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Interpersonal Psychotherapy: A 40-year Mixed Methods Review
International Society of IPT Conference
London, U.K. June 13th, 2015
Paula Ravitz MD, Jamie Park PhD,
Holly Swartz MD, Priya Watson MD,
Michael Constantino PhD, Samantha Bernecker PhD, Myrna Weissman PhD
Disclosures/Acknowledgements
No pharmaceutical industry or external funding. Thanks to the Mt. Sinai Hospital Department of Psychiatry (Toronto) & Morgan Firestone Psychotherapy Chair, and to our respective universities, U. Toronto, U. Pittsburgh, U. Massachusetts, & Columbia U.
Royalties Myrna Weissman
-Perseus Press, Oxford Press, APA Press, Multihealth System
Holly Swartz -UpToDate
Paula Ravitz & Priya Watson -WW Norton
What has shaped IPT’s growth? iscoveries, innovations & external factors
Public health needs, scientific discourse, policies & guidelines
Building on discoveries, shaped by multiple forces
Interpersonal Psychotherapy (IPT) Klerman & Weissman
The first IPT depression study was published 40 years ago, and since then, new applications of the model have emerged, informed and driven by research and public health needs.
METHODS Search May 2014
“Interpersonal” & “Therapy” or “Psychotherapy” in Web of Science, Embase, Medline and Psych Info databases (English only)
N= 3082
Excluded books, book chapters, book reviews, dissertations, conference proceedings, non-English papers, and duplicates
N= 1341
3 authors sampled 120 papers to exclude non- IPT papers (e.g psychodynamic
interpersonal psychotherapy) Inter-rater reliability kappa 0.85.
Included IPT papers for data extraction (including trials, reviews, case reports, guidelines, and editorials)
N= 940
Abstracts selected for closer review N=1741
Depression, Perinatal depression
N=448
Late life depression, Bipolar disorder, Eating disorders, Substance abuse,
Complicated grief N=282
Adolescent depression, LAMIC, Anxiety, PTSD, Medically ill
N=307
Process research N=217
Excluded non-IPT papers N= 801
Example view of Data extraction sheet
Type of data extracted I
Paper Type: RCT, Case control, Cohort trial, Primary review-IPT focused, Secondary review-IPT mentioned, Case report, Meta-analysis, Consensus guideline, Editorial, Other (e.g. clinical guideline, program description, training paper, implementation paper)
Process research (Yes/No) – [process research further coded]
Type of Data Extracted II: Clinical Characteristics - WHO?
Demographics: adolescent, adult, late life; gender (mixed, female, male)
Diagnosis: depressive disorders, anxiety, eating, bipolar, PTSD, substance abuse, other
Medical comorbidity: cancer, HIV, cardiovascular disease, etc.
Noteworthy characteristics: perinatal, low SES, traumatic experiences, caregiver, etc.
Implementation outpatient- academic medical, outpatient-community, non psychiatric medical setting, school-based, inpatient, in-home, other
IPT treatment characteristics Format: 1-on-1, multi-person, telephone, internet
Treatment phase: acute, maintenance, prevention
Original model (Yes/No)
Adherence measured (Yes/No)
Innovation/Adaptation (Yes/No; specify)
Type of data extracted III WHAT, WHERE, WHEN & HOW?
METHODS cont.
Coded 5 batches of papers clustered by time periods, with team conference-calls to discuss trends, themes & tensions of IPT, noting parallel social, health policy and clinical guideline developments.
-1970’s and 1980’s
-1990’s
-2000-04
-2005-9
-2010-14
What has shaped IPT’s growth? iscoveries, innovations & external factors
Building on discoveries, shaped by multiple forces
The early years 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984
Deinstitutionalization
1988
HMO
FDA double-blind placebo
Meta-analysis psychotherapy
DSM II DSM III
Klerman IPT manual
Mobile phone
Counterculture; Civil rights, Free speech, Anti-war, Women’s rights, Environmentalism, Gay liberation, New Left
Fluoxetine
Personal computers
Rise of manualized therapies
Neuroimaging techniques; PET, CT, MRI
Weissman & DiMascio
IPC
The middle years
1998 2000
Lessening of psychoanalysis as leading treatment
Neurosciences: fMRI, PET/CT Internet
1o Care Depression
APA Depression CANMAT Depression
Empirically supported treatments APA
DSM IV
TDCRP trial
Recurrent depression
Therapeutic alliance
ECA National Comorbidity Survey
1992 1996 1988 1990 1994
1o Care
TDCRP moderator
IPT - PPD
Eating disorders
IPT-A
Late life depression Long-term TDCRP
Rise of integration
Roth & Fonagy
IPT-HIV
The later years
2000 2002 2004 2006 2008 2010 2012 2014
APA Eating disorders
ISIPT formed
US Surgeon General MH, Culture, Race, and Ethnicity
APA Bipolar
NICE Depression and ED Guidelines
CANMAT Bipolar
National Comorbidity Survey
NICE Bipolar
Evidence-based medicine (EBM)
APA adopts EBM in psychology
Neurosciences: neurogenetics, neurobiology, neurochemistry
DSM V
WHO call to action Policies to address MH Disparities
WHO: mhGAP
IPSRT
IPT-GU
NIMH Implementation of Research Domain Criteria (RDoC)
Neurosciences: epigenetics and proteomics
MANAS trial
Brain metabolic changes IPT inpatients
Binge eating disorder
Bergin & Garfield
IPT-Brief
IPT- telephone
