Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. This episode covers interpersonal psychotherapy (IPT) with Dr. Paula Ravitz, an Associate Professor of Psychiatry at the University of Toronto and Senior Clinician-Scientist at the Lunenfeld-Tanenbaum Research Institute of Mt Sinai Hospital. Dr. Ravitz held the Morgan Firestone Psychotherapy Chair at Mount Sinai Hospital from 2011 to 2021 and is a past president of the International Society of Interpersonal Psychotherapy.
The learning objectives for this episode are as follows:
By the end of this episode, you should be able to…
Define interpersonal psychotherapy
Describe the core principles and phases of IPT
Become familiarized with some psychological theories underpinning IPT
List some patient selection considerations for IPT
Describe the efficacy and evidence base for IPT
Understand how IPT is practically carried out
Briefly compare and contrast IPT to other common psychotherapies
Guest: Dr. Paula Ravitz (paula.ravitz@sinaihealthsystem.ca)
Hosts: Jake Johnston and Sena Gok
Audio editing by: Jake Johnston
Show notes by: Jake Johnston
Interview Content:
Introduction - 00:00
Learning objectives - 02:10
Definition/overview of IPT - 02:53
Core principles and phases - 07:20
Psychological theories - 19:30
Patient selection considerations - 24:42
Contraindications - 35:57
Evidence base and history - 38:10
Practical components of IPT - 43:57
Maintenance IPT - 59:52
IPT vs other psychotherapies - 62:56
Closing comments - 71:17
Online IPT course - 74:30
Resources:
Summary of IPT written in layman's terms: https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/interpersonal-psychotherapy
The International Society of Interpersonal Psychotherapy (ISIPT) has a helpful overview of IPT and helpful resources for finding more information and IPT training opportunities: https://interpersonalpsychotherapy.org/
‘Psychotherapy Essentials to Go’ book series mentioned during episode: https://www.penguinrandomhouse.ca/series/CNL/psychotherapy-essentials-to-go
Course for learning IPT mentioned at the end of the episode (email Dr. Ravitz at Paula.Ravitz@sinaihealth.ca to inquire about access): www.learnipt.com
References:
Bernecker, S. L., Coyne, A. E., Constantino, M. J., & Ravitz, P. (2017). For whom does interpersonal psychotherapy work? A systematic review. Clinical psychology review, 56, 82–93. https://doi.org/10.1016/j.cpr.2017.07.001
Chaimowitz, G., Weerasekera, P., & Ravitz, P. (2021). Psychotherapy in Psychiatry. The Canadian Journal of Psychiatry, 66(11), 999–1004. https://doi.org/10.1177/07067437211040958
Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis. The American journal of psychiatry, 173(7), 680–687. https://doi.org/10.1176/appi.ajp.2015.15091141
Dennis, C. L., Grigoriadis, S., Zupancic, J., Kiss, A., & Ravitz, P. (2020). Telephone-based nurse-delivered interpersonal psychotherapy for postpartum depression: nationwide randomised controlled trial. The British journal of psychiatry : the journal of mental science, 216(4), 189–196. https://doi.org/10.1192/bjp.2019.275
Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R., Pilkonis, P. A., Leber, W. R., & Docherty, J. P. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments. Archives of general psychiatry, 46(11), 971–983. https://doi.org/10.1001/archpsyc.1989.01810110013002
Klerman, G. L., Dimascio, A., Weissman, M., Prusoff, B., & Paykel, E. S. (1974). Treatment of depression by drugs and psychotherapy. The American journal of psychiatry, 131(2), 186–191. https://doi.org/10.1176/ajp.131.2.186
MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 61(9), 588–603. https://doi.org/10.1177/0706743716659276
Parikh, S. V., Quilty, L. C., Ravitz, P., Rosenbluth, M., Pavlova, B., Grigoriadis, S., Velyvis, V., Kennedy, S. H., Lam, R. W., MacQueen, G. M., Milev, R. V., Ravindran, A. V., Uher, R., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 61(9), 524–539. https://doi.org/10.1177/0706743716659418
Ravitz, P., & Watson, P. (2014). Interpersonal Psychotherapy: Healing with a Relational Focus. FOCUS, 12(3), 275-284. https://doi.org/10.1176/appi.focus.12.3.275
Ravitz, P., Watson, P., Lawson, A., Constantino, M. J., Bernecker, S., Park, J., & Swartz, H. A. (2019). Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017). Harvard review of psychiatry, 27(3), 165–180. https://doi.org/10.1097/HRP.0000000000000219
Swartz, H. (2021). Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy. UpToDate. Accessed 2021-10-12.
CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.
For more PsychEd, follow us on Twitter (@psychedpodcast), Facebook (PsychEd Podcast), and Instagram (@psyched.podcast). You can provide feedback by email at psychedpodcast@gmail.com. For more information, visit our website at psychedpodcast.org.
PsychEd+episode+42+-+IPT+with+Paula+Ravitz.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Jake Johnston:
Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. This episode covers Interpersonal Psychotherapy or IPT for short. I'm Jake Johnston, a fourth-year medical student at UBC, and I'll be hosting this episode. I'm joined by my colleague Sena, who will be co-hosting. Sena why don't you introduce yourself?
Sena Gok:
Hi. I'm Sena Gok, a doctor with international training and huge passion for pscyhiatry. I'm really excited to be here!
Jake Johnston:
Awesome! Thanks. And last but not least, we have the privilege of hosting Dr. Paula Ravitz as our guest expert for this episode. Dr. Ravitz is an associate professor of psychiatry at the University of Toronto and senior clinician scientist at the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital. She was the director of Psychotherapy, Humanities and Education Scholarship Division, the University of Toronto Department of Psychiatry. Dr. Ravitz is also one of three authors on the latest Canadian Psychiatric Association position Statement on Psychotherapy in Psychiatry, just published in November 2021. The last position statement was published in 2003. Dr. Ravitz, would you like to introduce yourself?
