IPT vid PTSD -”to get it as good as it gets”

Posted on 15 februari, 2016 Updated on 15 februari, 2016

Torsdagen den 14 April besöker MD John Markowitz Göteborg. Svenska IPT-föreningen IPTs har bjudit in John att, utöver en kort historik och nulägesanalys om IPT, belysa  depressionsbehandling vid samtidig ångest och IPT som PTSD-behandling. Han kommer att göra en grundlig genomgång av IPT vid PTSD utifrån färska forskningsresultat och med tyngdpunkt på det kliniska handhavandet.  Fortbildningsdagen vänder sig främst till IPT-terapeuter med en god kunskap i metoden men andra är också välkomna.

För Dig som är nyfiken att närvara på denna fortbildningsdag, finns inbjudan uppladdad på länken nedan. Se även på IPTs hemsida www.interpersonellpsykoterapi.se Observera att sista datum för anmälan/betalning är 8 mars. Först till kvarn….

inbjudan markowitz april 2016 edit 4

IPT – Interpersonell psykoterapi, som sedan dess tillblivelse i början på 1970-talet, i upprepade studier,  visat sig ha starkt vetenskapligt stöd vad gäller depression (Cuijpers, van Straten et al. 2008, Cuijpers, Geraedts et al. 2011, Lemmens, Arntz et al. 2015), har hittills inte uppvisat lika bra resultat som KBT vid ångeststörningar (Markowitz, Lipsitz et al. 2014). De senaste 10 åren, i olika delar av världen, har flera studier genomförts med traumatiserade patienter där IPT har varit en av de behandlingsinterventioner som utvärderats med lovande resultat – både individuellt och i gruppformat.  (Robertson, Rushton et al. 2004, Robertson, Rushton et al. 2007, Krupnick, Green et al. 2008, Campanini, Schoedl et al. 2010, Ray and Webster 2010, Jiang, Tong et al. 2014, Markowitz, Petkova et al. 2015, Brown, Bruce et al. 2016).

2015 publicerades en RCT-studie där PE (traumafokuserad KBT), tillämpad avslappning och IPT jämfördes vid PTSD (Markowitz, Petkova et al. 2015). IPT med sitt fokus på att förbättra relationella aspekter i individens pågående liv, att bättre förstå och ta hand om sin interpersonella sårbarhet som en konsekvens av traumat samt att processa/hantera affekter, fick enbart marginellt sämre resultat än PE, som är ”the golden standard treatment of PTSD”. När det kom till patienter med en komorbiditet med samtidig depression fick IPT bättre resultat inte bara avseende PTSD utan även för samtidig depression samt färre avhopp än KBT (PE).

För patienter som inte är beredda att gå in i traumahändelserna/ inte kan tillgodogöra sig en traumafokuserad behandling, eller för individer med en samsjuklighet med annan psykisk sårbarhet där KBT inte visats lika effektiv, kan man tänka att IPT, som inte berör traumat, kan vara ett trovärdigt behandlingsalternativ – i synnerhet när individen lever under pågående hot, ovisshet om ex uppehållstillstånd eller andra stressorer, då vi vanligtvis inte rekommenderar  PTSD-behandling/traumaexponering. (Givetvis finns det andra lovande terapiformer vid trauma utöver IPT inom det relationella fältet. Detta inlägg belyser dock IPTs fördelar.)

IPT vid PTSD har uppmärksammats internationellt under 2015.  Richard. A. Friedman, Professor i klinisk psykiatri,  beskrev  i New York Nimes 2015-07-19 (Friedman 2015), Markowitz studie som ett vetenskapligt fynd. PTSD-studien kring IPT, PE m.fl., ges som ett exempel på att vi behöver fortsätta vara nyfikna och beforska psykoterapins möjligheter att avhjälpa lidande.

