SECTION ONE Mood Disorders
It is relatively rare that an interpersonal focal area receives specific attention in the IPT literature. Most published outcome studies do not report the breakdown of interpersonal problem areas in a manner elucidating process and outcome with different interpersonal themes. The grief focus is more richly served, however, both in conceptualizing this focal interpersonal problem area and in evaluating the relative benefits of using IPT compared with alternative approaches that target complicated bereavement.
The IPT therapist selects grief as an interpersonal focus when the onset of the patient’s symptoms is associated with the death of a significant other and manifests in a bereavement-related depression (Weissman et al., 2000). The reaction differs from the predictable sorrow associated with bereavement—the experience of deprivation and desolation. The DSM-IV echoes this distinction by excluding immediate bereavement reactions in making the diagnosis of major depression. Clinicians may diagnose major depression only if symptoms persist for more than 2 months after the death or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation (DSM-IV-TR, 2000).
Distinguishing grief following bereavement from bereavement-related depression can be difficult. Some symptoms of grief, including neurovegetative symptoms and sadness, are considered normal following the death of a loved one. The characteristic reactions of a bereavement can closely resemble those we see in depressed patients: persistent sadness, a sense of emptiness, loss of interest in normally enjoyable activities, disturbed sleep, and impaired memory and concentration are all common. Estimates of the proportion of individuals who meet diagnostic criteria for major depression following bereavement have ranged from 30% to 60% in the month after a death. Estimates a month later are roughly half as high, and half again at the end of the first year after bereavement. However, for this smaller number of 7% to 16% , major depression persists into the second year of bereavement (Zisook et al., 1991a, 1991b, 1993a), suggesting that some individuals have great difficulty moving on and endure the added burden of a depressive episode.
Bereavement-related depression is more likely to occur when patients suffer multiple bereavements, have delayed onset of symptoms, or neglect to use social support at or after the time of the death. For some the grief is so consuming they need look no further for an interpersonal focus in IPT: the deaths of a spouse or child are typically rated as the most stressful life events one can face. For others, delay in symptom onset and complicated ramifications in other relationships can obscure the picture. If the sequence of events appears interrupted, with depressive symptoms emerging only after a delay, patients may struggle to connect their loss to their symptoms and to see the logic of working on one to alleviate the other. Many depressed patients find themselves gripped by a terrible dilemma: Does being happy now mean I didn’t love him or her then? Does being depressed prove I did?
One patient opened her first IPT session by saying, “It all started when my husband died . . .," but still expressed surprise when the therapist suggested the grief focus two sessions later. When asked why, she said that she had seen others recover from similar losses more quickly and so had ruled out bereavement as an explanation for her current distress. In other cases, the manner of the death and the availability of support can interact to obstruct recovery. One young man was present when the person who subsequently killed his friend arrived in their home. Aware of this individual’s potential for unpredictable behavior and afraid for his own safety, he fled before the individual entered the house. Returning hours later, he discovered the murder scene and was distraught to have, in his view, abandoned his friend to this fate. He believed his friends subsequently blamed him for not having done more and withdrew from all contact with them. He essentially lost his best friend and wider network in one event and, suddenly and simultaneously bereaved and isolated, had few social resources to help him recover from his depression.
There is debate in the literature on the overlap between depression and complicated grief. Complicated grief is not currently a DSM-IV diagnostic category. ICD-10 classifies it as an adjustment disorder. Some authors have argued that complicated or traumatic grief should be considered a distinct disorder rather than a variant of depression (Boelen et al., 2003; Horowitz et al., 1997; Prigerson et al., 1997, 1999).
Estimated comorbidity of depression and complicated grief ranges between 24% and 54% (Prigerson et al., 1995). Diagnosis of complicated grief refers to a cluster of symptoms similar but not identical to those of major depression, which have been estimated to characterize 10% to 20% of bereaved individuals (Middleton et al., 1996). The symptoms of complicated grief include extreme focus on the loss and reminders of the loved one; intense longing or pining for the deceased; problems accepting the death; numbness or detachment; preoccupation with the sorrow; and bitterness about the loss. This chapter focuses on IPT as an intervention for bereavement-related depression. Readers interested in the treatment of complicated grief specifically and the evolution of treatments integrating IPT and cognitive-behavioral therapy (CBT) strategies should read Shear et al. (2005) and Simmons et al. (2008).
Levenson et al. (2010) analyzed comparative outcomes across the focal interpersonal problem areas in IPT for depressed patients (N = 182) and found no difference in time to remission as a function of focal area. Use of IPT, and where necessary medication, yielded equivalent clinical success across the four interpersonal themes. Markowitz et al. (2006) reported retrospective evaluations of progress in interpersonal problem areas by patients with dysthymia and posttraumatic stress disorder (PTSD), using the Interpersonal Psychotherapy Outcome Scale (IPOS). This retrospective analysis revealed less improvement for those who worked on grief than those facing interpersonal transitions and disputes. The authors noted, however, that the rate of endorsement of focal problem areas by the patient sample was high, suggesting a broader definition of the focal areas than therapists would have employed, and consequently may reflect a more general evaluation of working with grief and loss than the specific work outlined in the IPT model. This broader definition of grief is a common issue for therapists new to IPT and should be addressed through careful attention to specific, clear formulation and negotiation of treatment goals.
Reynolds et al. (1999) examined IPT for bereavement-related depression in older adults, usually following the loss of a spouse. They found that IPT plus nortriptyline, nortriptyline alone, and placebo yielded superior remission rates than IPT plus placebo. There was little evidence of an additive effect of IPT with medication over medication alone, although the study authors noted that the small sample size of 17 for combined treatment was underpowered to demonstrate such a difference. Combined treatment of IPT and medication did demonstrate greater treatment retention than the other interventions.
Ellen was thirty-two years old, unmarried, and lived alone. She had been raised Catholic and continued to attend church occasionally, describing her faith as private but important to her. She had not been involved with the church community since leaving school. She had had a boyfriend, Pete, for two years and no children. She worked as a classroom assistant with children with special educational needs. Ellen presented with a fluctuating two-year history of agitated depressive and anxiety symptoms that began following her father’s death in a traffic accident.