Dr. Paula Ravitz:
Sure. First of all, thank you so much, Jake and Sena, for inviting me to participate in this. And it's my pleasure to be able to share some ideas about Interpersonal Psychotherapy. IPT I have been involved in teaching and practising and also researching IPT for the last 20 years or so, and I'm delighted to be able to share some of the ideas about the core principles of IPT in this episode for interested learners.
Jake Johnston:
Thank you so much for coming on to this episode, Dr. Ravitz. We are truly lucky to have you. Without further ado, I will launch into our learning objectives. By the end of this episode, you should be able to one define Interpersonal Psychotherapy to describe the core principles and phases of IPT. Three become familiarized with some psychological theories underpinning IPT. Four, List some patient selection considerations for IPT. Five, describe the efficacy and evidence base for IPT. Six, understand how IPT is practically carried out. Seven, briefly compare and contrast IPT to other common psychotherapies. Now the learning objectives are out of the way, Dr. Ravitz will take us away. We'll start off with the question; what is IPT?
Dr. Paula Ravitz:
Well, first of all, I think IPT is predicated on the centrality of relationships in our lives. Relationships matter in health and disease and resilience, in coping with stress and in recovery from illness. So this is the rationale for IPT, which is a time limited psychotherapy model that focuses on relational aspects of experience and mental health. And there's a strong evidentiary base. I know we're going to get into that a little bit later, but there are both phase and focus specific tasks of IPT. So there's a beginning, middle and end phase. Generally it is anywhere from 4 to 16 sessions. In my clinical practice and teaching, I use a 12 session model of IPT and in many low and middle income countries we use a briefer version of IPT. So for example in an implementation project we did a number of years ago in Ethiopia, we used a 4 to 8 session model of IPT. Generally. I know there are a number of questions, but the beginning phase of IPT is similar to what we do in psychiatry and an assessment. So we begin to establish an alliance with the patient. We learn about what they're struggling with. So that's what we do in the diagnostic assessment and in the history of presenting illness. So we learn both about symptoms about, but as well in the story of the context of what's going on in their lives right now.
Dr. Paula Ravitz:
And IPT focuses on these universal life events of loss of change and of conflict and relationships that are often associated with the onset or worsening of symptoms. And so there are therapeutic guidelines for the middle phase, for grief, for what we call role transitions, which has to do with large life changes. And that happened to us all. We all have multiple social roles which kind of determine what we expect from one another, depending on kind of the social roles. And social roles change inevitably in a lifetime, and sometimes the changes are planned and wished for and sometimes they're unplanned and I've wished for. And these can be associated with distress or symptom onset or worsening. And then of course there are conflicts or non-shared expectations that can unfold in relationships and that are often kind of the salt in the wound and IPT is predicated on this idea that what happens in our relationships and what might unfold in terms of symptoms or distress are bi-directionally linked. So it's when people are in a state of depression, it's often more difficult to engage or utilize social supports. And similarly, when there are difficulties in relationships or people are more disengaged or in conflict or they've experienced losses in their social network, that can also exacerbate or contribute to symptoms.
Jake Johnston:
Thank you so much for that eloquent overview of IPT. It sounds like it's somewhat of a feedback loop where relationships feed into mood and mood feeds into relationships. With that, I'll pass the mic over to Sena for our next learning objective.
Sena Gok:
Thank you, Jake. So, Dr. Ravitz, could you please tell us further about the core elements of IPT?
Dr. Paula Ravitz:
So in terms of the core elements, first of all, I want to emphasize common factors in psychotherapy that I think apply to every therapeutic engagement session, whether we're providing follow-up psychiatric care, doing a psychiatric assessment or delivering any of these evidence supported psychotherapy models. So these are included in the core elements. So first and foremost, it's really important to establish a therapeutic alliance in which there is a trusting bond. And we need to earn our patient's trust and we need to actively listen, use empathy, engage with our patients with positive regard, seeing them for their strengths, for their healthy wishes to recover and to find their way to feeling and doing better and for receiving care and help in a time of need. The core elements as I mentioned, there are three phases of IPT. So in the beginning phase of IPT, in addition to conducting an assessment of symptoms, getting agreement on the patient's goals and at a very high level, the goals of IPT are the same as we have for all medical care to help our patients feel and do better. And the way we do that is by helping them to connect with support of others. We try to identify one of four interpersonal problem areas or focal areas of IPT. The four focal areas have to do with what I've already alluded to. Grief is one of them related to loss of a significant other.
Dr. Paula Ravitz:
Role transitions, which has to do with life changes, for example, becoming coupled or becoming separated, becoming a new parent, moving, migrating, whether it's chosen migration or forced migration, graduating from a training program and starting your new role as a practising professional. So starting a new job. Losing a job. So life changes, as I say, are kind of very common. There's lots of literature of IPT in perinatal depression for people who are becoming new parents and a very strong evidentiary base as well. There's lots of evidence for IPT, for different age groups. So in adolescence there's lots of life changes as as young people begin to affiliate more with peers and get a sense of their identity separate from their families of origin. And in adjusting to a medical illness that might be disabling or life shortening or disfiguring and in in late life, right. Adjusting to retirement or the loss of some of a functioning or certain social roles. There's also role disputes where there's non shared expectations and then there's a default focus that in earlier manuals of IPT was called interpersonal deficits. I think many of us see that term is somewhat pejorative. And so what I tend to use is the more 21st-century term of interpersonal sensitivities, and that's for individuals where there doesn't seem to be any clear life event associated with onset or worsening. But oftentimes as we dive into the work, we will learn of smaller life events.
