Interpersonal Psychotherapy (IPT) for Common Mental Health Problems in the Perinatal Period

Core Components

Interpersonal psychotherapy (IPT) is a time-limited psychological intervention, originally developed for the treatment of depression, but subsequently adapted for the treatment of other mental health disorders (e.g. binge eating disorders, bulimia nervosa, and bipolar disorder). This attachment-based intervention is present centred and focuses on addressing ‘here and now’ interpersonal problems areas (e.g. grief or complicated bereavement, role dispute, role transition and interpersonal deficits) for the purpose of helping patients achieve enhanced interpersonal functioning, increased social support and symptom remission. IPT has four key features that help achieve its treatment goals. These include:

1. Focus on interpersonal relationships and social support: IPT recognises the contribution of interpersonal distress to the emergence and sustenance of psychological distress and mental health disorders. It therefore helps patients communicate better within relationships or alter their demands or expectances from relationships. It also helps patients to strengthen their social network so that they can mobilize social support in times of interpersonal distress.
2. Based on biopsychosocial/cultural/ spiritual model of psychological functioning: IPT conceptualises patient functioning in the context of five factors, i.e. biological factors (e.g. genetics and physiology); social factors (e.g. social relationships and support); psychological factors (e.g. disposition and attachment style); cultural factors; and spiritual factors. These five factors align with the theoretical foundation of IPT which recognises attachment and effective communication as being intrinsically linked to psychological functioning.
3. Short-term in its acute phase: In the acute phase, IPT is a brief intervention that is typically delivered over 12-16 sessions, depending of complexity of patient’s condition, followed by longer maintenance therapy, also dependent on complexity of patient’s condition. The short-term approach of IPT prevents transference from being the focus of therapy, as transference issues detract from IPT’s focus on patient’s relationships outside of therapy. The time-limited nature of the acute phase therefore affords therapists enough time to address interpersonal issues, social support, and patient’s formation of attachment relationships outside of therapy.
4. A non-transferential approach: IPT’s key focus is on relationships that are outside of the patient-therapist relationship. Transference, which ensues in the course of therapy, provides the therapist with key information about patient’s distorted perception in relationships or attachment style. This enables the therapist infer on patient’s interpersonal functioning outside of therapy, recognise potential problems that could be encountered in therapy, predict the possible outcomes of therapy, and work out a good conclusion for therapy. Discussion of the patient-therapist relationship is not the focus of IPT, as the focus lies on interpersonal relationships outside of therapy.

IPT sessions are typically delivered weekly, with each session lasting about 45-50 minutes. These sessions are delivered in three phases:

1. Initial phase: Delivered over sessions 1-4 and consists of; i) Evaluation phase- To diagnose the disorder and comorbidity, and to conduct comprehensive review of relationships; ii) Case formulation phase- To define target diagnosis and link diagnosis to current interpersonal problem (i.e. interpersonal inventory); iii) Agreement on a treatment plan
2. Middle phase: Delivered over sessions 5-12 and aims to resolve the interpersonal problem
3. Final phase: Delivered over sessions 13-16 and aims to bring a good conclusion to the treatment

In the perinatal context, IPT addresses interpersonal problem areas (e.g. low social support, changes to social circumstances, role transition, and partner/ spouse conflicts) that are linked to distress and symptoms of mental health disorders in the perinatal period. Delivery of IPT during this period aims to enhance coping skills, promote resolution of partner/ spouse conflicts, and expand social networks. These can translate to reduced symptomatology and improved interpersonal functioning.   

Fidelity

NICE recommends that interventions in the perinatal period should be delivered by competent practitioner(s) with ongoing supervision. The intervention(s) should be delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure consistency in delivery of intervention. The use of competence frameworks developed from the treatment manual should also be considered. Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions.

IPT adherence and quality scale is a validated scale used by IPT supervisors and therapists for clinical supervision, as a guide to conducting IPT, and as a measure of adherence to treatment. Higher scores on the scale correlate with better psychological outcomes.

Modifiable Components

IPT is available as Family Based Interpersonal Psychotherapy (FB-IPT) for depressed preadolescents, and Interpersonal psychotherapy for depressed adolescents (IPT-A).  IPT is an individualised intervention, but has been evaluated as a group and couples intervention. In addition to face-to-face delivery (in clinic, medical and community settings), IPT has been delivered via telephone. It is typically delivered over 12-16 sessions, however, an 8-session brief format has been evaluated. This brief format has been delivered to socio-economically disadvantaged and racially diverse women. IPT has also been modified into Interpersonal Counselling (IPC), a scripted intervention for subsyndromal depression and anxiety symptoms, delivered by non-mental health nurses. IPT resources are available in English and have been translated into several languages including German, Italian, Spanish, Japanese, Korean, Mandarin, Dutch, French, Turkish and Portuguese.

Support for Organisation / Practice

Implementation Support

Implementation support is provided by Interpersonal Psychotherapy UK (IPT UK), the UK based accredited body for therapists practicing Interpersonal Psychotherapy. They provide access to IPT training and supervision, IPT resources, accreditation documents, and CPD events.

Licence Requirements

Licence requirements not confirmed.

Start-up Costs

The 5-day standard IPT course costs £1325, with an additional £2600 for accredited supervision for practitioners working towards accredited practitioner status. IPT supervisor training for accredited practitioners working towards IPT UK accredited supervisor status costs £2245. Practitioners pay yearly IPT UK membership fees charged at £40, £75, £100 and £25 for trainees, basic members, member plus, and non-practising members respectively.

