Major Depressive Disorder. Role Transition
PAULA RAVITZ AND ROBERT MAUNDER
Relationships are essential for survival, growth, development, and health. IPT, a therapy that centers on interpersonal experience, is therefore appealing and clinically relevant and can be powerfully helpful to patients whose symptoms occur in the context of stressful life events (Frank & Levenson, 2010; Weissman, Markowitz, & Klerman, 2007). The goals of IPT for treating depression are to relieve symptoms through improving interpersonal functioning and resolving interpersonal problems (Markowitz, Bleiberg, Christos, & Levitan, 2006; Ravitz et al., 2008).
This chapter describes a case ofIPT treatment of major depressive disorder with a focus on role transitions. Social roles are central to our sense of identity, and we all hold numerous roles. A single individual may be a partner, child, parent, sibling, neighbor, and community member, besides having vocational roles as a colleague, employee, employer, or professional. Social roles determine the “rules of engagement” (e.g., around communication, sharing of responsibilities) and expectations we have of one another. A change in one’s social role, for example the change that accompanies losing a job, moving to another city, becoming partnered, ending a spousal or long-term romantic relationship, adjusting to a disabling or disfiguring medical condition, or becoming a new parent, can generate a shift in or loss of one’s sense of self. These role transitions also evoke changes in one’s needs for or access to social supports. A role change can be stressful enough to provoke an episode of major depression, especially in individuals with limited social support, insecure or disorganized attachment, or a history of or genetic vulnerability to depression (Bifulco et al., 2006; Bifulco, Moran, Ball, & Bernazzani, 2002; Bifulco, Moran, Ball, & Lillie, 2002; Constantino et al., 2008; Markowitz, Milrod, Bleiberg, & Marshall, 2009; Ravitz et al., 2008 ).
Barbara is a thirty-seven-year-old married mother of two daughters. She has been struggling with chronic major depression in partial remission, which began shortly after the birth of her second child seven years ago. Prior to her daughter’s birth she was a manager at a social service agency but has not worked since she became depressed. Her depression was initially treated six years ago with ten sessions of cognitive-behavioral therapy (CBT; Beck, Rush, Shaw, & Emery, 1979), a sound evidence-based choice, but she had terminated early. Her Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) scores diminished from the severe to the moderate range (from 32 to 24) during her course of CBT, but not to a degree that would be considered a treatment response. Afterwards, during a year-long period of medication optimization, her BDI score further decreased to 19. Pharmacotherapy had involved five trials of antidepressants (at optimized doses for sufficient duration [i.e., four to six weeks]). Some were discontinued due to intolerable side effects, others due to a lack of therapeutic benefit. Her symptoms improved on a combination of sertraline 200 mg and bupropion 150 mg, but she had significant continuing depressive symptoms and still did not meet criteria for response, much less remission. Thus, she was referred for IPT. With IPT, we would aim to identify and resolve interpersonal problems associated with the onset and perpetuation of this lengthy current depressive episode in order to reduce symptoms and improve her interpersonal functioning.
The tasks of the first phase (Sessions 1-3) of IPT include establishing a therapeutic alliance, conducting a comprehensive psychiatric assessment, providing psychoeducation about depression and IPT, and conducting an interpersonal inventory (Weissman, Markowitz, & Klerman, 2007). The IPT guidelines also call for evaluating the need for medication in the beginning treatment phase; however, in this case, pharmacotherapy optimization had been recently undertaken by a mood disorders expert. Although she arguably could have continued with further pharmacotherapy trials, the patient, her pharmacologist, and I felt it was worth trying to add IPT at this juncture. Given the chronicity of her symptoms, a combination of psychotherapy and pharmacotherapy was indicated, continuing the sertraline and bupropion (see Chapter 6).
Gathering the history of the present illness, social history, and interpersonal inventory facilitates the formulation of an interpersonal case conceptualization that uses the biopsychosocial model to integrate an understanding of the patient and organize the therapeutic work of the middle phase (Markowitz & Swartz, 2007; Stuart & Robertson, 2003).
therapist: The purpose of this first session is to begin to get to know you. I will be asking you many questions to learn about your struggles, symptoms, concerns, life circumstances, what kinds of psychiatric care and psychotherapy you’ve tried, and details of your past relationships. I’m gathering this information to provide you and your referring physician with an opinion regarding whether IPT can be helpful.
