Using Interpersonal Psychotherapy with Older Individuals
MARK D. M
LLER AND CHARLES F.
IPT is a good fit for older individuals. Although depression secondary to grief can occur at any age, the deaths of spouses, friends, or other relatives are more common in those aged sixty and older. IPT is an intuitively good fit for addressing the meaning of these losses and encouraging or rekindling the mourning process. Role transitions common to later life include retirement (Miller et al., 2003), relocation, increasing medical burden (and associated disability) (Lyness et al., 2006), awareness of cognitive decline, and ceasing to drive, as well as anticipation of the final role transition from living to dying (Miller, Wolfson, Frank, et al., 1998). The potential for role disputes declines for some couples, who seem to grow more comfortable over years of shared experiences and practice resolving their differences. Other couples experience increased interpersonal tension in late life due to their illness burden, greater interpersonal proximity following retirement, or the caregiving burden for an ill, failing, or dementing spouse. Sometimes role disputes in older patients involve ill, addicted, or financially dependent children or grandchildren as well.
Older individuals whose IPT focus is interpersonal deficit report a long history of unsatisfying relationships, isolation, or estrangement that may reflect poor interpersonal skills related to lifelong maladaptive personality traits. Some older individuals with borderline personality profiles, however, can show a mellowing of intense interpersonal interactions as they settle into a pattern where they maintain an optimal distance in key supportive relationships. Other older individuals, however, can face a crisis and resultant major depressive episode when aging or illness takes its toll on perceived desirability, or when they perceive influence upon others to decline with waning ability to compensate because of shrinking opportunities to seek fame, fortune, or stature.
IPT provides practical, user-friendly tools for addressing these common issues. Even the psychotherapy-naive individual can benefit immediately from IPT’s psychoeducational component. Other IPT features easily acceptable for older individuals include its short-term, pragmatic orientation and a format that feels conversational rather than jargon-filled and artificial. In our experience implementing IPT in research protocols, we felt no need to modify IPT for an older population other than accommodating for hearing loss and transportation problems, and sometimes using shorter sessions if chronic pain intruded. Telephone sessions were sometimes used to maintain therapeutic momentum when travel to and from the visits was difficult due to inclement weather or illness (Miller et al., 2008).
A thorough scholarly review of the accumulated evidence supporting the use of IPT for depressed late-life individuals exists in book form (Hinrichsen & Clougherty, 2006). We will briefly review key studies our group carried out in Pittsburgh before turning to our detailed case study.
Following the maintenance studies of Frank et al. (Frank et al., 1990, Frank, Kupfer, et al., 1991; Frank, Prien, et al., 1991) (see Chapter 19), who compared recurrence rates using double randomization to antidepressant medication versus placebo as well as IPT versus clinical management (CM) in midlife patients, our group similarly tested the efficacy of nortriptyline versus placebo and IPT versus CM in subjects over age sixty with recurrent major depression. In the Maintenance Therapies in Late Life Depression (MTLD) (Reynolds et al., 1999), one hundred eighty-six subjects (mean age sixty-eight) received combined IPT and nortriptyline acutely. Those who achieved and maintained a Hamilton-17 Rating Scale for Depression score (Hamilton, 1960) of 10 or less for three consecutive weeks were randomized to three years of monthly treatment. All three active treatment arms—nortriptyline + IPT, placebo + IPT, nortriptyline + CM, and placebo + CM—were statistically superior (in descending order) to placebo and CM. This study was not designed to test the acute-phase efficacy of IPT, as all subjects received combined therapy (nortriptyline and IPT). Systematically applying IPT to recruited subjects with major depression who did not necessarily come seeking psychotherapy provided invaluable experience about the acceptability and practicality of IPT to older individuals. A few subjects balked at the idea of “required talking therapy," but even subjects who would not have sought psychotherapy found the psychoeducation useful and informative, and the vast majority assimilated the IPT process and became willing collaborative partners.
