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BACKGROUND

Interpersonal psychotherapy (IPT) is derived from attachment theory and treats MDD by focusing on improving interpersonal functioning and exploring relationship-based difficulties. IPT addresses the connection between patients’ feelings and current difficulties in their relationships with people in their life by targeting four primary areas - interpersonal loss, role conflict, role change, and interpersonal skills. However, psychotherapy research is not clear on the classification of interpersonal therapy. In some systematic reviews, it is classified as a psychodynamic intervention and in others as a cognitive behavioral intervention.

ACTION STATEMENT

Individual Interpersonal Psychotherapy (IPT) is a recommended treatment option for adults (including older adults and pregnant women) with uncomplicated mild to moderate major depression.

RECOMMENDATIONS

1. Sixteen to 20 sessions of interpersonal psychotherapy (IPT) is a recommended treatment option for mild to moderate MDD. [A]

2. IPT in the treatment of mild to moderate MDD should be delivered by clinicians trained specifically in the delivery of IPT. [C]

3. IPT combined with pharmacotherapy is a treatment option for patients who do not respond to either monotherapy. [B]

RATIONALE

IPT refers to a specific manualized, brief psychotherapy intervention (usually 16 to 20 weekly sessions) originally developed by Klerman and colleagues (Klerman et al., 1984; Weissman et al., 2000). IPT, as a short-term psychological therapy, is well-researched and has been shown to be an efficacious intervention in a large number of well-designed research trials. Research findings indicate it is superior to control or placebo. IPT may be particularly useful in pregnant women who find the risks of antidepressant medication treatment to their fetus unacceptable.

EVIDENCE STATEMENTS

o One high quality clinical practice guideline (NICE, 2004), one systematic review specifically addressing IPT (de Mello et al., 2005), and one more RCT (Bolton et al., 2003) support the use of IPT for adults with mild to moderate symptoms of MDD.

o NICE (2004) found eight well-designed RCT trials that included IPT as a component, and de Mello and colleagues (2005) identified 13 (seven studies overlapped between the practice guideline and the review).

o IPT vs. placebo: de Mello and colleagues (2005) reported on nine studies that included IPT vs. placebo comparisons (653 patients, 337 in IPT and 316 in placebo). For acute treatment, IPT was associated with significantly greater symptom reduction at the end of treatment. IPT was also associated with higher rates of remission in most trials, but in the meta-analysis this was not statistically significant. An additional recent RCT suggests that IPT may not be superior to

12 weekly clinical management sessions lasting 20 to 25 minutes and covering education about depression and its treatment, reassurance, and encouragement to adhere to depression treatment (Lesperance et al., 2007).

o Of note, de Mello and colleagues (2005) misreported the number of patients for at least one study (reported 180 when it was in fact 80), reducing confidence in their conclusions.

o IPT vs CBT: Three studies compared IPT and CBT (a total of 204 patients, 102 in each condition). The meta-analysis indicated that while there was not a statistically significant difference for remission, IPT had significantly lower levels of depressive symptoms at the end of treatment.

o IPT vs Antidepressant medication: Nine studies compared IPT alone with pharmacotherapy (a total of 947 patients). Five trials reported acute treatment response, with IPTalone not leading to significant differences.

o IPT compared to a “usual care” placebo has effect sizes in the small to moderate range (de Mello et al., 2005; NICE, 2004). This effect size is similar to the effect size for antidepressants and other psychological therapies.

Pregnancy

o A systematic review of depression treatment during pregnancy or postpartum period identified 4 studies that tested IPT, with a total of 181 participants (three were RCTs, one was an open treatment trial). The overall effect size of 1.26 was significant and the authors conclude that IPT is a beneficial treatment for pregnant and postpartum women.

Older adults

o One RCT with 80 participants addressed acute IPT with older adults. IPT was not superior to pill placebo in this trial, but the low patient population (17 in the IPT group) suggest that the study was underpowered (Reynolds et al., 1999).

o IPT plus Antidepressant Medication: Three trials of IPT plus antidepressant medication compared with antidepressant medication alone found higher rates of remission after 4 months of treatment (N of 35, 96 and 157), but after 6 months, the rates of remission were all similar.. Limitations of the literature

o There are a limited number of available trials, although several are large scale and well- designed.

o Magnitude of effect for psychotherapy trials may be overestimated because of study design issues, including patients not being blind to treatment.

o Antidepressant medication treatment in comparison trials is not always provided in a manner consistent with best clinical practices.

EVIDENCE TABLE

Evidence Source QE Overall

Quality

Benefit SR 1 IPT is more beneficial for depression

symptom reduction and remission than no treatment or placebo, and provides a similar level of benefit as other evidence-based treatments

de Mello et al., 2005 Lindsayer et al., 2007 NICE, 2004

I Good Small A

IPT may be more beneficial than CBT for treatment of major depression

de Mello et al., 2005 II Fair Small B

2 Pregnant/postpartum depression: Individual IPT is better than no treatment and has benefits similar to other treatments for

pregnancy/postpartum depression

Bledsoe &Grote,

2006 I Good Mod B

3 IPT is better than no treatment and has outcomes similar to other active treatments for depression in older adults

Cuijper et al., 2006

Reynolds et al., 1999 II Fair Small C

IPT plus antidepressant medication is superior to antidepressant alone for initial treatment response; benefit does not appear to be maintained over time

de Mello, 2005

NICE, 2004 I Good Small B

QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A)