As a graduate student in the mid –1970’s, I had the great good fortune to learn Beck’s cognitive behavior therapy (CBT) from one of its original developers, Maria Kovacs. A more impassioned, committed, and rigorous supervisor one could not imagine. What made me particularly excited about learning this new therapy was that in an era of so-called “eclectic” treatment, CBT provided clear guide posts for the novice clinician who is frequently, for better or worse, lost in the therapy session. Indeed, I thought I had found in CBT a kind of holy grail of the treatment of depression. It fit so well with my own understanding of what not only initiated but maintained depressive symptoms and it seemed to have such an impressively positive effect on many of the individuals whom I was treating.
When, a few years later, I found myself required to learn Klerman and Weissman’s interpersonal psychotherapy (IPT) for a study that we were about to conduct, I was not enthusiastic. To me, IPT seemed soft in comparison to CBT, overly simplistic, and really just not as credible as a treatment for a serious medical condition such as major depression. However, in English we say, “There’s no zealot like a convert” and I am clearly a convert to IPT.
What, you might ask, has led to this conversion? First and foremost, the clear evidence for the efficacy of interpersonal psychotherapy in the acute and maintenance treatment of major depression. Studies conducted in various centers in the United States (1)-(3) and in our own work with IPT (4) (5) provide clear evidence that its ability to effect a full remission of depressive symptoms is roughly equal to that of pharmacotherapy.
Second, interpersonal psychotherapy is relatively easy to teach and relatively easy to learn. The typical experienced clinician can generally become competent as an interpersonal psychotherapist through the treatment of just two supervised cases. The typical inexperienced clinician or trainee can, under the supervision of an experienced IPT supervisor, develop both good general psychotherapeutic skills and specific proficiency in interpersonal psychotherapy having treated as few as three or four carefully supervised cases.
Third, IPT makes sense to patients. The rationale for IPT – that where depression exists there are invariably problems in interpersonal relations or social roles (regardless of the direction of causality) – is one that resonates with virtually every depressed individual. Indeed, the rationale for IPT is what your grandmother would have told you about how people become and stay depressed. It is this sense that IPT grows out of common human wisdom that cuts across socioeconomic, cultural, and intellectual boundaries and makes this treatment approach so broadly appealing to patients.
Fourth, and consistent with what I have said above, this is a treatment in which patients at all levels of educational attainment and intellectual capacity can participate. An extraordinary group of investigators were even able to make IPT a success using indigenous clinicians in tribal villages in Uganda (6).
Fifth, IPT offers the possibility of addressing marital and family issues that are often so fundamentally important to the maintenance of depressive symptoms even when the significant others who are involved in the marital or family problems are not willing to come for treatment. Indeed, in our clinic here at Pittsburgh we sometimes refer to IPT as family therapy with one patient in the room.
Finally, IPT combines exceptionally well with pharmacotherapy. The fundamental assumption of IPT – that major depression is a medical illness that arises in a psychosocial context but nonetheless has biological components – provides the perfect basis upon which to add pharmacotherapy to psychotherapy when indicated.
Is this a perfect treatment for major depression? Certainly not. If one sets sustained remission as the criterion, even with experienced IPT clinicians providing interpersonal psychotherapy to patients who appear consistently for treatment, only about 50% of those with moderately severe major depression will achieve remission with IPT alone. However, if one then adds SSRI to the treatment of those individuals who do not achieve remission with IPT alone, one arrives to a remission rate of 75-80%: certainly an acceptable rate of remission in any area of medicine.