CREATE trial IPT internet
IPT low SES + IPV
Norcross Meta-analyses
Dysthymia 1o Care “Pure” dysthymia
PTSD
Cuijpers Meta-analyses
Bergin & Garfield
2nd Uganda
Textbook Languages
Interpersonal Psychotherapy of Depression (Klerman, Weissman et al. 1984; 1997)
Spanish, German, Italian, Japanese , Korean
Comprehensive Guide to IPT (Weissman, Markowitz, Klerman; 2000)
Italian, French, Korean, Spanish, Japanese, Dutch
Clinician’s Guide IPT (Stuart & Robertson; 2003; 2012)
Turkish
Clinician's Quick Guide to IPT (Weissman, Markowitz & Klerman; 2007)
Japanese, Danish, German, Dutch, Spanish, Japanese, Portuguese, French
Treating Bipolar Depression IPSRT (Frank 07) Italian, Japanese, Turkish
Group IPT (Wilfley et al., 2006) Japanese
Casebook of IPT ( Markowitz & Weissman; 2012)
Japanese
IPT-A (Mufson et al.; 2004; 2011) Mandarin
Translated from English: IPT Texts
IPT Hubs United States:
New York: IPT-A, Global Mental Health
Pittsburgh: recurrent & late-life depression, IPSRT, IPT-B, sequencing, spectrum criteria & moderators (w/ Pisa)
Iowa City: IPT-PPD, dissemination
St. Louis: for IPT-G for ED
The Netherlands: Meta-analyses, RCTs
Germany: in-patient studies
Plus - UK, Canada, New Zealand, Sweden, Norway
LAMIC studies
Patel et al., 2010 (Goa, India)
Bolton et al., 2003 (South-west Uganda) Bass et al., 2006 (South-west Uganda) Bolton et al., 2007 (South-west Uganda)
Schaal et al., 2009 (Kigali, Rwanda)
Petersen et al., 2012 (North-east South Africa)
Meffert et al., 2011 (Cairo, Egypt)
Campanini et al., 2010 (Sao Paolo, Brazil)
Number of papers by clinical area and country of first author
0
50
100
150
200
250
Canada Germany Netherlands UK USA Other
# p
ape
rs
Country 1st author
Late life
Eating disorder
Bipolar
Depression
Perinatal
Adolescent
LAMIC
Number of papers per capita by country of first author
0
0.5
1
1.5
2
2.5
3
Canada Germany Netherlands UK USA Sweden New Zealand Norway Australia
# p
ape
rs /
1 m
illio
n p
op
ula
tio
n
Late life
Eating disorder
Bipolar
Depression
Perinatal
Adolescent
LAMIC
Total # papers
47 23 23 60 522 2 16 1 33
Population (million)
35.16 80.62 16.8 64.1 318.9 9.59 4.40 5.08 23.13
All IPT papers by clinical area over time
0
20
40
60
80
100
120
140
160
1974-1984 1985-1994 1995-2004 2005-2014
Late life
Eating disorders
Bipolar
Depression
Perinatal
Adolescent
LAMIC
Process
0
10
20
30
40
50
60
Late life Eating disorder Bipolar Depression Perinatal Adolescent LAMIC
# R
CTs
Clinical area
RCTs by Clinical Area
0
10
20
30
40
50
60
70
80
90
100
1974-1979 1980-1984 1985-1989 1990-1994 1995-1999 2000-2004 2005-2009 2010-2014
# se
con
dar
y re
vie
ws
Time period
IPT 2◦ Reviews: A proxy of uptake by larger community of practice
IPT outcome research through time
Progression from efficacy to effectiveness to dissemination with attention to understanding moderators and predictors
Additional emerging questions: How to train therapists to improve quality and access? Role of IPT in treatment algorithms/guidelines? Comparative efficacy/effectiveness? Adapting IPT for special populations? Role of technology?
1978-1984 1985-1994 1995-1999 2000-2004 2005-2009 2010-2014
Efficacy: Does IPT work for specific disorders?
Effectiveness: Does IPT work in “real world” settings?
Dissemination and Implementation
IPT process research through time
Consistent with movements in psychotherapy process research in general, the central questions were driven by “making sense” of findings of no difference between treatments in TDCRP
Questions remain about interactions of therapist factors, non-specific “common factors,” unique therapy ingredients, mechanisms & patient factors
1978-1984 1985-1994 1995-1999 2000-2004 2005-2009 2010-2014
Adherence: What are IPT therapists doing?
Predictors and moderators: For whom does IPT work?
Mechanisms: How does IPT work?
The Present Context: Challenges & Opportunities I
Limited resources, with gaps between needs & access
"In a difficult time of health budget cuts, value for money interventions has become more important than ever before" Arcelus, 2012
• Leverage technology to deliver treatments more efficiently • Use briefer treatments to conserve resources • More effectively disseminate, scale up w/ health systems
integration
Challenges & Opportunities II
Shifting diagnostic paradigms (RDoC; DSM5)
Identifying & targeting functional behavior constructs
Future IPT studies can "expand upon the assessment of the negative affect construct and include self-esteem and emotion dysregulation" Ansell 2012
“Will the extant research literature generalize to the diagnostic groups that will be identified under the new DSM-5 schema?" –Watson
Challenges & Opportunities III
Personalized medicine
Consider different predictors of treatment response (Rx v. IPT v. combination) to optimize patient matching
Adapting IPT to improve effectiveness, engagement, and to integrate into differing health contexts/systems
Prevention studies/paradigms
Process Research Mechanisms/mediators
What has shaped IPT’s growth? iscoveries, innovations & external factors
This is a work-in-progress and we welcome your insights and ideas.
Further analysis is underway.