”Fram till nu har exponeringsbehandling betraktats som den enda vägen ur ett trauma, behandling som kan upplevas alltför plågsam och svårgenomförbar vid samsjuklighet. Med stöd för forskning som denna, det som inte bara befäster tidigare antaganden utan visar på andra möjligheter, kan vi hjälpa fler”  (Friedman 2015).

http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?smid=fb-share&_r=1

I februari 2016 genomförs i London en konferens på initiativ från bl.a. Anna Freud Center & IAPT/NHS, där ledande inom respektive behandling belyser metodik och evidens för KBT, IPT och EMDR vid PTSD samt ser till hur man skall optimera behandlingsutbudet för denna patientgrupp i Storbritannien.

http://www.annafreud.org/training-research/training-and-conferences-overview/conferences-and-seminars/learning-from-each-other-comparison-of-three-effective-interventions-for-ptsd-cbt-emdr-ipt/

Intresset för IPT som PTSD-behandling är alltså stort och i April gästar John Markowitz oss här i Sverige. Att kunna erbjuda en ”traumabehandling” utan att patienten förväntas tala om sina trauman,  med fokus att få livet att kännas tillräckligt  tryggt med sig själv och andra, trots det som hänt, känner jag är ett skonsamt och fint alternativ i behandlingsutbudet. Tycker också det här  är i linje med Paul Wachtels resonemang om att det är onödigt att gå tillbaka i historiken här de relationella starkt känsloladdade dramerna spelas upp precis framför oss här och nu.

Vi ses på Järntorget i Göteborg den 14 April 🙂

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Malin Bäck

Referenser med sammanfattning för den ”vetgirige”:

Brown, W. J., et al. (2016). ”Affective Dispositions and PTSD Symptom Clusters in Female Interpersonal Trauma Survivors.” J Interpers Violence 31(3): 407-424.  Interpersonal trauma (IPT) against women can have dire psychological consequences including persistent maladaptive changes in the subjective experience of affect. Contemporary literature has firmly established heightened negative affect (NA) as a risk and maintenance factor for posttraumatic stress disorder (PTSD). However, the relationship between NA and PTSD symptoms is not well understood within IPT survivors, the majority of whom are female, as much of this research has focused on combat veterans. In addition, the connection between positive affect (PA) and PTSD symptoms has yet to be examined. With increased emphasis on ”negative alterations in cognitions and mood . . .” as an independent symptom cluster of PTSD in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), understanding the relationship between self-reported affectivity and the classic PTSD symptom clusters may be increasingly useful in differentiating symptom presentations of trauma-related psychopathology. The current study directly compared self-reported trait NA and PA with total severity and frequency cluster scores from the Clinician-Administered PTSD Scale (CAPS) in 54 female survivors of IPT who met criteria for PTSD. Results identify NA (but not PA) as a consistent predictor of total PTSD symptoms and, specifically, re-experiencing symptoms.

Campanini, R. F., et al. (2010). ”Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial.” Depress Anxiety 27(1): 72-77. BACKGROUND: Post-traumatic stress disorder (PTSD) is a highly prevalent condition, yet available treatments demonstrate only modest efficacy. Exposure therapies, considered by many to be the ”gold-standard” therapy for PTSD, are poorly tolerated by many patients and show high attrition. We evaluated interpersonal therapy, in a group format, adapted to PTSD (IPT-G PTSD), as an adjunctive treatment for patients who failed to respond to conventional psychopharmacological treatment. METHODS: Research participants included 40 patients who sought treatment through a program on violence in the department of psychiatry of Federal University of Sao Paulo (UNIFESP). They had received conventional psychopharmacological treatment for at least 12 weeks and failed to have an adequate clinical response. After signing an informed consent, approved earlier by the UNIFESP Ethics Review Board, they received a semi-structured diagnostic interview (SCID-I), administered by a trained mental health worker, to confirm the presence of a PTSD diagnosis according to DSM-IV criteria. Other instruments were administered, and patients completed out self-report instruments at baseline, and endpoint to evaluate clinical outcomes. RESULTS: Thirty-three patients completed the trial, but all had at least one second outcome evaluation. There were significant improvements on all measures, with large effect sizes. CONCLUSIONS: IPT-G PTSD was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. It led to significant improvements in social adjustment and quality of life. It was well tolerated and there were few dropouts. Our results are very preliminary; they need further confirmation through randomized controlled clinical trials.