Barbara quietly nods, flushed with emotion, eyes welling with tears. Although the tasks of the beginning phase require the therapist to be quite active in order to gather and communicate a lot of information, it was essential to respond to the affect in the present moment.
therapist: Barbara, I can see you’re upset. I wonder if you can tell me what’s behind the tears.
Barbara: I’m kind of scared you’ll not be able to help, or you’ll see me as a com- plainer.
therapist: Ah, okay. It sounds like you’re worried this won’t be helpful. Maybe you’re concerned that I won’t understand you. I want to do all I can to begin to get to know you so that, together, we can sort out what will most help you to recover and feel better. Your telling me about your concerns today helps me to understand that you really wish to be helped but worry that others will dismiss your concerns.
Barbara conveyed a sense of interpersonal sensitivity. Attentive to the importance of establishing a good therapeutic alliance, I chose in my response to reframe her fear of being seen as a complainer as an apprehension that I might be someone who would invalidate or dismiss her concerns. I aimed in this first session to reassure her of my intention to help, in the service of the important task of establishing a therapeutic alliance.
Barbara: (appearing more settled) Yes, that’s true. I’ve had experiences with people, a past therapist and colleagues, where this has been the case.
Her earlier cognitive psychotherapy trial had terminated prematurely, and that therapist’s diagnostic impression of Barbara had been that she had chronic depression with features of borderline personality. Barbara, however, had no history of selfharm or difficulties with anger or impulsivity, and had been able to work and maintain long-term relationships.
therapist: Good for me to know. I’ll want to hear more about you, about these difficulties, and about your relationships. Would it be okay for me to ask you some questions to learn more about your struggles and experiences?
Barbara: Yes, that’d be okay.
therapist: Let’s start with you telling me what brings you here and what you’re hoping to get from therapy.
Barbara described her longstanding struggles with depression and her wish to feel better and to return to work. It was important not to overlook this prelude to beginning the tasks of the first session, in which she provided important information that allowed me to start to conceptualize her difficulties and interpersonal sensitivity. It provided an opportunity to establish a therapeutic alliance by acknowledging her affect and validating her concerns, which helped her to feel psychologically safe enough to continue to speak about her relational experiences, her problems, and her worries. As we proceeded with the interpersonal inventory, I listened carefully for the antecedent relational experiences that predisposed her to the heightened sensitivity and negative expectations that she held of others, as she described her current relationships.
The history of Barbara’s present depressive episode dated back seven years, in the postpartum period following the premature birth of her youngest daughter, Karen, who had multiple developmental challenges (see Chapter 13). Barbara’s daughter required several hospital admissions during her first year of life. Barbara took maternity leave from her job that year. When it came time to return to work, she could not, due to ongoing depression. She reported continued struggles with daily periods of tearfulness and sleep difficulty with terminal insomnia. She initially lost her appetite, which had returned over the past year. She experienced significant weight loss to a level well below her baseline prior to the pregnancy, some of which she had gained back. She also endorsed symptoms of low energy, poor concentration, and a loss of self-esteem. She had strong feelings of guilt that she attributed to being an inadequate parent. Not only did she feel responsible for her daughter’s difficulties, which she feared were caused by complications during birth, she also believed that she should have been better able to manage the challenges of parenting Karen, given her capacities and strengths as a social services manager. Barbara spoke of missing the sense of competence she had felt in the workplace and expressed a wish to return to work as one goal of her treatment. She denied current or past suicidal thoughts, nor had she thought of self-harm or harming others. She had never experienced panic symptoms, substance abuse, psychosis, or manic symptoms. After her course of CBT and prior to starting pharmacotherapy a year before, she received intermittent counseling from her family physician. She was initially reluctant to take medications, but she eventually agreed because of her ongoing symptoms of depression. Since starting pharmacotherapy she felt somewhat improved; however on the BDI self-report measure of depression, she continued to score a 19, in the moderate range of symptoms on the BDI-II (Beck et al., 1996).
