) for Depression. (WHO generic field-trial version 1.0). Geneva, WHO, 2016.Weissman MM, Verdeli H. Interpersonal Counseling for Primary Care. Copywritten and available at [email protected].Wainberg ML, Gouveia ML, Stockton MA, Feliciano P, Suleman A, et al. Technology and Implementation Science to Forge the Future of Evidence-Based Psychotherapies: The PRIDE Scale-up Study. Evid Based Ment Health. 2021 Feb;24(1):19-24. doi: 10.1136/ebmental-2020-300199.Markowitz JC. In the Aftermath of the Pandemic. Interpersonal Psychotherapy for Anxiety, Depression, and PTSD. New York, NY: Oxford University Press; 2021.Myrna Weissman, Ph.D., is the Diane Goldman Family Professor of Epidemiology in Psychiatry at the Vagelos College of Physicians and Surgeons and the Mailman School of Public Health at Columbia University and chief of the Division of Translational Epidemiology at the New York State Psychiatric Institute. She is the winner of the Brain and Behavior Foundation’s 2020 Pardes Humanitarian Prize for the care of disadvantaged people suffering from depression. ISSUES NewArchived