We conducted a post hoc sub-analysis of subjects receiving only placebo in order to examine the effect of IPT alone without an active medication effect. This showed no significant difference in recurrence rates between patients receiving monthly IPT versus CM for patients whose acute-phase IPT focus was role transition or grief (Miller et al., 2003). When the original focus was role dispute, however, 100% (14/14) of patients randomized to CM had a recurrence of major depression within three years of monthly follow-up, compared to 46% (5/11) randomized to monthly IPT sessions (without medication). These subgroup data, although small in sample size, argue for monthly maintenance IPT for patients whose IPT focus is role dispute. Those with an acute-phase IPT focus of role transition or unresolved grief appeared to resolve these problem areas within the twelve to sixteen weekly sessions of acute- phase IPT, so that monthly maintenance IPT did not offer differential protection against a new major depressive episode. For role disputes, however, we hypothesize that the healthier coping strategies learned in acute IPT dissipated over time in CM patients but were continually renewed for those receiving monthly IPT sessions, which provided a protective effect in the absence of antidepressant medication against recurrence of major depression.
Another study (MTLD-II) of similar design targeted the “old-old” (mean age seventy-eight, vs. sixty-eight in MTLD-I) (Reynolds et al., 2006). Because cognitive impairment is commonly comorbid in this cohort, we included depressed individuals with a Mini Mental Status Exam (MMSE) (Folstein et al., 1975) score as low as 17 out of a possible 30 points (scores of 17-25 indicate mild cognitive impairment). In preparation for MTLD-II, we worried about cognitive impairment interfering with IPT delivery in patients with memory impairment and anticipated receiving more anxious calls from concerned caregivers than we had for younger geriatric patients in MTLD-I. The two-year follow-up results found paroxetine superior to placebo in preventing major depressive relapse but showed no statistically significant separation between depressed patients who received paroxetine combined with IPT versus CM.
Why did IPT protect against major depressive recurrence in MTLD-I but not in MTLD-II? Training and supervision of therapists were identical in both studies, and some of the same therapists participated in both studies. Attendance and retention rates did not differ between the MTLD-I and MTLD-II cohorts. The MTLLD-II cohort was on average ten years older and had greater medical burden and more cognitive impairment. These factors may been important in themselves—or perhaps, because of them, our therapists took a generally more purely supportive approach to this cohort, which may have inadvertently made it harder to detect a difference in recurrence rates between the maintenance IPT and CM groups, as both took a supportive stance. In retrospect, caregivers received more frequent supportive contact in MTLD-II than MTLD-I due to frequent family and caregiver requests for advice on managing the identified patient, and maintenance-phase CM sessions tended to be longer (thirty minutes in MTLD-II vs. ten to fifteen minutes on average in MTLD-1) (Carreira et al., 2008).
A third study examined subjects aged sixty and older to test whether partial responders to a fixed 10-mg dose of escitalopram for six weeks could reach remission by sequentially adding a sixteen-week course of IPT. All partial responders at six weeks (defined as a Hamilton Rating Scale for Depression [Ham-D] score of 11-14 [Hamilton, 1960]) were randomized to either an increase of escitalopram to 20 mg daily or to the same dosage increase of 20 mg plus weekly IPT sessions for sixteen additional weeks. Results showed a clear benefit for longer-term treatment with higher-dose escitalopram but failed to show added benefit for IPT augmentation. From these results one could conclude that IPT had little therapeutic potency combined with medication, or that the medication effect was so powerful that IPT added no measurable advantage (Reynolds et al., 2010).
This case illustrates the use of IPT in a late-life patient in two stages. The first stage outlines the use of IPT for major depression, which our patient Mr. Jones was diagnosed with and treated successfully for using combined antidepressant medication and IPT. At this first encounter, Mr. Jones showed some mild memory loss as well. Eighteen months after completing acute IPT, he showed more prominent cognitive impairment as well as a recurrence of major depression as he struggled with his continued role in the family business. Traditional individual IPT could not resolve this struggle due to his memory impairment and executive dysfunction. Thus, we undertook to engage concerned family members in the therapeutic process to better understand the scenario and to seek opportunities to facilitate the most reasonable course of action.
Mr. Jones, a seventy-five-year-old married white businessman, presented for help accompanied by his wife, Sarah, who had encouraged him to get treatment. Mr. Jones described feeling depressed and kept saying that he did not know why, as he really had nothing to complain about. He was not sleeping well, had trouble rising in the morning, and felt listless and sometimes useless. He denied ever feeling suicidal but said he sometimes asked himself what the point of life was.