Dr. Paula Ravitz:
But it's for individuals who have difficulties with forming or sustaining relationships and as I said, in the middle phase, we are guided by those focal areas which each have a set of therapeutic guidelines. For example, with social world transitions, we will explore the change. What do people miss and what are they grappling with? There's a sense of grieving, if you will, over positive aspects of what was and struggling with some of the challenges or negative aspects of the new role. And I like to divide the middle phase into two parts. Early middle is about deepening understanding. In the late middle phase, patients often become more emboldened, regain a sense of agency, begin to connect with support of others as they problem, solve and find ways to manage the new role. We focus very much on what happens in communication. So communication analysis is something that we do a lot of in the middle phase where we understand I like to think of it as way more than fact finding. We understand problems with understanding, with empathy, with non-reciprocity. We might brainstorm and do role plays or marginal role plays in order to help our patients clarify what their expectations are, how they might express them. And in the process of doing communication analysis, we often use principles of mental sizing, right? This idea of that, we all have thoughts and feelings and expectations of one another. These thoughts and feelings are not necessarily known. They're sometimes opaque. And sometimes what we assume in terms of what's happening in others may or may not be true. Right? So this is where I might intersect with some of the principles of cognitive therapy. Excuse me, in the early phase, I forgot to mention we really focus on what we call the interpersonal inventory. Getting a sense of who are supportive, others and which relationships and which focal area we want to work on. We try to limit the focus to two areas. Even though all there might be salience in all four areas because it is brief and it is structured so we mark time. I like to use validated measures such as the PHQ-9 and the GAD-7 and of course in research studies we'll monitor those symptoms week to week. But in usual clinical care you want to have repeat measures, so you want to do it at least three times beginning, middle and end. Or if you're doing a 12 session model, you might want to do it at least monthly or every few sessions. Remembering that there's a whole literature on self-report versus clinician rated symptoms, there's going to be a subset of patients who continue to endorse high. And you might notice as the clinician that they seem to be getting better, in which case you might want to do a HAM-D on them, a clinician rated, and see if there is a mismatch. There's also a subset of patients that seem to under-report, but you get a sense that they're suffering in functional.
Dr. Paula Ravitz:
Their struggles with functioning are more profound. So, we use measurement-based care, but we also want to use our clinical judgement. And then in the final phase of IPT, again similar to the beginning phase, which I think can be used in any therapeutic episode of care, right? It's about kind of doing an assessment, getting a sense of what's going on, where the problems are, where we might help our patients to find resolution to those problems. In the ending phase. I find that the termination phase tasks of IPT are very much generalizable to any episode of care, such as discharging someone from an inpatient stay or from a course of treatment in a day hospital program and in the termination phase we try to consolidate gains. So we look back and we'll ask patients thinking back to when we first started and now what are you taking away and what's your sense of kind of how you're feeling or doing differently or how things have changed? And so if I was a fly on the wall and I was doing competence ratings with my IPT hat, I could tell whether you were in a beginning, middle or ending phase. The ending phase is we need to be very deliberate in our practice in order to consolidate gains. There's going to be a subset of patients who struggle more chronically. Treatment works for 100% of patients, but there's still value in marking efforts and gains that might not result in full recovery or significant reduction in symptoms. So the other thing that we do in the end is we think about what next, what more, what else might make sense. In terms of sequencing care episodes it's very important to be able to have a good goodbye. So Winnicott wrote about how we have to navigate a gazillion separations in a lifetime and how you don't want to leave things unsaid. Right? The ending phase can be evocative of the termination phase of of any treatment. When we say goodbye, we might feel some emotions, some sadness in parting. And again, we it's helpful to differentiate what is normative sadness from full on clinical depression. So sometimes people might feel alarmed that they're feeling depressed again or feelings of sadness and IPT is focussed. And it's not that we want to make sadness go away. Sadness is an important, useful marker in the face of loss, right? That's the core emotion. So we want to help our patients for those who have recovered to be able to differentiate, tease apart normative sadness, who they might talk to, who else they might connect with and get support from, and when to recognize if depression is returning and have a contingency plan, for example, of connecting with their family physician or seeking reassessment.
Jake Johnston:
Thanks Dr. Ravitz, for walking us through the core principles and phases of IPT. We're curious to learn more about some of the psychological theories that underpin IPT. Our preliminary reading indicated that attachment theory is one of them.
Dr. Paula Ravitz:
Yeah. I mentioned earlier that at the time of Bowlby's work on attachment theory was very much kind of in academic discourse. And I think it has remained very central a relationships. This is based on Bowlby's work are critically important for survival and for thriving and that we need to have a secure base in order to explore, in order to manage now. Early relationships might shape these attachment patterns of relating because it's about survival. So for example, in individuals where attachment figures are generally unavailable, it's adaptive for individuals to become more self sufficient. Right? Remember that attachment patterns are only evident in times of stress. Otherwise, they might not be so evident when patients come in with symptoms of mental illnesses. They're in a state of distress, I mean this is true of medical illnesses. Right? And so that's when we might see these attachment patterns of relating, whether it's someone being somewhat kind of avoidant or dismissive of care or the other insecure attachment pattern is anxious, preoccupied. And again, if you think back, it might have been adaptive for someone to be signalling their attachment needs very loud and frequently in the face of others being inconsistently available. So the other theory that I draw from is contemporary interpersonal theory by the late Don Kiesler and Timothy Leary that talks about these universal needs that we have for affiliation or connection in our relationships, along with a sense of agency or power or influence in our interactions. They have developed what they call the interpersonal complex, where individuals can be mapped based on kind of our patterns of expectations of others.
Dr. Paula Ravitz:
And again, this intersects with attachment theory, right? Bowlby talked about these internal working models based on early life experiences of what we tend to expect from others. And contemporary interpersonal theory is interesting because there are some predictions about the polls that we have that might be distancing or might be silencing of others and lead to individuals being kind of inadvertently authoring distance or perpetuating this sense of being disconnected or disempowered in their relationships. And we did some process research at a number of years ago. I'm happy to share the article where we looked at both attachment, self reported attachment and mapping on the interpersonal complex and looking at changes with treatment. And we found that in IPT patients with depression and this is patients with depression tend to be disempowered and with chronic forms of depression tend to be disconnected. And so one way of conceptualising recovery and IPT is that we help patients regain their sense of agency and to become less disconnected in their relationships. And we found that patients who recovered fully from depression in a course of IPT, whether or not they were on medication or not, tended to regain their sense of agency and become less disconnected as well. They moved away from dimensions of attachment insecurity towards security. So we did find some validity to these models. However, in terms of movement towards attachment security, we only found that in patients who fully recovered from depression. So you might wonder about how the state of depression also might interact with these self reported experiences of attachment in relationships.
