2.
IPT-A CYP IAPT
Structure and treatment objectives
Collaborative
Routine outcome monitoring
Evidence based
Case management and supervision
Challenges of IAPT
3. IPT-A in CYP IAPT
A comprehensive CAMHS needs a range of
modalities and interventions
Year
one: CBT and Parent Training (3-10 years
olds)
Year two: IPT-A and Systemic Family Therapy
(CYP)
6. IPT-A: What does it do?
IPT-A focuses on the relationship difficulties that are
often very important to young people and that are
frequently identified as key features of their
depression stories.
Separation and individuation from parents
Increased focus on peer and romantic relationships
Initial experiences of bereavement
IPT-A is primarily interested in the current conflicts,
role changes, losses and difficulties in establishing
and
maintaining independent and
satisfying
relationships that so often trigger and maintain
episodes of depression for young people.
7. Basic Structure of IPT-A
Weekly for 12-16 weeks
Goals: reduce depressive symptoms and resolve related
interpersonal problems
Focal areas cover many common concerns and difficulties
for adolescents: grief reactions, parent-child disputes, peer
conflict, difficulty making transitions between life stages,
coping with changes in family structure and communication
problems.
Clarify early warning signs for future depression,
consolidate understanding and use of successful strategies,
generalize to future situations, plan for any future treatment
requirements.
8. IPT-A: Treatment Objectives
IPT-A aims to reduce interpersonal difficulties
and improve depressive symptoms through
psychoeducation
about
depression,
understanding
depression’s
interpersonal
context and developing communication and
problems solving skills in family and peer
relationships.
IPT-A also aims to boost self esteem and
confidence by helping young people to
negotiate and develop reciprocal and
supportive relationships that will protect
against depression in the future.
9. Social and communication skills
Address the immediate interpersonal crisis
Mourn loss
Resolve conflict
Adapt to new circumstance
Develop more satisfying relationships
Improve communication and problem solving
Select optimal time to talk and be specific
Communicate feelings and opinions directly
See problems from another’s perspective
Clarify objectives in communication and seek mutually
acceptable solutions
10. Modifications for adolescents
Specific focus on changes to family structure
Parent involvement in the treatment protocol during
each phase of treatment
Treatment objectives take into account developmental
tasks, such as individuation, developing intimate or
sexual relationships, initial experiences of death
Concrete and educative techniques are used to
monitor mood and for skills development (perspective
taking, negotiation, problem solving etc.)
Strategies include family members and address
specific issues, such as school refusal, physical or
sexual abuse, suicidality, aggression
12. Inviting participation and collaboration: Symptom
Signature
Low
mood
Wake early
Tired
Worst symptoms
Irritable Feel guilt
Tearful
Moderate symptoms
No
Don’t want to
interest see people
Want to
die
Not a problem
Not
eating
Can’t
concentrate
Bored
Colour coded grid is used to
identify the young person’s
symptom signature and to track
changes over treatment.
13. Personal timeline of episode of depression in interpersonal
context
• Interpersonal
trigger/response
to symptoms
starting
Symptoms
Symptoms
• What happened
next.....?
• And then?
• And then?
Symptoms
Symptoms
•What is still
troubling you
now?
14. Distant friends
e.g. time,
geography
Link to focus?
Common interests
e.g. Sport, music
Link to focus?
Professionals
Teachers, social
services etc.
Link to focus?
Opportunities
Link to focus?
Young
Perso
n
School
Lunch, after
school, when
absent
Link to focus?
Family
Current,
immediate,
extended, history
Link to focus?
Friends
Current patterns,
history, loss or
change
Link to focus?
Neighbours
Link to focus?