Barbara’s psychiatric history included two episodes of untreated major depression prior to Karen’s birth. The first was in high school, when Barbara’s mother expected her to help care for a younger brother who, like Karen, had autistic disorder. Tensions and disagreement arose when Barbara wanted more autonomy and less responsibility at home as a teenager. She had had many heated arguments with her mother, and although she had expressed her anger and protested against her mother’s demands, the situation remained unchanged. She spoke of learning that speaking up “just wasn’t worth it.” In her early twenties, Barbara had another depressive episode following the death of her grandmother, to whom she had been very close. In both cases the depressive episodes lasted approximately four months and according to her report resolved spontaneously. When I asked if she had considered seeking professional help during these periods, she replied that the stigma of mental illness and both her own and her parents’ lack of awareness were barriers to recognizing the symptoms as a clinical problem that warranted treatment.
Barbara described her CBT as unhelpful (although her depressive symptoms lessened by 25% during its course). She did not feel she could trust her therapist, and didn’t feel he understood her. They ended up agreeing to terminate treatment after several months and she was not interested at the time in an alternative referral.
Barbara was physically healthy and had no contributory medical illness. Her thyroid functioning and other baseline blood work were within normal range. She denied any history of past or current substance use or abuse.
The therapist can elicit an interwoven family psychiatric history, social history, and interpersonal inventory during the beginning phase of IPT. For the interpersonal inventory, the therapist can spend several sessions, if necessary, gathering information about important current relationships along with significant losses. There are many ways of going about this inquiry (Frank, 2005; Frank et al., 2010 Mufson, Dorta, Moreau, & Weissman, 2004; Stuart & Robertson, 2003; Weissman et al., 2007). The therapist asks the patient to describe each significant individual and their relationship. Important relationships are revisited in greater depth during the middle phase of therapy. This “first pass” gives a sense of the patient’s social network and begins information gathering about those in the inner circle, along with significant relationships that are distant or absent. When conducting the interpersonal inventory, helpful areas to explore include interpersonal expectations, understanding (or misunderstanding) of others’ intentions, the patient’s capacity to take alternative perspectives, the patient’s awareness of his or her impacts in interactions, and how the patient characteristically handles situations of disagreement or conflict in which he or she may assert or confront others. Examples of interactions with significant others are often characteristic of patterned interpersonal problems or attachment style, and they shed light on potential future therapeutic opportunities.
Conducting an interpersonal inventory provides information about social, emotional, and instrumental supports, the quality of important relationships, and how they have changed in the context of life stressors and in response to the patient’s depression. Through watching for nonverbal, affective cues and lapses in narrative coherence as the patient describes her important relationships, we can better understand which relationships currently trouble the patient while detecting patterns of relating and how relationships have shaped her as a person. In all phases of IPT, we use therapeutic opportunities to work on problematic relationships and interpersonal patterns—through the interpersonal inventory of the beginning phase, through communication analyses throughout the middle phase, and by hearing the stories patients tell about their experiences, interactions, and expectations in relationships.
Although no one in Barbara’s family had been formally diagnosed or treated for a psychiatric disorder, she described her mother as intermittently depressed and recalled episodes when she would stay in bed for weeks on end, neglecting to look after Barbara and her younger brother. Her mother did not work outside the home, but Barbara flushed with emotion when she commented on her mother’s many hobbies, including playing cards and jogging with friends. She described her mother as “caring, but selfish.” When asked for an example, Barbara said that when she and her children visited, her mother wouldn’t bother to curtail her hobbies to spend time with her grandchildren. She described her father as a “quiet man” and good financial provider who worked as a traveling salesman. When home, he was not involved with the family and often read, falling asleep in his chair most nights. Because of his developmental disability, Barbara’s younger brother was severely limited in his verbal communication. Barbara often babysat for him. She stated they were close, that she loved him and tried to look after him even though she was only one year older. Her memory of her childhood was one of neglect, and she tearfully recalled that little attention was paid to her. Barbara felt her parents’ approval was contingent on her looking after her brother and undertaking many of the household chores. As an indication of the magnitude of her contribution, she noted that when she married and moved out of her parents’ home, her brother was moved into supervised housing.
Learning these details helped me to begin to formulate an understanding of Barbara’s interpersonal expectation that others might overlook or dismiss her needs. Alerted to this, I listened carefully to her descriptions of other important relationships and interactions in which this pattern might recur. Barbara’s expectation of disappointment was forged in her experience with her parents; however, what was true “then and there” is not necessarily so in the “here and now.” It would be important to identify opportunities for her to have experiences that disconfirm her low expectations of others. I was aware of the importance of our therapeutic alliance (McBride et al., 2010), which needed to be a strong bond forged through agreeing on the goals and tasks of therapy (Bordin, 1994), and providing support and responsiveness without being overly directive (Constantino et al., 2008; Daly & Mallinckrodt, 2009; Horvath & Symonds, 1999). The beginning tasks of IPT provide a means to an important end: agreement on which interpersonal problem area will become the focus of therapy.
