Late-life depression: Focused IPT eases loss and role changes
Interpersonal psychotherapy focuses on here and now.
Mrs. E, age 74, has been distraught for 6 months since the death of her husband of 45 years. She is brought for evaluation by her daughter, who is exasperated and worried about her mother’s sad mood, frequent tearfulness, weight loss (11 pounds), and social isolation.
Mrs. E says she feels lost and paralyzed, that she “sticks out like a sore thumb” when among couples “that still have each other.” She refuses to go to church, though she attended regularly in the past.
Unresolved grief appears to be linked to the onset and persistence of Mrs. E’s depressive symptoms. After a thorough evaluation confirms major depression, the psychiatrist explains the diagnosis to Mrs. E. She agrees to begin an antidepressant and interpersonal psychotherapy (IPT).
IPT is easy to use and well-suited to address abnormal grieving, role transitions, and role disputes in depressed older patients. In controlled trials, IPT has been shown effective as acute1 and maintenance treatment2,3 of depression. This article describes how IPT can work effectively for depressed older adults and their clinicians.
IPT and elder depression
New-onset or recurrent depression is common in older patients experiencing retirement, relocation, disabilities, or loss of important persons in their lives (Box 1) 4 IPT recognizes that depression, regardless of psychosocial stress or biologic vulnerability, is expressed in an interpersonal environment (Box 2).5,6 The environment may have contributed to the depression, but it also can be a platform for intervention.
Depressed older adults who are verbal, nondemented, and engageable are candidates for IPT, with or without adjunctive antidepressant therapy. Psychotherapy is not indicated for patients with severe dementia, but this article will describe how IPT is being adapted for those with early dementia or mild cognitive impairment.
Depression causes specific to later life
Biologic insults. Any brain injury that is more common in late life or that accumulates with age (such as cerebrovascular, Alzheimer’s, or Parkinson’s disease) increases the risk of damage to the neural circuitry that maintains mood.4 Common metabolic abnormalities such as hypothyroidism and vitamin B12 deficiency also can contribute to late-life depression, which is why routine blood screening is recommended.
Older patients often take multiple medications, increasing the risk for interactions and adverse events. Drugs with depression as a potential side effect include antipsychotics, antihypertensives, and corticosteroids.
Losses in later life can include bereavement for departed family and friends; changes in ego support and financial security with retirement; lack of transportation to sustain hobbies and interests; and declining vision, hearing, and physical function such as urinary continence or ambulation.
Role disputes and interpersonal conflicts. Marriages may be strained by role changes related to retirement or to caring for a physically frail or cognitively impaired partner. Problems of adult children or grandchildren—illnesses, substance abuse, unemployment—can burden elders, especially if families expect financial support, child-care help, or cohabitation. Elder abuse or neglect may also add to late-life stress.
Death and dying issues. Older persons may worry about dying, experiencing pain, being a burden to their families, and whether their lives have been meaningful. Moving to a long-term care facility can demoralize those who view this transition as “the last abode before the grave.”
IPT targets depression’s themes, such as losses and role changes
Klerman et al5 developed interpersonal psychotherapy (IPT) in the 1970s while working with depressed adults. These authors adopted an empiric approach, reviewing the literature for evidence-based outcomes from various schools of thought to pull together elements that proved to be effective in treating depression.
Social workers on the team reported that interpersonal themes—such as family disputes, life changes, and grief reactions—seemed to trigger or perpetuate many patients’ depressions. Using these observations and the literature review, the group developed IPT as a practica psychotherapy to address depression in an interpersonal environment. IPT’s case discussions and guidelines are designed to help health professionals learn the approach quickly, use it with broad populations, and complete therapy within weeks rather than years.5,6
Case continued: ‘he made all the decisions’
At Mrs. E’s first IPT session, the therapist assigns her the “sick role.” They contract to meet 12 to 16 weeks, and Mrs. E’s daughter agrees to drive her to sessions.
In the next few weeks, the therapist explains depression’s biopsychosocial model and explores dual strategies with Mrs. E: to ease her mourning and explore new interests or relationships. The therapist encourages her to express her feelings and seeks to understand the dynamics of her marriage.
Mrs. E said she was raised by nurturing parents and married soon after high school. She depended on her husband for almost every decision, including their social calendar. She describes their relationship as mutually loving. As part of an interpersonal inventory, her therapist encourages her to describe in detail all the ways she misses him.
The ‘sick role.’ The therapist assigned Mrs. E the “sick role” to emphasize that major depression can be a severe illness. A therapist might say: “If you had pneumonia, you wouldn’t think of trying to rake leaves. You would rest and take care of yourself to speed the healing. Persons with major depression should do the same.”
The contract. The therapist also explained to Mrs. E that contracting to meet weekly for 12 to 16 weeks is part of the treatment. A contract:
- encourages patients to commit to an IPT trial for a reasonable time
- presses patients to achieve adequate progress by the deadline
- discourages digression, avoidance of painful subjects, and dependence on the therapist.