Cuijpers, P., et al. (2011). ”Interpersonal psychotherapy for depression: a meta-analysis.” Am J Psychiatry 168(6): 581-592. OBJECTIVE: Interpersonal psychotherapy (IPT), a structured and time-limited therapy, has been studied in many controlled trials. Numerous practice guidelines have recommended IPT as a treatment of choice for unipolar depressive disorders. The authors conducted a meta-analysis to integrate research on the effects of IPT. METHOD: The authors searched bibliographical databases for randomized controlled trials comparing IPT with no treatment, usual care, other psychological treatments, and pharmacotherapy as well as studies comparing combination treatment using pharmacotherapy and IPT. Maintenance studies were also included. RESULTS: Thirty-eight studies including 4,356 patients met all inclusion criteria. The overall effect size (Cohen’s d) of the 16 studies that compared IPT and a control group was 0.63 (95% confidence interval [CI]=0.36 to 0.90), corresponding to a number needed to treat of 2.91. Ten studies comparing IPT and other psychological treatments showed a nonsignificant differential effect size of 0.04 (95% CI=-0.14 to 0.21; number needed to treat=45.45) favoring IPT. Pharmacotherapy (after removal of one outlier) was more effective than IPT (d=-0.19, 95% CI=-0.38 to -0.01; number needed to treat=9.43), and combination treatment was not more effective than IPT alone, although the paucity of studies precluded drawing definite conclusions. Combination maintenance treatment with pharmacotherapy and IPT was more effective in preventing relapse than pharmacotherapy alone (odds ratio=0.37; 95% CI=0.19 to 0.73; number needed to treat=7.63). CONCLUSIONS: There is no doubt that IPT efficaciously treats depression, both as an independent treatment and in combination with pharmacotherapy. IPT deserves its place in treatment guidelines as one of the most empirically validated treatments for depression.

Cuijpers, P., et al. (2008). ”Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies.” J Consult Clin Psychol 76(6): 909-922. Although the subject has been debated and examined for more than 3 decades, it is still not clear whether all psychotherapies are equally efficacious. The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments. Each major type of treatment had been examined in at least 5 randomized comparative trials. There was no indication that 1 of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective supportive treatment (which was somewhat less efficacious than the other treatments; d = -0.13). The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression.

Friedman, R. A. (2015). Psychiatry’s Identity Crisis. The New York Times. Sunday Review. http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?smid=fb-share&_r=1 

Jiang, R. F., et al. (2014). ”Interpersonal psychotherapy versus treatment as usual for PTSD and depression among Sichuan earthquake survivors: a randomized clinical trial.” Confl Health 8: 14. BACKGROUND: Without effective treatment, PTSD and depression can cause persistent disability in disaster-affected populations. METHODS: Our objective was to test the efficacy of Interpersonal Psychotherapy (IPT) delivered by trained local personnel compared with treatment as usual (TAU) for Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) among adults affected by the Sichuan 2008 earthquake. A small randomized controlled trial of IPT + TAU versus TAU alone was delivered by local mental health personnel in Shifang, China. Between July 2011 and January 2012, 49 adults >/= 18 years with PTSD, MDD or both were enrolled and randomized to 12 weekly sessions of IPT + TAU (27) or TAU (22) alone x 12 weeks. IPT was then offered to the TAU group. Unblinded follow up assessments were conducted at three and six months. IPT was a 12 session, weekly one hour treatment delivered by local personnel who were trained and supervised in IPT. TAU was continuation of prescribed psychotropic medication (if applicable) and crisis counseling, as needed. MAIN OUTCOME(S) AND MEASURES (S): Clinician Administered PTSD Scale (CAPS) PTSD diagnosis; Structured Clinical Interview for DSM-IV (SCID) for MDD diagnosis. Secondary measures included PTSD/depression symptoms, interpersonal conflict/anger, social support, self-efficacy and functioning. RESULTS: Using an intent-to-treat analysis, 22 IPT + TAU and 19 TAU participants were compared at three months post-baseline. A significantly greater reduction of PTSD and MDD diagnoses was found in the IPT group (51.9%, 30.1%, respectively) versus the TAU group (3.4%, 3.4%, respectively). Despite the small sample, the estimates for time-by-condition analyses of target outcomes (2.37 for PTSD (p = .018) and 1.91 for MDD (p = .056)) indicate the improvement was better in the IPT + TAU condition versus the TAU group. Treatment gains were maintained at 6 months for the IPT group. A similar treatment response was observed in the TAU group upon receipt of IPT. CONCLUSIONS: This initial study shows that IPT is a promising treatment for reducing PTSD and depression, the two major mental health disorders affecting populations surviving natural disaster, using a design that builds local mental health care capacity. TRIAL REGISTRATION: ClinicalTrials.Gov number, NCT01624935.