Continuing the interpersonal inventory, I learned that Barbara’s husband of ten years worked as a bookkeeper, and that she had been the primary financial provider before her sick leave seven years ago. The family now struggled financially, living in a two-bedroom apartment. Although Barbara described her marriage as loving and unconflicted, she and her husband had not slept in the same bed since Karen was born. Barbara slept with Karen, who was unable to sleep on her own. Although their family had faced many challenges, Barbara thought that these challenges brought them closer together; she and her husband agreed on most things and shared many of the child care and household responsibilities. She described Kenneth as quiet, kind, and supportive. They rarely argued, and when they disagreed he tended to accede to her requests. She described both of her children in glowing terms, with much pride, smiling as she spoke. Her elder daughter, Danielle, was ten years old, an outgoing, creative, athletic, good student who got along well with her peers. As for Karen, Barbara and Kenneth first noticed when she was about a year old that she didn’t do the things that Danielle had at that age, like playing peek-a-boo, mimicking expressions and gestures, making eye contact, or responding when her name was called. Their pediatrician referred them to a child development specialist, who diagnosed autistic disorder. Although Karen had pervasive and severe difficulties with communication and reciprocal social interactions, Barbara thought she was affectionate and that they were especially close.
When I asked Barbara who knew of her depression, she answered that Kenneth was the only one. She “hadn’t bothered” to tell her parents or any friends or colleagues, as she feared they would judge her negatively and did not expect that they could help or understand. She had lost contact with former friends and colleagues over the past seven years. When she was feeling well, Barbara tended to be highly self-sufficient; and, the current depression had led to social withdrawal.
Always an excellent student, Barbara had received a master’s degree in occupational therapy. At the social service agency, she had been promoted to a management position in recognition of her capacity, conscientiousness, and responsibility. The esteem and sense of mastery she derived from her professional achievements contrasted starkly with her experience of parenting, in which she described feeling inadequate, guilty, and disappointed that she could not do more to help her younger child. With the pediatrician’s help, the family had secured part-time paraprofessional help in school: Karen was in a special needs classroom at the same school as her sister Danielle. Neither of Barbara’s parents nor anyone in the extended family provided any further help or respite care.
Towards the end of the first session, we discussed depression and IPT. Barbara met DSM-IV criteria for major depressive disorder, recurrent and chronic, of moderate severity. I tried to validate and de-stigmatize her experience of how the depression was affecting her physically, emotionally, interpersonally, cognitively, and occupationally. With the intention of instilling hope, we discussed that although she had tried numerous antidepressant treatments, including pharmacotherapy and a partial course of CBT, other talking therapies with empirical support remained that might well be helpful, including IPT. Although the medications had reduced her symptoms on the BDI-II from 25 to 19, adding IPT could provide further benefit, with the goal of attaining full remission of symptoms (APA Workgroup on Major Depressive Disorder, 2010). I confidently prescribed IPT, telling Barbara that it was in the consensus treatment guidelines for depression in Canada, the United States, the United Kingdom, and other countries (APA Workgroup on Major Depressive Disorder, 2010; American Psychiatric Association, 2000; National Institute for Clinical Excellence, 2004; Parikh et al., 2009), with numerous research studies supporting its antidepressant efficacy (see Chapter 1). I explained that we would monitor her therapeutic progress, interpersonal problems, and symptoms weekly. I asked her to pay close attention to her mood fluctuations in the context of her day-to-day interpersonal interactions and stressors, which we would focus on in therapy. I explicitly communicated the goals of IPT: to remit her depressive symptoms and improve her interpersonal functioning so that she could better recruit or use supports. I also told her that we would choose a specific interpersonal problem area to focus on, linked to the onset or perpetuation of her depressive symptoms.
Based on the chronological link between Barbara’s younger daughter’s birth and the onset of her depression, I formulated the focus on her role transition. Her depression was associated with significant life changes: from a working mother of one child, to losing her vocational role in the workplace as a source of esteem and collegial support, to being a stay-at-home parent of two children, one of whom had significant challenges with severe communication impairments and pervasive developmental problems.