Building Staff Competency

Qualifications Required

IPT is delivered by mental health practitioners including clinical psychologists, occupational therapists, psychiatrists, nurses, CBT therapists, counsellors and psychotherapists. Practitioners should hold current registration with a relevant professional body (e.g. HCPC, BACP, IACP, BABCP, GMC registered psychiatrist), and have considerable post qualification experience in delivering supervised psychological therapy.

Training Requirements

In the first instance, practitioners attend a 5-day standard IPT course which covers IPT theory, application, and clinical practice. Practitioners working towards accredited practitioner status will require accredited supervision. Under supervision, practitioners complete four cases, with recorded case sessions reviewed for IPT competencies. Accreditation certificate is issued when the required criteria are met. Additional training and supervision requirements apply for supervisor/ trainer certification.

Supervision Requirements

Supervision is provided weekly, with at least 12 of the 16 sessions attended per case.  Practitioners are required to receive a minimum of four hours of supervision per case. Supervision is provided face to face or remotely, in individual or group formats.

Theory of Change

The IPT model can be explained by the following theories:

1. Attachment theory: This theory describes the ways in which relationships are developed, sustained and terminated, as well as how problems can develop within relationships. When attachment needs are met, people function optimally. However, when these attachment needs go unmet, people can become vulnerable to psychological distress and can develop symptoms of mental health disorders. IPT therefore aims to strengthen attachment and social bonds that are critical to interpersonal functioning.
2. Interpersonal theory: This theory proposes that humans have an intrinsic drive to form interpersonal relationships. When interpersonal relationships are disrupted, psychological distress and symptoms of mental health disorder can be experienced. By resolving current interpersonal problems, IPT can help patients’ improve interpersonal relationships and extend social networks, translating to enhanced interpersonal functioning, increased social support and symptom reduction.

IPT can also be explained by communication theory, social theory, as well as research on stress and illness, as these capture IPT’s targeted focus on the ‘here and now’ interpersonal problem areas.

Research Design & Number of Studies

The best available evidence for IPT includes four systematic literature reviews and meta-analyses that evaluated the effectiveness of IPT in pregnant women (van Ravesteyn et al, 2017), in women in the postnatal period (Stephens et al, 2016; Claridge et al, 2014), and in women across the perinatal period (Sockol et al, 2018). 

Outcomes Achieved

Compared to the control group who did not receive IPT, the following outcomes were reported:

• Significantly reduced depressive symptomatology in pregnant women (van Ravesteyn et al, 2017), in women in the postnatal period (Stephens et al, 2016), and in women across the perinatal period (Sockol, 2018; Claridge, 2014) at post intervention. Long-term follow-up assessments in individual studies reported significant effects on depressive symptoms at 3 months (Mulcahy et al, 2010) and for up to 6 months post-partum (Grote et al, 2009)
• Significantly greater improvements in relationship quality (Sockol, 2018)

Values

Interpersonal psychotherapy (IPT) is a time-limited psychological intervention for the treatment of depression and other mental health disorders (binge eating disorders, bulimia nervosa, and bipolar disorder). IPT is present centred and focuses on addressing ‘here and now’ interpersonal problems areas for the purpose of helping patients achieve enhanced interpersonal functioning, increased social support and symptom remission. IPT can be explained by attachment theory, interpersonal theory, communication theory, social theory, as well as research on stress and illness.

• Do the underpinning theory and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?

Priorities

In the perinatal context, IPT addresses interpersonal problem areas that are linked to distress and symptoms of mental health disorders in the perinatal period. Research evaluating the effectiveness of IPT in perinatal mental health have included pregnant women and in women in the postnatal period. IPT has been delivered in individual and group formats; in-person and via telephone; as well as in standard 12-16 session format and brief 8-session format.

• Will your service deliver this intervention to women across the perinatal period, or will the focus be on specific points in the perinatal period (e.g. antenatal vs postnatal)?
• In what format will this intervention be delivered?

Existing Initiatives

• Does your service currently deliver interventions to treat non-psychotic perinatal mental health disorders?
• What perinatal mental health conditions does your service provide treatment for?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

IPT is delivered by mental health practitioners including clinical psychologists, occupational therapists, psychiatrists, nurses, CBT therapists, counsellors and psychotherapists, who hold current registration with a relevant professional body. To support the IPT delivery, practitioners attend a 5-day standard IPT course. Accredited supervision is required for practitioners working towards accredited practitioner status. Additional requirements apply for supervisor/ trainer certification. IPT is typically delivered to patients over 12-16 sessions.

• Does your service have qualified practitioners who are available and interested in learning and delivering IPT?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

IPT can be delivered without access to technology but access to telephones for remote delivery can be useful as is access to methods of recording sessions for review.

• Will IPT be delivered in-person or remotely?
• Does your service have the technology to support IPT remote delivery?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

IPT is typically delivered over 12-16 weekly sessions, each session lasting about 45-50 minutes. Face-to-face therapy sessions can be held in clinic, medical, and community settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will CBT be delivered?
• Does your service have a venue to deliver CBT sessions?
• Can administrative supports needed to deliver this intervention be provided?

Financial Support

The 5-day standard IPT course costs £1325, with an additional £2600 for accredited supervision for practitioners working towards accredited practitioner status. IPT supervisor training for accredited practitioners working towards IPT UK accredited supervisor status costs £2245. Yearly IPT UK membership fees range from £25-£100.

• How many practitioners will your service train?
• What accredited status would practitioners in your service attain?
• Can your service financially support associated training and supervision costs?

Comparable Population

IPT has been shown to be effective in the treatment of depression in women in the perinatal period, i.e. in pregnancy and within one-year of the postnatal period.

• Is this comparable to the population your service would like to serve?

Desired Outcome

IPT has been shown to effectively reduce depressive symptomatology in pregnant women and in women in the postnatal period.

• Is delivering IPT for the treatment of perinatal depression a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?