Abstract
Interpersonal Psychotherapy is part of a new series of the Annual Review of Psychiatry in which independent monographs have replaced the large volumes of individual sections. As a move towards the change, both the large volume of bound sections and the individual monographs were published separately in 1997. The response inspired the completion of the move to the new format in 1998, the Review of Psychiatry Series. The rationale for an annual publication is to improve accessibility to reviews of the overlapping areas of the latest clinical and research information. It is also a hope of the editors of the Series, John Oldham and Michelle Riba, to inspire new research and clinical trials by highlighting areas where further investigations would be beneficial. The 1998 Series included monographs on psychopathology and violent crime, new treatments for chemical addictions, psychological trauma, biology of personality disorders and child psychopharmacology, as well as the volume under review.
The topics of the Review of Psychiatry Series for 1998 are united to some degree in Interpersonal Psychotherapy by the breadth of the conditions to which interpersonal psychotherapy (IPT) has been applied. Major depression and depression associated with adolescence and adolescent pregnancy, parturition, bereavement and HIV-positive status are all included in the volume, while others such as primary care and geriatric depression were not included for lack of space. A major impetus for evaluation of depression across many conditions has been health care reform and changes in government policy related to medical and psychiatric practice, away from the more intensive, prolonged and necessarily expensive therapies towards pharmacotherapy and time-limited therapies of demonstrated efficacy. In the determination of the efficacy of IPT, contributors to the present volume have compared IPT not only with pharmacotherapy but also with that other, more established, brief intervention, cognitive–behaviour therapy (CBT). Brief, or short-term, is defined as weekly sessions for between 12 to 20 weeks. Therapy can be individual or group.
While IPT has been compared with CBT in bulimia nervosa, body dysmorphic disorder and panic disorder, it is documented in the present volume for bulimia nervosa only. Chris Fairburn, with his colleagues, was responsible for establishing and testing brief psychodynamic therapy in bulimia nervosa in the 1980s. It appears that it may have been reinvented as IPT. Whatever the designation, it worked almost as well as CBT and behaviour therapy for the clinical indicators of efficacy, frequency of vomiting and bulimia. It was also concluded that, over the longer-term follow up, IPT was superior to behaviour therapy in maintaining recovery.
Interpersonal therapy addresses problems of the here-and-now while acknowledging their aetiology or exacerbation in long-standing interpersonal difficulties. Dysthymic disorder, in which persistent modes of interpersonal dysfunction and associated misery were clinical features, was the original focus of intervention by IPT. In the introductory chapter, Myra Weissman and David Markowitz describe very briefly its clinical and theoretical background, leaving the interested reader, if moved sufficiently by the accounts of its efficacy in the ensuing chapters, to pursue more detailed accounts of the therapy elsewhere. An obvious starting point would be Markowitz's Interpersonal Psychotherapy for Dysthymic Disorders [1], reviewed in the Australian and New Zealand Journal of Psychiatry [2] but, as previously remarked, it is not a manual for therapy training. They also describe interactions between the three phases of therapy and one of the four designated areas of interpersonal problems: grief, interpersonal role disputes, role transitions and interpersonal deficits. The first phase includes diagnosis and history taking, the middle phase covers strategic assistance with the problem and the final phase is where therapeutic gains in the patient are consolidated by formalising development of independence and competence and preparing for longer-term maintenance. Readers are also referred to a patient guide with worksheets, practice guidelines and places where training in IPT can be obtained, including the Cornell Medical School.
Not only has the clinical population been broadened, but the therapy itself has been modified in response to the differing needs of diverse patient groups. As with development in any observation-based therapies in which evaluation of efficacy is important, the initial rigidity of the therapeutic formula has been relaxed. Experience has led to greater flexibility and to a greater clarity in the overlap of metaphors arising from different theoretical underpinnings. For example, the therapeutic emphasis on interpersonal problems of the here-and-now has been modified for geriatric depressed patients to include early life relationships.
The therapy has also become more complex, with the addition of obvious but extra-IPT elements such as shared problem solving. Each chapter defines the modifications and the reasons for them. Possible risks for relapse and methods for their amelioration are specified and maintenance therapy is evaluated; one trial in particular tested monthly sessions as a prophylactic for recurrent depression over a 3-year period. Case studies draw the reader in through our interest in the individual, and teach by example, clarifying the style of IPT.
A strength of the book is the inclusion of therapeutic failures. Its use in abstinence programs with drug abusers has not been successful. However, the hope is expressed that relapse prevention may benefit from IPT because of its proven efficacy with the social stressors known to predict relapse. Another strength is the advice on problems of and impediments to progress that may be encountered on the way to recovery. For example, with the adolescent depressed patient, sections on non-nuclear families, assaultive patients, school refusal, substance abuse, sexual abuse and learning disabilities are provided.
The volume details trials, work in progress and aspirations in various stages of formulation. Each chapter includes, for evaluation of the empirical research, analysis of response predictors, maintenance improvement, comparison with outcome from other therapies and the careful defining of the elements of the therapy to determine relative efficacy. What is not included is information to determine efficacy using an intention-to-treat model. Because individuals have the right to drop out of therapeutic trials if they are not satisfied with progress, the often hardy souls who remain and show marked improvement in some trials can create a false impression of efficacy. The remainder, who ‘failed the treatment’, often are not included in evaluation. While some work has been done in predicting those who do not remain in therapy, the switch to the intention-to-treat model would enable us to derive more information about the relative benefits for all who are offered it, to all who fulfill criteria for a specific disorder but who, in fact, may have individual characteristics that prevent full application of the therapy to them. We need to be able to recognise them and develop therapies more suited to them.
The way abbreviations are used throughout the book discourages dipping, as it often means a backwards search looking for an abbreviation's first reference. Little fat would have been added to this slim book if abbreviations had been limited to the most obvious, such as IPT. The difficulty with abbreviations occurs also with sections where the headings may lead the reader to expect information that, again, will only be revealed by reading backwards. The reader is enjoined to read each chapter from the start.
In summary, Interpersonal Psychotherapy is an easy read that encourages the reader not only to learn about its usefulness in clinical practice but also to consider the foundations of belief in the effectiveness of whatever may be his or her own usual therapeutic practices. To be challenged and to challenge ourselves can only help our patients. This volume should assist us.