How to Use Interpersonal Psychotherapy for Depressed Adolescents (IPT-A)

LAURA MUFSON

HELENA VERDELI

KATHLEEN F. CLOUGHERTY

KAREN A. SHOUM

KEY POINTS

The goal of IPT-A is to decrease depressive symptoms and help adolescents improve their relationships.
Monitor depression symptoms and do mood ratings at the beginning of each session.
Link mood to interpersonal events that have happened during the past week. Always monitor suicidal ideation and behavior weekly.
Provide psychoeducation about depression and encourage normal activities (especially school responsibilities) as a means to feeling better. Performance will improve as mood improves.
Stay focused on the interpersonal issues most closely related to the depression: triggers or interpersonal issues that may be maintaining the symptoms.
Keep the timeframe and time-limited nature of treatment in the foreground as a motivation for working hard in sessions.
Identify small and manageable “interpersonal experiments” in the middle phase to practice new skills.
Encourage self-mastery and independence.
During termination, highlight new interpersonal skills, and promote generalization of specific strategies and identification of warning signs of depression for relapse prevention.

Introduction

Interpersonal psychotherapy (IPT) is an effective, time-limited, manualized psychosocial treatment for depression originally developed for depressed, nonbipolar, nonpsychotic adults.1 IPT is a product of the interpersonal theorists and their emphasis on the importance of positive interpersonal relationships for mental health, and the belief that people experience distress when disruptions occur in their significant attachments, which result in a loss of social support. IPT identifies the relationship between the onset or maintenance of depressive symptoms and interpersonal events while recognizing that genetic, biologic, and personality factors also contribute to the vulnerability for depression. The IPT therapist intervenes by targeting depressed adolescents’ interpersonal skills to improve their relationships and decrease the depression symptoms.

Unlike other psychotherapies, IPT refrains from delving into the adolescent’s past and instead focuses on current interpersonal conflicts to improve relationships. IPT and cognitive behavior therapy (CBT) have a number of similar features, such as structure, time limit, focus on the here-and-now, and techniques. However, CBT focuses predominantly on assisting the individual in monitoring and changing behaviors and cognitions to bring about mood change (see Chapter 8). In
contrast, IPT focuses on the examination and modification of maladaptive communication patterns and interpersonal interactions in the context of significant relationships and roles that contribute to the onset or maintenance of the depression. Ultimately, IPT alleviates depressive symptoms by reducing current interpersonal stressors.

Based on strong efficacy data for adults, and similarities in symptom presentation between adolescent and adult depression, Mufson and colleagues2 hypothesized that IPT might also be an effective treatment for adolescent depression. Several characteristics of IPT make it especially relevant for adolescents, including its time-limited nature, which may fit with adolescents’ reluctance to seek or stay in treatment. IPT’s focus on the interpersonal context, such as major life choices in education, work, and the establishment of intimate relationships (of significant focus at this stage in development), make it especially relevant for treating adolescents. Additionally, in light of the research demonstrating the persistence of interpersonal problems after remission of depression symptoms,3 a treatment focusing on both the symptoms and the interpersonal domain might be advantageous for facilitating and maintaining improvement in the interpersonal realm after symptom improvement.

Several adaptations have been made to IPT to make it more developmentally appropriate for adolescents. The adolescent version of IPT (IPT-A) is an active treatment with a large psychoeducational component aimed at building the adolescent’s competencies and skills. It is structured and organized in such a way that the adolescent can take an increasingly more active role in the treatment as it progresses. IPT-A was adapted specifically to address important developmental tasks of adolescence, such as individuation from parents, development of romantic relationships, peer pressures, and so on, and it may include family members in various phases of the treatment.4

SUITABILITY FOR IPT-A

Because depressed adolescents often present with comorbid psychiatric diagnoses and IPT-A is designed to treat adolescents 12 to 18 years of age with nonpsychotic unipolar depression, treatment with IPT-A is suitable for depressed adolescents with comorbid anxiety disorders, attention deficit disorder, and oppositional defiant disorder. However, IPT-A is most effective when depression is the primary diagnosis and comorbid diagnoses are limited. Clinically, IPT-A is used in conjunction with medication for depression for adolescents with severe neurovegetative symptoms to assist them in deriving maximum benefit from the psychotherapy, as well as for adolescents who present with severe symptomatology and impairment. In addition, IPT-A is used with adolescents who are on stable doses of medication for ADHD. However, currently no clinical trials have been conducted on the effects of combined pharmacotherapy and IPT-A. IPT-A is not recommended for adolescents who are mentally retarded, actively suicidal or homicidal, psychotic, bipolar, or actively abusing substances.