Mr. Jones was a self-made man who had built a successful steel fabrication business he started shortly after graduating from a local two-year college. Three of his four children were employed in the business. They had plenty of work despite the economic downturn and actually had trouble finding enough qualified help. He worked six days per week but managed to take time to play golf and spend time with his grandchildren, although these pastimes no longer seemed to give him as much pleasure. All of his contemporaries were retired and spent hours on the golf course followed by drinking, a lifestyle he never really liked or wanted. His business seemed to be running well; he knew he could take more time off if he wanted to, but he enjoyed his business and found that it was an engrained habit to get up daily and go to work, which was located quite close to his home.
Mr. Jones had never been depressed like this before and had never had any mental health treatment or severe physical health problems either. He was normal weight, took Lipitor for high cholesterol and Flomax for an enlarged prostate, but had never had any surgery or serious illness. He drank alcohol socially. Sarah asked to join one meeting during his evaluation and reported he was driving too aggressively after he had had a couple of drinks on the golf course. Mr. Jones had not noticed this but agreed to limit himself to one drink. Advised to abstain completely from alcohol during the acute treatment for his depression, he said he would try. His wife voiced no further complaints about his driving, and his subsequent alcohol intake seemed minimal.
Mr. Jones’ father was an Eastern European immigrant who came to work in the steel mills and died at age fifty. His mother died of breast cancer when he was still in high school. Mr. Jones was the youngest of four brothers, two of whom had died already of cancer; he visited the third on holidays. Mr. Jones had four children: two daughters and one son worked with him in the family business, and his other daughter was married and lived in a distant city. None of his biologic relatives suffered from mental illness, to his knowledge, except alcohol abuse in both of his deceased brothers.
In providing an interpersonal inventory, Mr. Jones described having a pleasant and cooperative relationship with his wife. His eldest child, Rita, worked in the office and helped to manage the business, his son Stephen supervised the installation crews for the steel, and his youngest daughter, Gloria, was the bookkeeper. Rita was married with two young children, Stephen had two children and was struggling with a contentious divorce, and Gloria was unmarried. Mr. Jones deemed himself a workaholic because he spent so much time at work building up his business. He enjoyed the work and had made friendships with a number of his regular customers. He played golf with a handful of contemporaries but could not name a close friend or confidant he met on a one-on-one basis. He had known a few of his friends since high school. Mr. and Mrs. Jones socialized with some of these men and their wives by going to restaurants. He and his wife rented a Florida condominium for two winter weeks when business was slow, and their children sometimes visited them there. He belonged to no organized religion and his only hobby, beyond his weekly golf game, was more of a wish: he had purchased a potter’s wheel to take up ceramics but had never gotten around to setting it up.
Mr. Jones met DSM-IV criteria for major depressive disorder with an initial Ham-D score of 28. He agreed to participate in a depression treatment study in which he would receive antidepressant medication and IPT.
In the initial sessions, although Mr. Jones said he could not put a finger on a reason for feeling depressed, he began describing considerable anxiety about his future. He could see that all his contemporaries had retired and were leading lives of leisure, mostly playing golf. Mr. Jones feared that lifestyle would not suit him. He liked his work and was proud that his company provided a livelihood for three of his children. At age seventy-five, he knew he would not be able to work forever, however, but he could not seem to define an endpoint. He felt like a boat adrift in the currents. His wife was encouraging him to cut back and to cultivate hobbies like the ceramics he had never started. He feared being bored. He said he was thinking a lot about retirement but could not reach any decision, and that it bothered him that he could not. Even though Mr. Jones had not retired, his IPT therapist was thinking about his presentation as a role transition as Mr. Jones was struggling with whether to retire or not, and asked him whether he thought that this issue was the most salient on his mind. Mr. Jones agreed that it was and agreed to explore it further.
This dialog illustrates the use of IPT in the middle phase to explore in depth Mr. Jones’ feelings about his future and his potential choices:
therapist: Last week we began talking about the role you see yourself playing in your business in the future. Have you given it more thought this week? mr. jones: Yes I have. I am still not sure what I should do. I just can’t imagine being idle all day without a purpose, especially when I know there is work that I could be doing [pauses reflectively], work I have actually enjoyed. therapist: Yes, I can see that you struggle with these questions of whether, how, and when to consider a pullback from the business of some kind. It seems that this struggle has been consuming a lot of your energy, to the point where it has resulted in your becoming depressed.
mr. jones: Yes, I think that is correct. I have not been able to come to terms with it, or to put it aside, either.