Krupnick, J. L., et al. (2008). ”Group interpersonal psychotherapy for low-income women with posttraumatic stress disorder.” Psychother Res 18(5): 497-507. The aim of this study was to assess the efficacy of group interpersonal psychotherapy (IPT) for low-income women with chronic posttraumatic stress disorder (PTSD) subsequent to interpersonal trauma. Non-treatment-seeking predominantly minority women were recruited in family planning and gynecology clinics. Individuals with interpersonal trauma histories (e.g., assault, abuse, and molestation) who met criteria for current PTSD (N=48) were randomly assigned to treatment or a wait list. Assessments were conducted at baseline, treatment termination, and 4-month follow-up; data analysis used a mixed-effects regression approach with an intent-to-treat sample. The results showed that IPT was significantly more effective than the wait list in reducing PTSD and depression symptom severity. IPT participants also had significantly lower scores than waitlist individuals on four interpersonal functioning subscales: Interpersonal Sensitivity, Need for Social Approval, Lack of Sociability, and Interpersonal Ambivalence.

Lemmens, L. H., et al. (2015). ”Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: results of a randomized controlled trial.” Psychol Med: 1-16. BACKGROUND: Although both cognitive therapy (CT) and interpersonal psychotherapy (IPT) have been shown to be effective treatments for major depressive disorder (MDD), it is not clear yet whether one therapy outperforms the other with regard to severity and course of the disorder. This study examined the clinical effectiveness of CT v. IPT in a large sample of depressed patients seeking treatment in a Dutch outpatient mental health clinic. We tested whether one of the treatments was superior to the other at post-treatment and at 5 months follow-up. Furthermore, we tested whether active treatment was superior to no treatment. We also assessed whether initial depression severity moderated the effect of time and condition and tested for therapist differences. METHOD: Depressed adults (n = 182) were randomized to either CT (n = 76), IPT (n = 75) or a 2-month waiting list control (WLC) condition (n = 31). Main outcome was depression severity, measured with the Beck Depression Inventory – II (BDI-II), assessed at baseline, 2, 3, and 7 months (treatment phase) and monthly up to 5 months follow-up (8-12 months). RESULTS: No differential effects between CT and IPT were found. Both treatments exceeded response in the WLC condition, and led to considerable improvement in depression severity that was sustained up to 1 year. Baseline depression severity did not moderate the effect of time and condition. CONCLUSIONS: Within our power and time ranges, CT and IPT appeared not to differ in the treatment of depression in the acute phase and beyond.

Markowitz, J. C., et al. (2014). ”Critical review of outcome research on interpersonal psychotherapy for anxiety disorders.” Depress Anxiety 31(4): 316-325. BACKGROUND: Interpersonal psychotherapy (IPT) has demonstrated efficacy in treating mood and eating disorders. This article critically reviews outcome research testing IPT for anxiety disorders, a diagnostic area where cognitive behavioral therapy (CBT) has dominated research and treatment. METHODS: A literature search identified six open and five controlled trials of IPT for social anxiety disorder (SAD), panic disorder, and posttraumatic stress disorder. RESULTS: Studies were generally small, underpowered, and sometimes methodologically compromised. Nonetheless, minimally adapted from its standard depression strategies, IPT for anxiety disorders yielded positive results in open trials for the three diagnoses. In controlled trials, IPT fared better than waiting list (N = 2), was equipotent to supportive psychodynamic psychotherapy (N = 1), but less efficacious than CBT for SAD (N = 1), and CBT for panic disorder (N = 1) in a methodologically complicated study. IPT equaled CBT in a group residential format (N = 1). CONCLUSIONS: IPT shows some promise for anxiety disorders but has thus far shown no advantages in controlled trials relative to other therapies. Methodological and ecological issues have complicated testing of IPT for anxiety disorders, clouding some findings. The authors discuss difficulties of conducting non-CBT research in a CBT-dominated area, investigator bias, and the probable need to further modify IPT for anxiety disorders. Untested therapies deserve the fairest possible testing.