Before initiating IPT-A, a complete diagnostic evaluation should be conducted with the adolescent and custodial parent(s) to assess current symptoms and diagnoses, as well as psychiatric, family, developmental, medical, social, and academic history (see Chapter 3). This evaluation is the equivalent to what many clinics refer to as an “intake.” The therapist should gather information to assess whether or not the adolescent is suffering from a depressive illness while determining his or her suitability for IPT-A treatment. The therapist also gathers information about possible triggers or factors that maintain the depression symptoms, such as a death in the family, a change in the family or transition for the adolescent, significant disruptions in important relationships, a trauma, or chronic stressors. The therapist revisits and explores these issues further during the initial phase of treatment.

PARENTAL INVOLVEMENT

IPT-A is conceptualized as an individual treatment that recommends (but does not require) parental participation. It is recommended that parents attend at least one session in the initial phase of treatment to become educated about depression and the IPT-A treatment. Parents are also told they may call the therapist if they have any concerns or to report significant events in the adolescent’s life that might impact treatment. Parents are treated as “experts” on their children who can contribute information to assist the therapist with the treatment.

ADAPTATIONS FOR ADOLESCENTS

The grief problem area has been adapted to treat adolescents who may be experiencing a severe grief reaction to assist them in mourning the loss and in preventing a delayed or abnormal grief response in the future. Another adaptation is the use of the telephone between sessions to assist in the development of the therapeutic alliance in the initial phase, and to maintain therapeutic momentum in the middle phase, especially if the adolescent is unable to attend a session. In the initial phase, a therapist is encouraged to call the adolescent between sessions to check on his mood, to remind him of the upcoming appointment, and to express interest in seeing him at the next session. Later in treatment, if it is impossible to have a session in a given week, the therapist can conduct the symptom check-in over the phone and facilitate continued work on the identified problem area (Table 9.1).

TABLE 9.1 INTERPERSONAL PROBLEM AREAS WITH GOALS AND STRATEGIES

Problem Area	Goals	Strategies
Grief: death of an important person or pet	• Mourn the loss of the important person • Reestablish relationships and interests to substitute for what was lost	• Encourage the adolescent to talk about the loss in great detail • Discuss the sequence of events prior to, during, and after the death, along with associated feelings • Help the adolescent find ways to meet new people and develop new social supports to fill the loss
Interpersonal role disputes: ongoing disagreements with an important person	• Identify the dispute and specific stage^a • Make some choices about a plan of action • Modify communications • Modify expectations • Find resolution of the dispute	• Explore unrealistic or mismatched expectations and their contributions to the dispute • Assess and modify maladaptive communication strategies • Teach the art of negotiation
Role transitions: life changes; can be positive or negative	• Mourn the loss of the old role • Find a way to accept and move into the new role with less difficulty • Develop new social skills • Develop new attachments and social support in the new situation/role	• Understand what change means to the adolescent • Identify what is gained and lost in the new role • Master new skills needed to move into the new role
Interpersonal deficits: loneliness and social isolation/difficulty making and sustaining relationships	• Review in detail past and current relationships identifying recurrent patterns, negative and positive • Reduce social isolation by improving social skills • Strengthen current relationships and assist in finding new ones	• Relate depressive symptoms to problem of social isolation • Rehearse new social skills for the formation of new relationships and deepening of existing relationships
^aStages of Disputes:
• Renegotiation: Adolescent and significant other are still communicating but have faulty skills and have been unsuccessful at resolving dispute. Both want to resolve dispute.
• Impasse: Attempts at resolution have failed. Adolescent believes that nothing will get better, and he has stopped trying. A relationship still exists with the significant other, but discussion and even arguments about the dispute have stopped. Therapist attempts to get the two parties talking again.
• Dissolution: Adolescent and significant other want to dissolve the relationship. Therapist explores with adolescent whether or not he might make “one last try” at renegotiation. If the adolescent won’t agree or if the adolescent tries but no improvement in the dispute is achieved, the therapist helps the adolescent to end the relationship. The dissolution approach is rarely used when the dispute is between the adolescent and his parent(s).