17. Formulation: restating the
problem to allow a solution
Quality, nature
and course of
depression
Focal area and
associated
strategies
Current
interpersonal
difficulties
Protective and
vulnerability
factors
Current
interpersonal
resources
18. Involving parents and
professionals
During assessment phase
During middle phase, when required
During ending phase
Liaison with school and other professionals
during treatment
Psychoeducation
Promoting
appropriate and consistent
expectations
19. Routine outcome monitoring
Fits well with weekly IPT-A symptom review and
interpersonal goals related to agreed focal area
Important to monitor BOTH symptoms and
interpersonal difficulties
Reviewed in detail at mid point and in ending
phase of therapy in IPT-A
IPT-A interventions are not equated with
completing an outcome measure
The outcome measure is the start of the
conversation, not the end of it.
Practitioners often have to learn the skill of using
outcome measures therapeutically
20. What is an empirically based
treatment?
The treatment must be manual based
Sample characteristics must be detailed
Depressed adolescents 12-18 years
Treatments must be tested in a randomized
clinical trial
IPT-A for depressed adolescents 2nd ed. (Mufson et
al, 2004)
6 published RCTs on IPT with depressed
adolescents
At least two different investigatory teams must
demonstrate intervention effects
Independent teams have evaluated IPT-A with
adolescents and it has been delivered in
community settings by community clinicians
21. NICE Guidelines, 2005
Steps 4 and 5: Moderate to severe
depression
Children
and young people with
moderate to severe depression should
be offered, as a first-line treatment, a
specific psychological therapy (individual
cognitive behavioural therapy [CBT],
interpersonal therapy or shorter-term
family therapy; it is suggested that this
should be of at least 3 months’ duration).
22. Evidence base for IPT-A for depression in
CYP
Author
Comparison
Outcome/efficacy
Mufson et al (1999)
n=48
Waiting list
IPT more
efficacious
Individual CBT, waiting list
IPT, CBT > WL
IPT>WL on SE and
social adaptation
Mufson et al (2004)
N=63
Usual care
IPT more
efficacious
Young et al (2006)
n=63
Counselling
IPT more
efficacious
Young et al (2006)
n=63
Usual care (school clinic)
IPT more
efficacious
Rossello et al 2008
n = 112
IPT-G, CBT-G, IPT-I, CBT -I
Both robust
treatments
Rosello et al (1999)
n=132
23. Mufson, L. et al (1999) The efficacy of interpersonal psychotherapy for
depressed adolescents. Archives of General Psychiatry, 56, 573-79.
57 referred adolescents with MDD identified with a
clinician-rated scale, self report scale and 2 clinical
interviews.
48 agreed to randomization and 32
completed.
Majority were Hispanic from single parent families
IPT-A or clinical monitoring,
IPT-A: 12 weekly sessions with additional parent
sessions during initial and ending phase and when
needed in the middle phase.
24. Results
Completed: 88% IPT-A v 46% clinical
monitoring
Recovered: 75% IPT-A v 46% clinical
monitoring (HRSD)
Significantly greater improvement for IPT-A
subjects in overall social functioning, improved
peer and dating relationships, and social
problem – solving skills (completer and ITT)
25. Mufson, L. et al (2004) A Randomized Effectiveness Trial of
Interpersonal Psychotherapy for Depressed Adolescents.
Archives of General Psychiatry, 61/6(577-584)
N= 63, 12-18 years, 74% Hispanic
IPT delivered by local mental health clinicians in school
Adolescents treated with IPT-A compared with TAU showed greater symptom
reduction and improvement in overall functioning.
Analysis of covariance showed that compared with the TAU group, the IPT-A
group showed
significantly fewer clinician-reported depression
Hamilton Depression Rating Scale (P=.04),
symptoms
on
the
significantly better functioning on the Children's Global Assessment Scale
(P=.04),
significantly better overall social functioning on the Social Adjustment
Scale-Self-Report (P=.01),
significantly greater clinical improvement (P=.03),
significantly greater decrease in clinical severity (P=.03) on the Clinical
Global Impressions scale.
26. Young, J et al (2006) Impact of Comorbid Anxiety in an Effectiveness Study of
Interpersonal Psychotherapy for Depressed Adolescents. Journal of the
American Academy of Child & Adolescent Psychiatry 45/8(904-912)
N=63, IPT or TAU, delivered by school MH clinicians
Comorbid anxiety was associated with higher depression
scores at baseline (p < .01) and poorer depression outcome
post-treatment (p < .05).