IPT’s framework. IPT sees clinical depression as having three components: a symptom function, social and interpersonal relations, and personality and character problems (Table 1).5,6 Because IPT is brief, its interventions focus on the first two components. The third may be addressed indirectly, such as when a patient with a depressogenic personality style learns new social skills, compensates better, and improves his or her symptoms.
IPT begins with a complete psychiatric evaluation, including the patient’s past, family, and social histories; alcohol and drug use; medical comorbidities; mental status exam; and sometimes blood screening to rule out metabolic abnormalities. Antidepressants are prescribed as needed to relieve vegetative symptoms and are used during IPT when indicated.
Interpersonal inventory. Each of the patient’s interpersonal relationships is then systematically reviewed. This inventory sets the stage for exploring relationships that may be linked to the depressive symptoms or offer opportunities for trying alternate coping trategies, such as learning to seek social support (Table 2).
IPT’s understanding of depression comprises 3 component processes
Biological or psychological causes may trigger neurovegetative signs and symptoms
Interpersonal and social relations
Influenced by childhood learning, social reinforcement, personal mastery, and competence
Personality and character problems
Enduring traits such as excess anger, guilt, impaired communication, or low self-esteem may impair patient’s ability to maintain satisfying interpersonal relationships
Source: References 5 and 6
‘How-to’ checklist of IPT procedures
IPT’S FOUR FOCI
IPT’s goal is to relieve depressive symptoms by identifying and focusing on problems that may have caused or are perpetuating those symptoms. Most of the reasons depressed patients give for seeking help fall into four foci: unresolved grief, role transition, role dispute, and interpersonal deficit (Table 3).5,6 The therapist uses clarification, interpretation, confrontation, and testing of perceptions and performance to address each focus, as detailed in the IPT manual.6
The therapist acts as the patient’s advocate, and focuses treatment on interpersonal relationships in the “here and now,” not past traumas, childhood conflicts, cognitive-behavioral interventions, or intrapsychic themes. No attempt is made to restructure personality.
Progress in relieving depressive symptoms is reviewed regularly, and treatment ends within the contract’s time limits in many cases. Older patients may need additional sessions because they often take longer to respond to antidepressant trials (6 to 8 weeks, compared with 3 to 4 weeks for younger adults). We allow older patients to “catch up” with additional sessions if illness, lack of transportation, or other problems prevent them from receiving the “full dose” of IPT.
IPT does not work for all patients. Consider other types of treatment if a patient shows no discernable benefit.
IPT’s 4 foci, specific to late-life depression
Emotional reactions to the death of another person (not the loss of a job or one’s health)
Difficulty adjusting to life change (such as retirement, ceasing to drive, or moving to an apartment)
Nonreciprocal expectations between two or more persons that predispose or perpetuate depressive symptoms
History of social impoverishment or inadequate or nonsustaining interpersonal relationships
Source: References 5 and 6
Case continued: stalled in grief
As the weeks pass, Mrs. E improves but remains hypoactive and reclusive. She seems afraid to take any action without her late husband’s approval. Thinking about making independent decisions overwhelms her, and she withdraws to her couch to hide.
Her therapist discerns that Mrs. E needs more-active confrontation to accept that her new life requires her to make choices, even though decision-making is difficult for her. They develop a game, hronicling all decisions Mrs. E has made for the first time, such as calling a repairman and planting the summer vegetable garden by herself.
The therapist applauds these “firsts” and points out that Mrs. E’s depressive symptoms have improved as her list of completed decisions has grown. Mrs. E holds the power to make decisions, the therapist stresses, and bears the consequences of not taking action.
Applying ipt to late-life depression
- Older patients without psychotherapy experience or psychological sophistication can easily participate.
- Persons with limited education can understand IPT’s informal explanations of depression.
- Two foci of IPT—grief and role transition—address common themes of aging, such as spousal role disputes after retirement or caregiver stress when one partner becomes ill or shows signs of dementia.
In this research, median time to recurrence of major depression was 69 weeks in IPT-treated patients compared with 16 weeks in similar patients treated with monthly clinical management. Age, depression severity, or medical burden did not determine whether a patient got well with IPT plus nortriptyline.
Only minor IPT adaptations were required for older patients, such as:
- shorter sessions for those who reported physical discomfort
- accommodating for hearing loss, arranging transportation, and conducting sessions by telephone when patients were ill or shut in by inclement weather.
Case continued: more ‘firsts’ build confidence
Mrs. E makes slow, sometimes painful, but steady progress. Her therapist encourages her to keep trying more “firsts,”such as going back to church and attending her first social event alone, and to review her emotional reactions.
Mrs. E’s depressive symptoms wane as her confidence builds, and she readjusts her self-image to that of a widow who enjoyed a good marriage with a benevolent but overprotective husband. Her therapist links her progress to her string of successful “firsts” and to the contributing benefit of anti-depressant medication.
IPT As maintenance therapy
In the Maintenance Therapies for Late Life Depression (MTLLD) study—a randomized, double-blind, placebo-controlled trial12—we showed IPT to be effective as maintenance therapy for recurrent depression in patients age 60 and older. The 187 patients (mean age 67, one-third age ≥70) with nonpsychotic unipolar major depression were first treated to remission with IPT plus nortriptyline (80 to 120 ng/mL).