Interpersonal psychotherapy for depressed adolescents: Theory, practice, and research

Adolescent Psychiatry, 2000 by Mufson, Laura, Dorta, Kristen Pollack

A variety of psychosocial and medication interventions exist for the treatment of adolescent depression. Unfortunately, very little research has been conducted to assess the efficacy of these treatments. To date, the only randomized controlled clinical trials of individual treatments for adolescent depression have been conducted for fluoxetine (Emslie et al., 1997), paroxetine (Klein, 1999), cognitive-behavioral therapy (Brent et al., 1997), and interpersonal psychotherapy (Mufson et al., 1999). Studies have demonstrated the effectiveness of group therapy in the treatment of adolescent depression (Lewinsohn et al., 1990; Clarke et al., 1995).

Depression, a common disorder among adolescents (Birmaher et al., 1996; Prosser and McArdle, 1996), often runs a chronic and relapsing clinical course (Lewinsohn et al., 1993). Prevalence rates for depression symptoms and depressive disorders range from 1.3 percent to eight percent (Rutter et al., 1976; Kashani et al., 1987; Weissman et al., 1987). Clinical and epidemiological data have documented that depressed adolescents are a largely underserved population (Burns, 1991; Keller et al., 1991; Hoberman, 1992; Wu et al., 1999). Few depressed adolescents are ever identified as needing treatment, and those who are identified rarely receive the services they need. The undertreatment of adolescents can be explained by a combination of their limited access to and underutilization of mental health care. Developing treatments that are brief, manageable, and regarded by adolescents as "more immediately relevant" must be an objective for anyone aiming to better meet the needs of the multitude of depressed adolescents. Given the substantial rates of depressed mood and depressive disorders within the adolescent population and the negative developmental trajectories associated with adolescent depression, this area deserves considerable attention with respect to clinical intervention.

Interpersonal psychotherapy for depressed adolescents, or IPT-A, is an adaptation of interpersonal psychotherapy (IPT). IPT is a brief treatment that was developed and tested for depressed adults (Klerman et al., 1984). The focus of IPT treatment is on the patient's depressive symptoms and their current interpersonal context regardless of the etiology of the disorder. Therefore, the general goals of IPT are to decrease depressive symptoms and improve interpersonal functioning. The theoretical roots of this treatment can be found in the interpersonal schools of thought and, more specifically, in the teachings of Harry Stack Sullivan and Adolf Meyer. An interpersonal approach to the conceptualization and treatment of depression is well supported by research (Hammen, 1999; Joiner, Coyne, and Blalock, 1999). Research has demonstrated that depression, even at subclinical levels, is related to significant interpersonal problems and interpersonal stress (Puig-- Antich et al., 1985; Puig-Antich et al., 1993; Aseltine, Gore, and Colten, 1994; Stader and Hokason, 1998). In addition, research has documented that interpersonal experiences are often precipitants of the onset of depression (Hammen, 1999).

Rationale for the Development of IPT-A

EMPIRICAL EVIDENCE

As already stated, in the early 1990s there continued to be a lack of empirical evidence supporting the use of specific treatments for adolescent depression. In the wake of this dearth of empirically supported interventions, there was an interest in developing and testing new treatments, particularly those that are short-term and manualized. Such treatments are more reasonable to assess in controlled clinical trials and more consistent with current trends in managed health care.

Clinical research conducted in the 1970s and 1980s clearly established the efficacy of IPT for the treatment of depression in adults (DiMascio et al., 1979; Weissman et al., 1979; Elkin et al., 1989). Given the success of IPT in clinical trials with adult outpatients as well as the documented similarities between adult and adolescent depressive symptoms, it was hypothesized that IPT could be useful with adolescents as well.

CLINICAL NEED

IPT-A is a treatment approach that may be easily disseminated to a variety of settings, as it is manualized and brief. Given the need to reach adolescents, this could prove helpful in increasing access to care. In addition, IPT-A defines a more flexible role in treatment for the family. It offers a variety of methods for incorporating family into the treatment-including seeing them in face-to-face visits, working with telephone sessions, or using role-playing techniques with the therapist and adolescent during session. With the latter technique, the adolescent first practices with the therapist and then tries to use the techniques at home, between sessions. The therapist remains available by phone or offers additional sessions to support the adolescent in his or her efforts to institute change.

DEVELOPMENTAL RELEVANCE

IPT was selected for use with adolescents due to its developmental relevance to the adolescent population. IPT-A focuses largely on current interpersonal issues that are likely to be areas of most concern and importance to adolescents. Discussing interpersonal events is something adolescents can relate to and are accustomed to in their daily lives. In addition, research has clearly documented the critical role interpersonal events and interpersonal skills can play in the development and sequelae of adolescent depression (Gotlib and Asarnow, 1979; Marx and Schulze, 1991; Stader and Hokason, 1998; Hammen, 1999).