Jake Johnston:
Thanks, Dr. Ravitz, for touching on and contextualising some of the psychological theories that are important in IPT. One thing you had mentioned was that no treatment works in 100% of patients, which is something we all know is true in medicine. With that in mind, are there any characteristics that make people better or worse candidates for IPT? Specifically, we're curious if there are any indications or contraindications for IPT and some patient selection considerations.
Dr. Paula Ravitz:
So based on this idea that IPT has these therapeutic guidelines for grief, for social transitions and parole disputes, it makes sense that especially for depression, where there's the strongest evidentiary base and the most IPT studies, that if an individual is presenting with depression and in the timeline in the history of present illness, it's clear that the depression, the onset of worsening depression seems very much linked to the death of a loved one, to disagreements in important close relationships, or to big life changes. Then for sure, IPT is likely to be a good model. Right? And then I started doing clinical research where the inclusion criteria was depression in not acutely suicidal because of course, then we need to move to kind of acute crisis care or higher level in order to ensure safety. It might require admission for patients who are not psychotic. So there really haven't been a lot of studies showing that. There's only one study that I know of that shows that IPT can be helpful for patients with affective psychosis. This was done at CAMH years ago and there was a poster presentation with Janice Harris who used to work at the Effect of Psychosis Clinic at CAMH. So depression, not acutely substance abusing or functionally impairing substance abusing, I should say. Not acutely psychotic and not acutely suicidal. So I started in the context of doing research studies with inclusion and exclusion criteria, found that patients who intuitively I wasn't so sure that IPT was going to help, that I started discovering that the IPT model actually helped patients who even in this fourth category of interpersonal sensitivities or whether there was no clear precipitating or triggering life events.
Dr. Paula Ravitz:
So I would say for your first training cases to try IPT because the middle phase therapeutic guidelines are so useful and can be applied. However, I think that IPT is really a good depression treatment. It's very powerful and it has sustained effects, sustained improvements. For a depression treatment, Ellen Frank and Holly Swartz. Ellen is a professor emeritus from University of Pittsburgh, has done a lot of the landmark IPT studies, including for patients with more chronic and recurrent forms of depression, and has adapted IPT for individuals with bipolar disorder. Holly Swartz is doing an NIH study looking at comparing IPT and Quetiapine IPT as a monotherapy for patients with bipolar disorder. It includes kind of a behavioural element with what they call "using a social rhythm tracking" where they find that if they can stabilize social rhythms, it actually significantly extends the period of wellness. Like not only does it aid recovery, but it delays relapse. Originally, it was in combination with mood stabilizing medications for Bipolar 1 Disorder for sure. As well, IPT has been researched for eating disorders, particularly for Bulimia in a group format.
Dr. Paula Ravitz:
Earlier studies were done by Chris Fairburn and Denise Wolf showing that compared to IPT, compared to CBT. That. Actually, it's interesting. It's kind of the turtle and the hare, the horse race that if you look long-term that IPT actually surpassed CBT. But in the short-term there were CBT seemed to work better in the kind of short-term follow up, but they're both powerful models. IPT has been extensively researched in adolescence for adolescent depression. This has been led by Laura Mufson and Jami Young has looked at group IPT as a preventative treatment and is doing work in high schools in the US. Using her model, a family-based IPT model has also been shown to be helpful by Laura Dietz. And again, for people who are interested in learning more about these models, there are many publications. We did a 40-plus year scoping review of IPT, looking at trends and themes over time and looking at all the different clinical populations including in low and middle-income countries. IPT for PTSD, I suspect, will be in future guidelines. As you know, in these guideline panels you have to have a minimum of two randomised controlled trials conducted by different groups of researchers in order to control for kind of allegiance or bias of the research group and the original gold standard study conducted by John Markowitz compared to the prior gold standard which is exposure based CBT and shown this was the first non-exposure based structured treatment to be as effective as exposure based CBT. Since that time, others are kind of have done studies in other settings, including in Brazil. What's interesting about the adaptations of IPT is that the model is generally the same in contrast to some other models of therapy that have been adapted for specific patient populations that differ quite a bit like exposure-based or exposure and response prevention for PTSD or OCD in CBT. Whereas with IPT, the model is essentially kind of preserved. So there's a bit less variation in the adaptations of IPT. As I mentioned, there's very strong evidentiary base of IPT for postpartum and perinatal depression, and many of us have been numerous studies, including one that was led by Cindy-Lee Dennis and Sophie Grigoriadis and myself were the clinical leads where we supported nurse therapists in the delivery of telephone IPT. This was published back in 2020 and found that 85% of our patients who started out meeting full criteria based on skid with 12 sessions of telephone IPT remitted. Again, there were no differences in patients who were on medication versus not on medication and with sustained improvements over time.
Jake Johnston:
Thank you very much for that thorough answer. Dr. Ravitz. So just to sort of summarise and reiterate, you're saying that IPT has the best evidence for major depressive disorder. According to the CANMED guidelines, IPT is a first line treatment for acute depression, second-line maintenance treatment for depression. And as you were saying, according to the can guidelines is a first-line treatment for depression in several special populations, including children and youth, mild to moderate, major depressive disorder in pregnancy and mild to moderate postpartum depression during breastfeeding. It's such a strong treatment that it is recommended before medications even in these populations. Dr. Everts, you had also mentioned that there's evidence for use in some other disorders, including Bipolar Disorder, Bulimia Nervosa and PTSD. One clarifying question I wanted to ask was if you could comment on IPT's use in anxiety disorders.
Dr. Paula Ravitz:
Yeah. John Markowitz and the late Joshua Lipsitz did a review looking at the evidentiary base for IPT and anxiety disorder. At present we don't really have sufficient evidence for it to make it into guidelines. But what I can tell you is that depression and anxiety are often comorbid. As mentioned in all of the depression studies that I've participated in, we monitor both GAD- and PHQ-9 and in our perinatal in our postpartum IPT telephone IPT study, we found that the patients who had comorbid levels of depression and anxiety seemed to benefit even more. In all the clinical trials that I've participated in, including a current clinical trial that I'm a clinical lead on using behavioural activation for women with perinatal depression the SUMMIT Trial. Interestingly, in the back channels I'm noticing that the anxiety scores are also going down significantly. So I think for patients who have comorbid depression and anxiety, both symptoms often decrease significantly. And perhaps surprisingly, because we're not directly targeting anxiety. But IPT is not only interpersonally focussed, it's affect focussed.