Markowitz, J. C., et al. (2015). ”Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD.” Am J Psychiatry 172(5): 430-440. OBJECTIVE: Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). The authors tested interpersonal psychotherapy (IPT), which has demonstrated antidepressant efficacy and shown promise in pilot PTSD research as a non-exposure-based non-cognitive-behavioral PTSD treatment. METHOD: The authors conducted a randomized 14-week trial comparing IPT, prolonged exposure (an exposure-based exemplar), and relaxation therapy (an active control psychotherapy) in 110 unmedicated patients who had chronic PTSD and a score >50 on the Clinician-Administered PTSD Scale (CAPS). Randomization stratified for comorbid major depression. The authors hypothesized that IPT would be no more than minimally inferior (a difference <12.5 points in CAPS score) to prolonged exposure. RESULTS: All therapies had large within-group effect sizes (d values, 1.32-1.88). Rates of response, defined as an improvement of >30% in CAPS score, were 63% for IPT, 47% for prolonged exposure, and 38% for relaxation therapy (not significantly different between groups). CAPS outcomes for IPT and prolonged exposure differed by 5.5 points (not significant), and the null hypothesis of more than minimal IPT inferiority was rejected (p=0.035). Patients with comorbid major depression were nine times more likely than nondepressed patients to drop out of prolonged exposure therapy. IPT and prolonged exposure improved quality of life and social functioning more than relaxation therapy. CONCLUSIONS: This study demonstrated noninferiority of individual IPT for PTSD compared with the gold-standard treatment. IPT had (nonsignificantly) lower attrition and higher response rates than prolonged exposure. Contrary to widespread clinical belief, PTSD treatment may not require cognitive-behavioral exposure to trauma reminders. Moreover, patients with comorbid major depression may fare better with IPT than with prolonged exposure.

Ray, R. D. and R. Webster (2010). ”Group interpersonal psychotherapy for veterans with posttraumatic stress disorder: a pilot study.” Int J Group Psychother 60(1): 131-140. Group-based interpersonal psychotherapy (IPT-G) was provided to nine male Vietnam veterans with posttraumatic stress disorder (PTSD) to reduce interpersonal difficulties. Standardized measures of posttraumatic stress, depression, interpersonal problems, and functioning were administered pre- and posttreatment and at 2- and 4-month follow-ups. Individual (reliable change indices) and group analyses (repeated measures ANOVAs) indicated improvements in interpersonal and global functioning (not maintained at follow-up), as well as for PTSD and depressive symptoms (maintained at follow-up). Qualitative feedback indicated reduced levels of anger and stress as well as improved relationships. IPT-G for Vietnam veterans shows promise in improving interpersonal functioning and reducing psychological distress. However, since not all improvements were maintained over time, future studies may need to explore relapse prevention strategies.

Robertson, M., et al. (2007). ”Open trial of interpersonal psychotherapy for chronic post traumatic stress disorder.” Australas Psychiatry 15(5): 375-379. OBJECTIVE: The aim of this study was to investigate the feasibility of adapting group-based interpersonal psychotherapy (IPT-G) for patients with chronic post traumatic stress disorder (PTSD). METHODS: Thirteen subjects with DSM-IV-defined PTSD, with symptom duration greater than 12 months, entered the study, an 8-week treatment programme conducted in a clinical setting using IPT-G modified for the treatment of PTSD. Data obtained were analysed qualitatively and quantitatively. RESULTS: All 13 subjects completed the treatment programme and showed significant improvement in social functioning, general wellbeing and depressive symptoms. Treatment completers demonstrated a moderate reduction in the avoidant symptom cluster of PTSD. These improvements appeared stable at 3-month follow-up. Benefits appeared to be associated with perceived intra-therapy progress in resolving identified IPT problem areas. Qualitative analysis found that themes of ‘reconnection’ and ‘interpersonal efficacy’ were core parts of the experience of the treatment. CONCLUSION: IPT-G modified for PTSD appears to be of modest symptomatic benefit, but may lead to improvement in social functioning, general psychological wellbeing and enhanced interpersonal functioning. Further studies are indicated.

Robertson, M., et al. (2004). ”Group-based interpersonal psychotherapy for posttraumatic stress disorder: theoretical and clinical aspects.” Int J Group Psychother 54(2): 145-175. Posttraumatic stress disorder (PTSD) is a condition that engenders both symptomatic distress and severe disruption in interpersonal and social functioning. Most of the empirical research on treatment has emphasized interventions that aim to alleviate the symptoms of PTSD, despite the persisting impairments in social, occupational, and interpersonal functioning. In clinical practice, achieving relief from symptoms such as irritability or phobic avoidance is a worthwhile goal, yet significant distress and disability derived from disruptions to interpersonal attachments, social networks, and confiding intimate relationships persist. Interpersonal psychotherapy (IPT) has been shown to be efficacious in research settings for depression and eating disorders, in both group and individual formats. Recent pilot data also suggests the potential usefulness of IPT in anxiety disorders. The aim of this paper is to provide a rationale for the use of group-based IPT as an intervention for PTSD as part of a management package, arguing from theoretical and clinical viewpoints. The integration of IPT therapeutic processes with the therapeutic group process is discussed, and a detailed case discussion is presented as an illustration.