therapist: Would you like to take a closer look at this question today, then? mr. jones: Yes, that would be good.
therapist: Let me play the devil’s advocate for a moment and ask, Why don’t you just keep on working and forget about retirement? mr. jones: I thought about that, just keep working until I drop dead on the job or something. I wouldn’t mind it for myself, but my wife is pressuring me to cut back, like working is not good for my health or something. She asks me why I don’t retire like everyone else my age. I am seventy-five, you know.
therapist: Yes, I am aware of that, and it is true that most people have retired by the time they reach your age, but what are your feelings about it? mr. jones: When I try to imagine being retired, fully retired, I think I would wake up and wonder what is going on in the plant, what orders are being filled and how many are pending, etc. I guess it is in my blood by now or something. I get a big kick out of seeing custom product installed to the customer’s satisfaction . . . and I like to see checks headed to the bank too! Of course, business is not all fun, there are always headaches . . . those I won’t miss. therapist: So it seems clear that you get a great deal of satisfaction from watching your business work like it is supposed to . . . you make a quality product . . . the customer is happy, hopefully, they pay you for your service, you make a living as do your employees, including three of your children, and you feel proud of your accomplishment. Do I have that about right? mr. jones: Yes, that about sums it up. therapist: So why do you continue to struggle as you do? mr. jones: That’s just it! I can’t seem to make a decision one way or the other. therapist: You told me earlier your wife is pressuring you to retire. How does that affect you?
mr. jones: Yeah, she wants me to take up a hobby and cut back and act my age or something. I never was much for hobbies, but I did buy that potter’s wheel, which is still in the box. I’ll get around to it someday, but I just don’t seem to have the time.
therapist: What is your feeling about your wife’s stated preference for you to cut back your time working?
mr. jones: She is trying to be helpful, that’s all. We have always had a good relationship and she has never interfered with my business decisions. She says it is ultimately up to me but that she thinks I should slow down and enjoy my “golden years” before it’s too late. therapist: What do you say to her?
mr. jones: I tell her that I know she is right on some level, that it is perfectly legitimate for me to cut back and act like every other retired person. I know my good health won’t last forever either, so I know she is also right that I should probably capitalize on my good fortune of good health and a sustaining business and do something else. [pauses pensively] The problem for me is, when I look around at what else there is, and none of it excites me. therapist: Lots of retired couples take time to travel and do more things together. Do you feel your wife is advocating for that in what she is saying to you?
mr. jones: I don’t think so. She is pretty much of a homebody. We go to Florida every winter and all she can talk about is when the kids are coming to visit. I see her for lunch every day when I am working since I can walk home from the plant, so it is not like we don’t see a lot of each other. No, I don’t think her reasons for me to retire are selfish ones at all. She just does not want to see me work myself into the ground.
therapist: I see. [pause] Do you see this retirement dilemma as all or none? Have you considered a compromise plan, something in between? mr. jones: Do you mean like a phase-out plan or partial retirement? therapist: Yes, something like that. What are your feelings about it?
mr. jones: I have sort of been trying to do that, it is just that we are short-handed at work and I feel bad about leaving all the work to the staff. I feel guilty, I guess, if I am on the golf course and two miles away, they are scrambling to fill orders.
therapist: Do you need to hire more help to meet your workload so that you would not feel so guilty being around less?
mr. jones: Yes, we thought about that. It is hard to find skilled people these days and you have to watch the bottom line too. I have a lot of loyal employees because I have not had to lay off anyone when things slow up. therapist: I see, but you said yourself that you know you will not be able to keep working forever; at some point they will need to look for additional help, right? mr. jones: I suppose we could hire someone to be the extra hands that I am helping out, but it is really about me . . . whether I am ready for that or not. therapist: I can see you really are struggling with this.
mr. jones: Yes, I seem to think about it all the time. I can’t seem to just make a decision and go with it.
therapist: Well, to play the devil’s advocate again, not making a decision to change anything is a decision in its own right. Maybe you are voting for the status quo by not making any move in the retirement direction. Maybe you are saying that you wish to continue as is until something else forces a change upon you? mr. jones: Maybe I am, but I can’t seem to get the issue out of mind. therapist: Well, that’s why you’re here, right? We are trying explore what your true feelings are on the matter and to help you to chart a course for your future, including the option of keeping everything just as it is for the time being, right? mr. jones: Yes, I like the way you put that.