Jake Johnston:
Okay. Thank you for the information on the indications for IPT. Are there any contraindications?
Dr. Paula Ravitz:
I think if patients are kind of acutely suicidal, we need to provide kind of crisis support and we need to assess safety. So I think that clinically you need to just shift your focus and not necessarily proceed regardless of what their therapeutic model you might have in mind to be rendering. There really isn't evidence for a patients with psychosis. There's been some really important and helpful modifications of CBT for psychosis, and there is some evidence of the adaptations of that model. That work hasn't been done in IPT. It might be eventually over time, but in our thus far, over these last 40 years, there haven't really. There really isn't evidence for it. So I don't think it's indicated. And for patients who are struggling with functionally impairing substance misuse, it's really important to address the Concurrent Disorders and see if we can kind of help our patients with that. It doesn't mean that you can't still integrate some of the principles of these other useful evidence supported therapeutic models such as CBT or MI or IPT. I think they can still be integrated, but there really isn't research showing that it's helpful.
Jake Johnston:
Thanks, Dr. Ravitz, for walking us through some of the patient selection considerations for IPT. You've already touched on the some of the evidence base behind IPT. I'm wondering if you would be able to take us and our listeners through a brief history of sort of how IPT was developed and maybe a deeper dive into the evidence base behind IPT.
Dr. Paula Ravitz:
The first controlled study for depression was published over 40 years ago and originally there was a study conducted by Gerald Klerman and Myrna Weissman and others that compared IPT to medication. So this was, as I said, over 40 years ago, and what they tried to do was operationalize what effective, well-respected community-based therapists were doing. So in a way, it was a descriptive study of kind of good psychotherapy where they discovered that patients were coming in with these universal relational life events. So it was kind of a life events based model. At the time of IPT's genesis, Bowlby seminal work on Attachment Theory was kind of in in academic discourse as well. Brown and Harris studies on the associations between bereavement and depression were being published, and the etiological links between biological and psychosocial factors were becoming influential in discourse on illness and recovery. Since that time, the importance of relationships for health, coping and resilience has been well established. And in the very first study, to Gerald Klerman surprise and he was a pragmatist, he found that patients who received this structured psychotherapy and at that point in time it was a 16 session model. And partly the reason for the dose was because they also wanted to compare it to pharmacotherapy over time, they found that IPT worked as well as medication as pharmacotherapy. Now remember back then it was the tricyclic antidepressants, but that led to IPT being included in what still stands as a landmark study, the TDCRP study with Irene Elkin that was published long ago in which IPT-CBT pharmacotherapy and a kind of comparative, just supportive response to when patients requested it was conducted.
Dr. Paula Ravitz:
It was the first multi-site RCT that compared IPT and CBT. And in that study Lester Luborsky wrote a paper that quoted the Dodo bird from Alice in Wonderland that said "all must have prizes and all have won". So in the initial analysis, they found that everyone seemed to improve even the low-contact patients. There have since been multiple analyses of that study looking at process factors, looking at moderating factors, and they looked at baseline patient severity and when they examined that, the patients and pharmacotherapy did best, followed by IPT, then CBT and then the kind of low contact model. And subsequent to that study, there have been many studies of both IPT and CBT in particular showing that both models are highly effective, thus included in many international consensus guidelines as a depression treatment, especially including the World Health Organization here in Canada, the Canadian Association of Mood and Anxiety Treatments. It's amongst a very short list of three first-line treatments for depression based on many effectiveness and efficacy studies. And for people who are interested, there's Pim Cuijpers in the Netherlands has done many well conducted meta-analyses and the most recent one published in 2016 was a transdiagnostic meta-analysis of IPT showing that IPT is is helpful in the horse races. Comparing IPT and CBT in particular, they're both shown to be highly effective treatments, thus both recommended in consensus treatment guidelines here in Canada, in the US and in other parts of the world, including the World Health Organisation. So it's long been included in the mental health gap and guidelines of the World Health Organisation.
Jake Johnston:
Thank you, Dr. Ravitz for that comprehensive answer. You mentioned the IPT being cited as one of the three most effective psychotherapies in the CANMED guidelines. And I'd just like to point out that I noticed your name on the author list for that paper and just for our listeners, all of the papers that Dr. Ravitz has mentioned, we'll make sure to include in the show notes. So Dr. Ravitz, you've sort of gone through and given us a really good idea of what IPT is. The principles behind it are some of the patient selection considerations and some of the evidence behind it. And I'm curious, can you go through some of the more practical elements of going through a course of IPT? You know, you mentioned that it's usually sort of 12 ish sessions. There's a beginning, middle and end phase. And I'm curious if you could sort of paint a picture for our listeners what it's like to actually go through and maybe experience each of those phases and what type of things happen in each of those phases.
Dr. Paula Ravitz:
So, first of all I think that the provider needs to be aware of the structure. So a number of sessions. So when I first meet with a patient, if I'm doing IPT, I will orient them to the different phases and explain to them the rationale. I might say, "thank you for coming. Today is our first session of 12" and I explain the phases. So, "in these first few sessions, I am going to learn more about you as a person, about what's been going on in your life that's associated with you feeling worse. I am also going to ask you about important relationships so that we together can decide on which relationships and which focus we want to pursue in the middle phase of our work together. I'm going to be monitoring your symptoms as we go along using these two questionnaires, the the physician health questionnaire, which is nine items, which asks you about the last two weeks, how you have been feeling and to what extent it's affecting you, along with another short questionnaire about anxiety symptoms. The reason I do this is because the goal of our work together is to help you feel and do better. So this is one way I can track how you're feeling and doing in order to lessen the symptoms of depression and anxiety. And in the middle phase of our work together, once we decide which relationships in which focus I, we will go through a process of, first of all, deepening our understanding of what's been going on with respect to changes or losses or conflicts in your relationships that are linked to the moments when you're feeling worse or better. Then in the final 1 to 2 sessions, we'll try to consolidate our gains and what you've taken away if necessary. Think about next steps. Again, as I mentioned, I'm going to be tracking your symptoms over time so that if you're feeling worse or not feeling better, we're not going to wait for 12 sessions to think about what next. I might, depending on your symptoms, make recommendations".
