A Word about Caregivers
Mr. Jones’ wife and daughter were not IPT patients per se. The IPT-ci therapist did not solicit their overall life problems but rather engaged, educated, and worked with them where their misunderstanding of depression and cognitive impairment complicated their interpersonal relationships with Mr. Jones and his role in the family business. IPT-ci engages caregiver(s) not as patients but as significant others who desire help adjusting to new caregiving roles and to maximize their ability to cope with the identified patient’s current status. Should the caregiver need help with other issues, the IPT-ci therapist makes referrals, which might include individual psychotherapy for the caregivers themselves. This demarcation allows the IPT-ci therapist to focus on the identified patient’s needs and not try to act as therapist for caregivers. Establishing this position is important since, in rare instances where elder abuse might emerge, the IPT-ci therapist must be prepared to advocate for the identified patient even if it means reporting a caregiver to the AREA AGENCY ON AGING or other appropriate protective service. Caregivers may well benefit from IPT-ci as their understanding of the patient improves and they focus on the reality of the identified patient’s cognitive ability, but this is incidental to the goal of improving the identified patient’s supportive social environment.
The goal of IPT-ci interventions for an older depressed individual with cognitive impairment is to achieve and maintain an optimized, steady state of function commensurate with the patient’s current cognitive ability, maintaining readiness to reassess new problems, mood changes, and further cognitive decline over time. If an older individual is cognitively intact, IPT can be applied as it is for younger patients to resolve depressive symptoms. If cognitive impairment is the presenting complaint, whether or not comorbid with depression, the IPT-ci model can be useful to help caregivers and the identified patient maintain optimal function consistent with current cognitive ability and maintain regular follow-up visits at an interval appropriate to evaluate and facilitate coping strategies for the patient’s lifetime.
Presentation of IPT-ci at conferences and meetings has yielded feedback from geriatric clinicians that its concepts are useful. Other clinicians report having intuitively evolved a similar working strategy, and that IPT-ci clarified and integrated their experience. Perhaps the best use of IPT-ci is as a teaching format for the next generation of healthcare professionals planning to do psychotherapy with the exploding population of individuals developing cognitive impairment. No systematic research studies have yet evaluated IPT-ci. One recent Quality Improvement Pilot Project using social workers to implement IPT-ci at the Benedum Geriatric Center in Pittsburgh showed a statistically significant drop in mean PHQ-9 scores (therapist rated) in 10 cognitively impaired subjects from 17.6 at baseline to 10.2, 9.1 and 7.5 at 3, 6, and 12 months respectively (unpublished data).
Working in Late-Life Settings
The themes illustrated in Mr. Jones’ case are common in geriatric settings. We therefore recommend background familiarity with gerontology and geriatric psychology/ psychiatry as prerequisite to IPT-ci. Master’s-level social workers working in geriatric settings may be ideally suited to understand care options as well as to learn the IPT-ci skills of tactfully interviewing impaired patients in the company of family members, to understand common presentations of cognitive impairment, and to explain test results and observations to both caregivers and patients with limited insight. Working on a collaborative team that includes primary care physicians, neuropsychologists, and geriatric psychiatrists is ideal. More details for successfully implementing IPT-ci are available elsewhere (Miller, 2009).