PHASE I: MODIFICATIONS

To address the special needs of hospitalized and mostly severely depressed patients, we slightly modified the original IPT concept. We transferred some IPT strategies (e.g., psychoeducation about depression) to a group format, added behavioral elements (e.g., structured homework), and systematically integrated different members of the treatment team into the treatment process. The most relevant modifications appear in Table 21.1 .

These modifications are described in an additional manual (Schramm, 2000). The modified strategies were tested in single case studies and revised if necessary. The additional group sessions are also manualized (Schramm & Klecha, 2010).

The program was evaluated in two different phases and studies. It augments algorithm-driven pharmacotherapy with twelve to fifteen individual sessions conducted two or three times a week by a medical or psychological psychotherapist, plus eight to twelve group sessions.

Initial Treatment Phase (Three to Six Individual and Two or Three Group Sessions)

IPT treatment starts as soon as the patient has adapted to the inpatient setting (usually after three to five days) and disabling symptoms (including suicidality) are

Table 21.1 IPT in the Inpatient Setting: Modifications and Features

Setting

• The severity of symptoms (e.g., lack of concentration) may require shorter sessions (twenty to thirty minutes) at the beginning of therapy.

• An extended initial phase (four to eight sessions), focusing on symptom management, acceptance of the diagnosis, and instilling hope is warranted.

• A higher frequency of sessions (two or three times per week for approximately five weeks) is usually applied.

• The therapy program is conducted by the entire ward team, all of whom should be familiar with the IPT concept. All other interventions should be compatible with it.

• The active involvement of significant others is mandatory (with the patient’s consent): to educate about the diagnosis, illness, and treatment strategies (including written material), to explain the treatment concept, to encourage the family to accept the patient’s sick role, to agree on general treatment goals, and to request familial support in solving interpersonal conflicts and problems.

• Opportunities to transfer learned strategies into everyday life are limited in the acute treatment phase and should be compensated by sending inpatients home for a night or weekends (so-called “stress tests”) as often as possible.

• Termination may be associated with stronger and more complex emotions than in outpatients, as inpatients separate not only from the therapist but also from other patients, the treatment team, and a protective, caretaking environment. In extreme cases (e.g., after an extended hospital stay) the discharge can be dealt with as a role transition in itself.

Content

• Most hospitalized patients report suicidal thoughts. A thorough evaluation of acute suicidality and previous suicidal attempts needs to be conducted in each session and suitable interventions (e.g., locking the ward) need to be taken.

• The therapist is even more active and supportive (e.g., offering direct help, setting short-term goals) than in outpatient IPT.

• The therapist is even more flexible (e.g., regarding the duration of sessions, the length of the initial phase, the frequency of contact with the patient’s significant others, networking with the treatment team and other treating healthcare professionals).

• The patient’s acute events and concerns (e.g., results of physical examinations, conflicts with other patients or treatment team members) may interrupt the work on the determined focus. These events can be addressed as crisis management and ideally integrated in the relevant problem area.

• Direct feedback about the patient’s interpersonal style from members of the treatment team can be crucial. The setting can be used as a field to practice.

sufficiently reduced that the patient can be interviewed and will not be overwhelmed by the requirements of the program. Like in standard IPT, the individual sessions of the initial phase focus on the interpersonal inventory, identification of the relevant problem area, and the treatment contract, whereas delivery of information about depression mainly occurs in a group format. A significant other should attend to

Table 21.2 Example of a Symptom Management Form Filled Out

by a Patient

Present symptom

(please name)

Which strategies did you try out?

(please describe)

Did it help?

  • 0 = not at all
  • 1 = a bit
  • 2 = it was good
  • 3 = it was very good

Insomnia

Work out in the evening

0

Go to bed late

1

No sleep during the day

2

Sleep ritual (reading)

will try out

Relaxation exercise

will try out

discuss the content and duration of the treatment program. The individual sessions also provide an opportunity to evaluate whether a patient is able to participate in a group program.

The initial phase may take longer in hospitalized patients because they are usually more symptomatically stressed than outpatients, presenting with suicidal symptoms, severe rumination, and compromised decision-making capacity and motivation. Nurses help the patient to systematically develop and practice strategies for symptom management (Table 21.2).

All other psychoeducational and symptom-coping elements of the initial phase are conducted in two or three group sessions—for instance, providing information about depression and treatment options and giving the sick role. Due to some limitations of acutely ill hospitalized patients such as agitation and poor concentration, group sessions should not exceed one hour in duration, and important messages and facts should be highlighted on a flipchart. An example of the topic “acceptance of the sick role” is:

We collected some examples of depressive symptoms and realized that depression affects not only your mood but your whole system. I want to discuss with you what it means to suffer from depression and be sick. Which daily duties and tasks are you still able to perform (even with depressive symptoms)? What are your limits? How can you find relief? What are the responsibilities associated with being a patient?

The initial phase concludes when the patient’s symptom level allows work on the focal interpersonal problem area.

 
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