Dr. Paula Ravitz:
In my mind, I'm also monitoring for the need for medication and safety monitoring. So then I proceed similar to what we do in psychiatric assessments to getting their identifying data. Chief Complaint History of present illness and a symptom review along with family, psychiatric and medical history, their past psychiatric history, medications, they are on. And then in the psychosocial history, the interpersonal inventory is kind of it happens in the beginning session and I usually begin with a genogram, but I ask them using the interpersonal inventory to tell me more about the important relationships where I learn about kind of maybe 6 to 10 closest relationships. I like to use questions from the adult attachment inventory, some of them. So I'll ask "Who raised you?". I love that question because it doesn't assume that it was biological parents. Sometimes people will say, "I raised myself or it was my big sibling or my neighbour or a teacher or a religious leader". It gives me, again, similar to doing communication analysis, data about their back story about whether there might be unresolved developmental trauma. I also watch and listen very carefully. If there are lapses in narrative coherence and I watch for affect, when do they become flushed with emotion or when do they tear up? Because again, this is data for me to revisit most important relationships in the middle phase. That's how I might introduce IPT. I track time. And at three points at the beginning when I'm kind of contracting and this is again, there might be times when you are post call or a crisis comes up and you have to reschedule or it could be just a word conflict or a personal conflict, and the same might be true for them. So you want to kind of set some ground rules. "I will let you know ahead of time but I understand that emergencies come up and you can let me know". I try to reschedule in the same week, where possible. And again, "I don't think we have time today, but there's going to be a subset of patients that it's it's hard for them to come within a period of time". Or they keep cancelling that they there's this might signal problems in the alliance of a tendency to kind of withdraw or be reluctant to trust or to engage. And that's a topic for another conversation. But I then in the middle so it's session six, say "we're halfway through".
Dr. Paula Ravitz:
People are often surprised, but do you want to mark time and you also want to get a sense I will sometimes work it as a middle session, but I'll also ask like what more else? Like thinking back to kind of where we are right now and that we have six more sessions including today. "What more else do you think would be helpful and important for us to focus on that seems to be linked to your distress?" and as I mentioned, the homework that I assigned in IPT has to do with paying attention to their emotions, to their affect both times when they feel more upset or distressed or annoyed or disconnected or sad or angry or scared. So any negative emotions but also positive emotions are really important for us to mark and track the times when they feel better, because hopefully it's linked to times when they feel more connected or understood or a sense of belonging or a sense of having begun to master some of the interpersonal problems that brought them in. Then in the last 10 minutes of the third from last session, so if I'm doing 12 sessions last 10 minutes of the 10th session, I'll say something like, "We have two more sessions after today". Again, that's a very different homework assignment. I'll say "Between now and when we meet, I'd like you to give some thought, and I will as well give some thought to this thinking back to when we first started and now what are you taking away? And also thinking back and this is again of a bit of a pre-post, what's changed? How you feeling different or what's changed in terms of your life or your relationships?" So one has to do with kind of of all the things that we've done and talked about.
Dr. Paula Ravitz:
This is such great data for learners and for therapists because sometimes the things that we think are the most salient or most important in terms of kind of supporting change and recovery are not necessarily what our patients report. So I think it's iterative discovery, joint discovery, and you want to also give some thought to that such that if I was a fly on the wall or I was doing a competency rating in the final two sessions, the first, maybe third of the session, 15, 20 minutes, you want to unpack whatever they bring again? I often I ask from session two onwards, How have you been since we last met? If they report events, I'll ask. And how did that affect your mood or symptoms? If they affect if they report motor symptoms? I want to ask and how did that and what's been going on? So again, we begin to socialise our patients to making those bidirectional links. Over time, patients just spontaneously report both right and so. You want to give some thoughts to those same questions that we ask our patients? And when you begin to ask those questions to say, okay, this is our second from last session, as I mentioned last week, we want to take some time today.
Dr. Paula Ravitz:
So it's similar to agenda setting that we might do in more highly structured therapy like CBT. "Thinking back to when we first started what are you taking away or thinking back to when you first started? What's changed?" You want to use therapeutic communication 101. So open-ended questions, empathic, paraphrasing or summarising what your patient tells you and not parroting, but paraphrasing. So this is part of the skill set that I think in all therapies our clinicians can improve over time and that will help them in all their clinical interactions, regardless of what kind of medicine you're going to practice. Actually, sometimes questions pop up in your mind that are like, yes, no questions that I often invite trainees. It's a good question. So how can you rephrase that to be more open-ended questions such as or prompts such as "Can you say more about that?" or to paraphrase. So, "You had an argument with your partner last week and it was really upsetting to you". Full stop. Don't even ask the question. Just paraphrase. Nine times out of ten, when our patients feel like we're really with them in that moment, they'll just elaborate spontaneously. There will be a subset of patients where it's like pulling teeth. And you actually have to ask, "Can you say more?" or "I'm not sure I quite understand."
Dr. Paula Ravitz:
And I want to just go back to communication analysis, because oftentimes when patients come in, they'll just give us the tip of the iceberg, the most heated moment of the argument or the way that they were feeling or the resentment that they experience from feeling kind of misunderstood or mis misinterpreted or responded to in ways that felt just kind of really empathic or miss a tune. And you want to roll the tape back. You get "Hang on, so this is what happened at the end and how you were feeling." So. "Where were you" and "What time of day" and "What day of the week" and "How did this start", "What was going on just before the interaction started?" And you want to get what words did you use or what did you say and how did they respond and how will you feel and what do you think they were thinking and what do you think they were feeling or what do you think they thought you thought. So you begin to draw kind of this figure eight linking of kind of two people in an interaction. And again, that gives us data about misunderstandings, about difficulties with empathy or with mental sizing and whether expectations or wishes are both reasonable and realistic. Sometimes we need to lower expectations, considering limitations of others. Sometimes we need to be more clear in our communication, right? In being in the way we give voice to things.