IPT-A was non-significantly more effective in treating the
depression of adolescents with comorbid anxiety (p = .07).
Adolescents whose depression and functioning improved
during the course of treatment also showed an improvement
in anxiety (p < .01), largely irrespective of treatment condition.
Adolescents with comorbid depression and anxiety present
with more severe depression and may be more difficult to
treat. Structured treatments like IPT-A may be particularly
helpful for comorbidly depressed adolescents as compared to
supportive therapy.
27. Rosello & Bernal (1999) The efficacy of Cognitive-Behavioural and
interpersonal treatment for depression in Puerto Rican adolescent.
Journal of Consulting and Clinical Psychology, 67 (5) 734-45.
N =71: CBT, IPT, WL
Pre, post, 3 mo follow up on depressive
symptoms, self esteem, social adjustment, family
emotional involvement and criticism, behavioural
problems.
IPT, CBT > WL reducing depressive symptoms
IPT (82%) CBT (59%) below cut off on Children’s
Depression Inventory (ns)
IPT> WL increasing self esteem and social
adaptation
82% IPT-A and 59% CBT functional following
treatment
28. Rossello et al (2008) Individual and Group CBT and IPT for Puerto
Rican Adolescents With Depressive Symptoms. Cultural Diversity and
Ethnic Minority Psychology, Vol. 14, No. 3, 234–245
N= 112 Puerto Rican adolescents (12-18
years)
CBT or group CBT or IPT or group IPT.
Both treatments produced substantial
reduction in depressive symptoms
62%
CBT
57% IPT
CBT > IPT reduction in depressive symptoms
and improvements in self-concept
Treatment format did not have a significant
effect on outcome.
29. Tang, TC et al (2009) Randomized study of school-based intensive
interpersonal psychotherapy for depressed adolescents with suicidal risk and
parasuicide behaviors.
Psychiatry and Clinical Neurosciences, 63/4(463-470)
N= 73 Taiwanese adolescents, intensive IPT v
TAU
2x face to face (50 mins) and one telephone call
(30 min) per week for 6 weeks.
Adolescents and their families were educated on
reduction of suicidal risk by resolving
interpersonal problems
IPT-A-IN group had significantly lower postintervention severity of depression, suicidal
ideation, anxiety and hopelessness than the TAU
group.
30. Young, J. et al (2006) Efficacy of Interpersonal PsychotherapyAdolescent Skills Training: an indicated preventive intervention for
depression. Journal of Child Psychology & Psychiatry, 47 (12), pp
1254-1262
n=41 adolescents with 2 or more subthreshold
depressive symptoms.
M age = 13.4 (SD=1.2), 85.4% female
66% single parent family, 92.7% Hispanic
IPT-AST (group) vs school counselling (individual)
IPT-AST: 2 individual sessions, eight 90-min group
sessions
In the six months following treatment 3.7% of IPTAST group met criteria for depression and 28.6%
of the SC group
31. Miler L. et al (2008) Interpersonal Psychotherapy with pregnant
adolescents: two pilot studies. Journal of Child Psychology &
Psychiatry 49: 7, pp733-742
Group IPT –A for management and treatment
of depressive symptoms in pregnant
adolescents
Pilot 1: n= 14 Pilot 2: n= 11
Results Depressive symptoms reduced by
50% in pilot 1 (baseline subthreshold) and
40% in pilot 2 (diagnosed depression).
