Interpersonal Psychotherapy for Inpatients with Depression
Why did we develop an inpatient treatment program based on the IPT model? In Germany and in many other countries, a high percentage of patients with affective disorders are fully or partially hospitalized for intensive treatment of their illness (Schulz et al., 2006). More than ninety psychiatric and psychotherapeutic clinics in Germany have established specialized depression wards with an average inpatient treatment duration of forty-six days (Wolfersdorf & Muller, 2007). This is far longer—and perhaps more reasonable—than the current U.S. mean inpatient stay of a week or less (e.g., Case et al., 2007).
Recent studies (Wolfersdorf, 1997; Wolfersdorf & Muller, 2007) reveal the need to optimize the cost-effectiveness of traditional treatment strategies for this patient population. This includes reducing the length of stay while at the same time improving short- and long-term outcomes. Because of the high cost of inpatient care, the development and evaluation of effective therapy programs have particular relevance. Psychodynamic and cognitive-behavioral approaches dominated inpatient treatment models for depression in Germany before the introduction of IPT in the mid- 1990s. The numerous obvious benefits of the IPT model in a hospital setting (e.g., the simple, plausible rationale and ease of adoption by all members of a treatment team) have led to the widespread dissemination of this method in German (Wolfersdorf & Muller, 2007) and other European inpatient settings.
Originally designed for outpatients, the IPT model has several characteristics that suit it for inpatient use. In addition, IPT has some advantages for hospitalized patients relative to cognitive-behavioral therapy (CBT) or psychodynamic approaches:
- 1. IPT has proven effective even for more severely depressed patients
- (de Mello et al., 2005; Elkin, 1994). Two thirds of hospitalized depressed patients suffer from severe to extremely severe forms of depression (Wolfersdorf & Muller, 2007).
- 2. IPT is designed for a brief duration, which is mandatory for inpatient treatment.
- 3. Based on a medical model, IPT complements the usual procedures of experienced psychiatrists and works well in combination with antidepressant medication. The rationale is simple and plausible and can be easily explained by the therapist to the patient and the patient’s family with the following words:
Interpersonal psychotherapy assumes that depression is an illness that is based on several factors such as genetic vulnerability, biochemical changes, developmental factors, etc. Independent of the causes, depression always occurs in an interpersonal context, which means the individual’s relationships and social roles are affected by the disorder. Conversely, those relationships and role fulfillments have an impact on the onset and course of depression. There are several approaches to treating depression, such as antidepressant medication and different forms of psychotherapy.
We will use a combination of IPT and medication to treat your depression because this approach has proven to be effective in more severe forms of depression. Inpatient treatment also involves other interventions, which I will explain to you when we go through your individual treatment plan.
- 4. IPT is structured and described in a manual (Schramm, 2000,2010; Weissman et al., 2007), which helps to train residents, younger clinicians in training, and nurses relatively quickly.
- 5. The manual can be used flexibly and adapted to the needs of an individual patient, for example a patient who can only be briefly hospitalized. This also enables the therapist to use his or her personal therapeutic style.
- 6. The IPT principles can be used in the daily clinical hospital routine by all members of a treatment team: nurses, social workers, etc. For example, all can collaborate in giving the patient the sick role.
- 7. Relative to comparable psychological treatments such as CBT, IPT is less challenging in requiring information processing by severely disturbed patients, older patients, or less educated patients. The connection of mood to life events is straightforward.
- 8. Several modified forms of IPT exist for subtypes of mood disorders commonly seen in the inpatient setting: for instance, IPT-Late Life for geriatric patients (Hinrichsen & Clougherty, 2006; Miller, 2009), IPT for bipolar patients (Frank, 2005), and IPT for dysthymic patients (Markowitz, 1998).
Figure 21.1 IPT treatment program
DEVELOPMENT OF THE CONCEPT
Besides numerous and severe symptoms, hospitalized patients often report suicide risk, comorbid disorders, and a history of treatment resistance. Thus, an intensive treatment program including multidimensional psycho- and pharmacological as well as traditional inpatient treatment strategies (occupational therapy, physiotherapy, etc.) is indicated (Schramm et al., 2007; see Fig. 21.1).
The program we have pioneered has been in operation since 1995 and has developed in several phases.