Jake Johnston:
Thanks. I'm sure of it. So that communication analysis sounds a lot like chain analysis, DBT for Borderline Personality Disorder which is actually a good segue way into our last learning objective. But all parking lot that for now, that was a beautiful way you took us through sort of how IPT is practically carried out in the focus of the various phases. A couple of more pointed questions. You mentioned it's about usually about 12 sessions in total. How long does each session last?
Dr. Paula Ravitz:
There's variability. Generally, I think the shortest sessions are 30 minutes and depending on kind of whether what practice setting you're in and also patients, they may or may not have time ideally, I think 45 to 60 minutes. So psychologists tend to do 60 minute sessions and psychiatrists do, like 45, 46 minute sessions. I think this is partly been driven by funding plans, but that's been my practice and that seems to be a good amount of time to really kind of cover a good amount of material using the IPT model, both phase and focus specific guidelines. Generally, it's once weekly, but for example, 12 sessions can take as long as four months because of holidays or interruptions. But you want to probably complete it. You want to complete it with them, 4 to 5 months or 4 to 6 months, I would say if it's 16 sessions within six months.
Jake Johnston:
And could you comment on maintenance IPT? Is that something that you practice?
Sena Gok:
Yeah, so I do. I was very much influenced by Dr. Alan Franks studies, I've showed that what gets you well, keeps you well. IPT alone can be very helpful. So if our patients, we have a more a history of chronic depression have gotten well with IPT rather than just kind of concluding with no follow up at the end of 12 or 16 sessions, what I do instead is the last few sessions I increase the time frame between. So it's a tapering, right? So let's say they've recovered by session ten or 12. I might then schedule sessions every other week for the next few sessions, then every third week and then offer monthly follow up for because they're at higher risk of relapse as well in the event that they become ill or severely symptomatic. We have a good alliance, so they're more likely to accept medication if I think it's indicated based on severity, functional impairment. So, they may have said no to pharmacotherapy in the past, but agreed to it in the future. And I find that there's a subset of patients who actually recover and then they just naturally taper off because they enter into their lives and no longer feel the need for mental health care and support. I usually keep my door open in the event that they're in crisis or feeling unwell that they can call. And I'm happy to reassess or sometimes I'll do some booster sessions with them. And again, having already had a relationship and know a little bit about their back story and their relationships, we can move into kind of therapeutic action pretty quickly. Right? In just a few sessions I can help to stabilise them. So that's in my clinical practice how I tend to work and with the residents that I provide supervision to the guidance that we give for patients who recover but who have a history of more longstanding struggles with depression. I suggest you kind of extend those 12 to 16 sessions over a longer time period, especially.
Jake Johnston:
Towards the end. I love that you call them booster sessions. It's like extending our immunity on the assaults on our mental health.
Sena Gok:
Yeah, that's a that's a beautiful metaphor.
Jake Johnston:
Yeah, absolutely. Thank you, Dr. Ravitzt. So that was a really helpful overview of the practical aspects of IPT. Just wrapping up now with our last learning objective, I'll pass the mic over to Sena.
Sena Gok:
Thank you, Jake. So Dr. Ravitzs, you mentioned earlier that IPT might have some advantages when compared to CBT. Could you explain these further, and are there also other advantages to other common psychotherapy methods?
Dr. Paula Ravitz:
So I think that we as clinicians need to have a repertoire of approaches because no one treatment works for everyone. I think as well that clinicians have models that just feel like a better fit, right? And so I think that just like is as medical students, you will kind of have preferences or things, areas, clinical populations or therapeutic tasks that are more appealing and feel like a better fit in terms of your motivation to gain expertise. The same is true in these different psychotherapy models, but what is also true about these psychotherapy models is that there are factors that are common to them. All right. And that are included right in the teaching of them and I think if you only learn one, you might not know that. Right? You might think this is IPT or this is CBT, when in fact it is an important common element for people who are interested in that. John Norcross and Bruce Wampold have done some wonderful work and looking at common factors and in fact in the most recent can that guidelines, we include a list of the common factors. We got permission from John Norcross who vetted it to include that run across such as the therapeutic alliance, use of empathy, positive regard, presence. These are very important having agreement on the goals and the tasks of whatever treatment you're doing.
Dr. Paula Ravitz:
So being explicit, being collaborative, being authentic and being non-judgmental, using open-ended questions and empathy and using paraphrasing and summative comments really go a long ways. No matter what you're doing, no matter which brand or guilt of practice you identify with, CBT is highly effective. And I think CBT has been shown to be effective diagnostically more. So there's been more studies but IPT the evidence is that the jury is out. It's the effect size is like compared to a cholinesterase inhibitor that has an effect size of over 30. The effect size of in terms of number needed to treat in IPT is over 30 for cholinesterase inhibitors and it's three for IPT and something like seven or eight for for CBT. But again, it depends on the practitioner, your preference, your style. As I mentioned, I think IPT is particularly helpful in the context of existential life events, right, in which one's appraisal might have, you know, a degree of accuracy. S,o I also think that it's helpful to actually have more than one model in your therapeutic repertoire. You don't want to be to have kind of a one size does not fit all. Procrustes was a famous innkeeper in Greek mythology that used to the idea of a one size fits all, because he used to cut the legs of long-legged people or stretch the legs of short-legged people in order to fit the one-size bed.