8/11 in pilot 2 no longer met diagnostic criteria
for depression
Gains maintained 20 weeks post partum
32. Case management and
supervision
Supervision is a condition of practice
Access to supervision is a condition of
attending training
+ve: more than doubled the number of IPTUK
registered IPT practitioners during 3 years of
IAPT
Limited supervision capacity, especially in
CAMHS
33. Case management and
supervision
For accreditation
Four
cases completed under supervision
Must cover at least two focal areas
All sessions are recorded and three complete
sessions are reviewed per case
Self assessment throughout supervision
15 mins supervision per case per week
Minimum of monthly IPT peer supervision
following accreditation
Distance supervision (telephone, Skype) is the
norm
34. Challenges of IAPT
A practitioner does not make a service
Where
possible two trainees are recruited from
each partnership
Service targets v evidence based practice
Ensuring protected time to learn and contribute
to service transformation
Baseline numbers of IPT practitioners and
supervisors in CAMHS are very small
Working across adult and CYP services
35. Training opportunities
Initial focus on IPT supervisors
Supervisor
training for existing IPT-A practitioners
(2013)
IAPT/CYP top up training for existing IPT
supervisors (2013)
Supervisor training for CYP IPT practitioners from
2015
CYP IAPT IPT-A practitioner training available
in 2014
36. IPT-A: Increasing Equitable Access
Despite being an evidence based therapy, IPTA remains difficult to access for young people
with depression as the number of IPT
practitioner and supervisors remains small.
The CYP IAPT programme will more than
triple the number of IPT-A supervisors in the
the first year and will generate an equivalent
increase in the number of therapists accessing
practitioner training and accreditation level
supervision.
37. IPT-A: In summary
IPT-A is a time limited, evidence based treatment for
depression in adolescents.
It targets key interpersonal issues that trouble many young
people who seek treatment and collaboratively formulates a
treatment plan to focus on their primary relationship
difficulties
It monitors symptom reduction and progress towards
interpersonal goals on a weekly basis and has been shown to
achieve outcomes that are equivalent or superior to existing
treatment approaches to depression in young people.
Training in 2013-2014 will triple capacity to provide IPT-A for
adolescents with depression and supervision for therapists in
training.
Notas del editor
Issues of following on from established mode of practice.
Implementing NICE guidelines but also creates an opportunity to generate evidence through routine outcome monitoring.Within my own service we aim to move from a choice agenda to a locally generated evidence agenda. NICE is not enough for many but we may be more persuaded by what happens to the people who come through our clinic doors. This relies on use of the different modalities to establish their utility within our service settings.ROM – disorder specific, therapeutic alliance, experience of service, different perspectives – service users, parents and carers, professionals in the team. To monitor outcome for the individual but also to be able to evaluate across services. Taking research out of the ivory tower and onto the front line. Supervision as a condition of training and practiceCollaboration in service development, care pathways, patient choice, evaluating the work, redirecting when necessary, across professional groups
The Interpersonal Inventory collects a range of information about a broad selection of relationships to identify the primary resources and difficulties that might serve the focus of treatment
HAM-D, BDI, Schedule for affective disorders, Schizophrenia for School Aged Children (K-SADS)Clinical monitoring: assigned a therapist, had one session per month and could call if another session was required. Bimonthly meetings with the independent evaluator. Telephone contact with therapist during the 1 week of the month without face to face contact.Assessments at weeks 0,2,4,6,8,10,12Outcome monitoring: diagnosis and symptoms HRSD, BDI, Clinical Global Impression Form (CGI), global and social functioning (Children’s Global assessment scale ans social Adjustment scale –SR, Parental Bonding Instrument, life events and social problem-solving inventory –R.All analyses with completers and ITT.
Significant attrition and they did not conduct ITT analysis, limiting confidence in the genralizability of the findingsThis study did not use the modifications outlined by Mufson.
None modified version of IPT
TAU delivered by teachers with basic counselling and psychoeducation skills.Medication was permitted in both armsOutcome analysis used the pre-intervention scores as covariates BDI M 32 to 20 for IPT and 32 to 31 for TAUDifferent treatment stucture to Mufson’s studies
End: IPT: 0 SC: 0; 3mo: IPT 1 SC 2: 6mo IPT 0 SC 3Outcome did not vary with initial severity
ADDITIONAL NOTE:THERE IS ALSO WORK WITH MOTHER’S OF CHILDREN WITH PSYCHIATRIC PROBLEMS WITH GOOD RESULTS.