The concept of the limited sick role (see Session 1 tasks, page 117) is another adaptation in which the adolescent and parent are informed that depression can affect motivation to participate in normal activities as well as influencing performance. The adolescent is encouraged to participate in as many activities as possible with the awareness that performance will improve as the depression remits. The parent is encouraged to help the adolescent engage in his once-typical activities instead of supporting his avoidance and social isolation. The parent is also reminded to refrain from criticizing and blaming the adolescent for poor performance in activities at school (e.g., low grades) and at home (e.g., incomplete chores).

MAIN PHASES OF TREATMENT

The treatment is divided into three phases: initial, middle, and termination. Each phase consists of approximately four sessions. A session-by-session description of the tasks to be covered in each phase is described here.

INITIAL PHASE (SESSIONS 1–4)

Following a comprehensive clinical and psychosocial assessment to determine appropriateness for IPT-A, the initial phase is conducted over four sessions. During these meetings, the therapist aims to (1) educate the adolescent and parent(s) about depression while giving hope, (2) explore how depression affects and, in turn, is affected by the adolescent’s significant relationships and roles, and (3) explicitly contract with the adolescent on the interpersonal problem area(s) that will become the focus of the remainder of treatment. Problem areas derive from key aspects of an adolescent’s life circumstances or relationships that appear to trigger and/or maintain the current depressive episode.

The four interpersonal problem areas of IPT-A include the following:

Grief (actual death of a significant other, person, or pet)
Interpersonal disputes (parent–child conflicts, arguments with peers, or the breakup of a romantic relationship)
Interpersonal role transitions (difficulty making transitions between stages in life or changes in life circumstances, such as parental divorce, moving to a new town, illness of a sibling, transition to high school)
Interpersonal deficits (social isolation and/or significant communication problems that lead to difficulty in starting or maintaining relationships)

The following is a description of the tasks that typically take place in the initial phase of IPT-A (Sessions 1 through 4).

Session 1

Therapist should administer a DSM-IV checklist or other measure of depression (e.g., Hamilton Rating Scale for Depression or Beck Depression Inventory), making sure to cover suicidality (even if denied during past assessment) as well as depression symptoms idiosyncratic to the adolescent (pains/aches, rejection sensitivity, etc.).

Task: Start with a symptom check to be repeated in the beginning of every session. Teach the adolescent how to do a mood rating.

“Rate your mood on a scale of 1 to 10, with 1 being the happiest you could feel and 10 being the saddest. How would you rate your mood this past week? Was there a time in the past week when you felt worse than you do now? (Obtain rating). Was there any time you felt better? What happened when you were feeling that way?”

Task: Educate the adolescent and parent about depression. Explain treatment options (medical model).

“Bill, your recent trouble with studying, your cutting back on seeing friends and playing baseball, being easily annoyed with people, trouble with falling asleep (list other symptoms) are symptoms of a depressive episode that started this fall. Depression affects 1 in 10 adolescents; you are not alone. It is a real medical illness. We are all here to help you recover. The good news is that we have a number of treatments that work very well for depression like yours, such as medication and psychotherapy (talk therapy).”

Task: Assign the “limited sick role” to the adolescent and parent.

“Due to your depression, you may have trouble doing a number of things that you want or need to do. If you had broken your leg, you wouldn’t expect to run in a week. However, you would need to push yourself to walk around, otherwise your muscles would be weak and your healing would take more time. It’s important to do the same here. Try not to miss school but also try hard not to be upset if your grades drop. We have learned that as you begin to feel better, your performance and motivation will improve. The most important thing right now is to get out of this depression. Everything else will follow.

Mrs. Smith, it is important that you recognize that Bill is having trouble doing these things not because he is trying to be difficult and get out of his responsibilities, but rather because he is depressed and that significantly affects his motivation. So it would be really helpful if you can encourage Bill to be active and go to school as much as possible, and be supportive knowing that his performance will improve as he begins to feel better.”

Only gold members can continue reading. Log In or Register to continue