therapist: Do you feel that we are exploring the correct subject matter that has been weighing on you to the point that it has brought on depression, or might there be another issue that you find stressful as well? mr. jones: No, I think we are in the right place for exploration. Everything else in my life seems to be doing OK. Sometimes I forget what it was that I wanted to say to someone, but I guess that is to be expected for my age. therapist: Your memory testing that we did as part of the study actually did show some mild memory impairment that was a bit more than one would expect for someone at your age and with your education. You scored 25 out of a possible 30 points on that paper-and-pencil test called the Mini Mental Status Exam. mr. jones: Yes, I recall that they told me that. I don’t really think it is a big deal, though. It is that retirement thing that just bugs me every day. therapist: I see.
mr. jones: Something just occurred to me as we are talking. Now that we have talked about this subject from every angle, I never thought that doing nothing was an option. I guess no one is insisting that I do anything different really. They have made suggestions, my wife, my kids, and my golf buddies that is, but there is nothing stopping me from just saying no, I don’t want to retire yet, period, end of story. I can just announce that I intend to keep working until further notice and if they don’t like it, well tough, it’s my decision. therapist: It seems that you feel some relief in being able to say that you do not intend to cut back significantly on working at this time. mr. jones: You’re damn right! It’s my company, isn’t it?
therapist: It certainly is. You seem suddenly passionate about defending your right to keep working as long as you please.
mr. jones: Yes, I guess I do. If only I felt as confident out there about making such a decision.
therapist: Well, how about talking more about the ways in which you might express your opinion to these various individuals and how you would defend your position if they were to challenge you on it? mr. jones: That sounds good to me. Let’s see, I’ll start with my wife...
Exchanges like this continued over the ensuing weekly sessions. He received feedback from his wife, kids, and golf buddies that they understood his wish to keep working as long as he could or until he changed his mind at some point in the future. Mr. Jones had been struggling to weigh the relative merits of the arguments for and against retirement that others put to him without adequately exploring his own feelings. His IPT therapist felt her role was to help him to complete this subjective exploration and then help him to examine his own preference against the caveats raised by others. Mr. Jones seemed to be responding to this work in IPT: his Ham-D score dropped from 24 to 14, he reported sleeping soundly for the first time in months, and he actually enjoyed golfing after realizing that he had been avoiding going to avoid those who chided him for not retiring to play more often. After twelve weeks, Mr. Jones’ Ham-D had fallen to a score of 8 for two consecutive weeks and his major depression was declared remitted.
The IPT techniques used to relieve Mr. Jones’ depressive symptoms (in addition to his antidepressant medication) were (1) clarification of his social role within the company and in his larger social sphere; (2) decision analysis about whether, when, and how to begin implementing a retirement strategy; and (3) communication analysis to explore how he heard and responded to the queries of others in his interpersonal inventory about his plans for retirement. Helping Mr. Jones to first clarify his own preference for continuing to work was the necessary first step for him to explore how to present his decision to others and to defend it, if necessary, in the face of opposition from those he cared about.
As per the study protocol, Mr. Jones entered the follow-up phase, where he was assessed monthly for signs of worsening depression and annually for cognitive status for two years.
Mr. Jones remained well for over a year and one half in monthly follow-up visits as he continued working daily in a hands-on way in the company he had built. Unfortunately, his memory continued to deteriorate during this period, making his work more frustrating for him and a dilemma for those who worked with him: they noted his struggles and increasingly his mistakes, which usually involved forgetting important steps in a given project. Mr. Jones, aware of these errors, was frustrated with his performance and again began questioning whether he should retire as he felt he was no longer doing a good job. This resurgent retirement dilemma now seemed clearly related to his cognitive decline. Once again, he felt paralyzed by inability to decide upon the best course of action. His Ham-D score of depressive severity rose from consistent monthly scores below 10 to 22. Cognitive retesting confirmed a significant drop in his Folstein MMSE score from 25 to 18, and he now met DSM-IV-TR criteria (and on standardized cognitive tests) for dementia, a diagnosis confirmed by independent experts at the Pittsburgh Alzheimer’s Disease Research center. Mr. Jones was offered another course of IPT, only this time using IPT adapted for use with cognitive impairment and depression (IPT-ci).
Before returning to Mr. Jones’ clinical course, we will provide background and justification for IPT-ci.