Dr. Paula Ravitz:
So one size does not fit all. And so that's why I really encourage people interested in having kind of these powerful psychotherapeutic approaches. And again, we've used we've trained nurses, we've trained family medicine residents and family physicians and into professional providers of social workers. It's not just for mental health specialists, because we know from the work of Martin Prince and Vikram Patel and those landmark articles that were published in the Lancet that there is no health without mental health, and it's incumbent on us all to be alive to struggles with mental health, which can help our patients in their recovery and in their functioning. So IPT focuses on clinician, on thoughts, CBT focuses on relationships, they are both affect focused, they're both structured, they're both time limited, they're both evidence supported. Jake, you mentioned comparing communication analysis to chain analysis in DBT. DBT has strong evidence base for our patients with Borderline Personality dDisorder. A handful of studies of IPT would be PD, but I think that right now, mentalising based therapy and DBT have the strongest evidentiary base for our patients with Borderline Personality Disorder. But communication analysis and chain analysis are not dissimilar and in behavioural activation, we look at helping our patients in a more kind of concise and simple way with communication of feelings or asking for help or being assertive, you know, by kind of starting with facts, feelings, a request or expression, but also thinking about impact which is important in thinking about sometimes we say things that aren't understood or aren't clear or don't land well with others for all kinds of reasons.
Dr. Paula Ravitz:
And so I think that there's lots of intersection and some of the things that we describe in these different models. It's a matter of semantics. And if you train and I have trained and taught and edited books on kind of multiple models of therapy, including through one series that learners might be interested, it might be in the library collections of the different schools where you go called Psychotherapy Essentials to Go that have both videotapes, and they're kind of learner's guides for some of the key principles of IPT for depression, CBT for depression, CBT for anxiety, affect regulation, skills from DBT and Motivational Interviewing along with a book on Common Factors and Improving Alliances and Outcomes. So I encourage learners to peruse these different models and make sense of them. You know that sometimes it's a matter of semantics and there's lots of similarities. But I also think that these different models of therapy give us different frameworks that are really useful to make sense of patients experiences and to give us kind of a roadmap for fostering reflection and exploration that will then lead to patients kind of finding their way in problem solving and adjusting to new roles or resolving disputes or processing grief through bereavement.
Jake Johnston:
That was a beautiful comparison, Dr. Ravitz, and a great way to sort of wrap up the learning objective part of this episode. I think we better let our listeners off the hook here pretty soon. It's been a ton of information and you've shared a lot of your expertise with us. Do you have any closing thoughts before we wrap up?
Dr. Paula Ravitz:
First of all, I think that psychotherapy has a role in the armamentarium of especially mental health specialists in both the training and provision of care. A group of us, Gary ChaimoWitz, Weerasekera and myself, recently published a position paper on psychotherapy in psychiatry with the Canadian Psychiatric Association, reaffirming the role. And I think that as mental health specialists, we are the ones who see patients who are at higher risk, who have higher levels of severity, chronicity, comorbidity, functional impairment. So it's really important that we have a full armamentarium of therapeutics, both to establish alliances, to understand, to monitor and to provide care and treatment to people who maybe have failed treatment from multiple first trials of either therapeutics or self-help or pharmacotherapy. I think the good news is our Mental Health Commission of Canada has done a really wonderful job of decreasing stigma and raising awareness of how common struggles are and with mental health and how we really need to scale access and treatment to mental health care. And there are apps and online treatments and lower intensity treatments that are being studied and offered. But when those aren't sufficient, I think that we as for those of you who want to become mental health specialists, I really encourage you to get training in a number of these evidence supported psychotherapies. They're powerful treatments. And for those of you who are going to become other kinds of specialists, I think it will really serve you and your patients and the teams that you work on well to. It's easily accessible to get more training and learning, including through these terrific podcasts that your group is hosting on these evidence-supported psychotherapy models.
Jake Johnston:
Thanks, Dr. Ravitz. Those are some beautiful closing thoughts and I really like the way how you framed it within the broader context of psychotherapy and within the broader context of our healthcare system. Before we wrap up the episode, Dr. Ravitz, you had mentioned a website that you're currently developing that could be useful for learning more about IPT.
Sena Gok:
Thank you Jake, for reminding me of that. So with IPt experts and instructional designers and learning management system programmers, we've developed what I think is a really exciting learning resource for people interested in kind of taking a deeper dive into learning about IPT. It's called www.learnipt.com. At present we're just at the tail end of completing an educational research study and we're in conversations about extending access to medical learners at different levels across the educational lifespan. So for people who are interested in doing the course, where we have all kinds of videotaped demonstrations that are captioned and transcribed so it can be translated into different languages, interactive case based learning exercises and brief segments of different experts talking about therapeutic aspects of IPT, including a welcome message from Myrna Weissman, who is the founder of IPT and John Markowitz, who has done more IPT studies than anyone I know. They're both at Columbia University. A brief segment from Holly Swartz, from Ellen Frank. So I've mentioned some of these and from Wanda McGinn along with psychologist Giorgio Tasca, talking about kind of colonic common elements and the therapeutic alliance. So I know I'm biased, but I think it's terrific learning resource. We've gotten wonderful feedback from learners and people can email me directly. So it's not open access at this point, but we hope there will be. We will find ways to open access over time. So I'm at Paula Ravitz at Sinai Healthcare and you can probably kind of put that in the resources for people who want to contact me or who want for the readings as well.
Jake Johnston:
Sounds great. We'll do. Well, Dr. Ravitz, on behalf of the entire team, we thank you very much for coming to speak about IPT on this episode. And we would also like to thank our listeners for your continued support and dedication to our podcast. Until next time!
Dr. Paula Ravitz:
Thank you so much, Jake and Sena for your interest and for this really enjoyable conversation about IPT.
Jake Johnston:
PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Jake Johnston. The episode was hosted by Jake Johnston and Sena Gok. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music. A special thanks to the incredible guest, Dr. Paula Ravitz for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.
Sonix is the world’s most advanced automated transcription, translation, and subtitling platform. Fast, accurate, and affordable.
Automatically convert your mp3 files to text (txt file), Microsoft Word (docx file), and SubRip Subtitle (srt file) in minutes.
Sonix has many features that you'd love including upload many different filetypes, automated subtitles, powerful integrations and APIs, world-class support, and easily transcribe your Zoom meetings. Try Sonix for free today.