The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Interpersonal psychotherapy (IPT) is a time-limited psychological intervention, originally developed for the treatment of depression. This attachment-based intervention focuses on addressing ‘here and now’ interpersonal relationships by working on one of four interpersonal focal areas (grief, role dispute, role transition and interpersonal sensitivities). IPT was based on the fundamental principle that there is a reciprocal relationship between life events and depression (or other mental health presentations) e.g. that while interpersonal life events affect depression, depression can also affect interpersonal relationships. The dual goals of IPT are to improve interpersonal functioning and to reduce mental health symptomatology. IPT has four key features that help achieve its treatment goals. These include:
- A “here and now” focus, specifically on interpersonal relationships and social support. IPT recognises the contribution of interpersonal difficulties to the onset and maintenance of psychological distress and mental health disorders. It therefore targets a current interpersonal issue related to the maintenance of a mental health difficulty by building on communication and interpersonal skills, and strengthening an individual’s social network so that they can mobilise social support in times of interpersonal distress. IPT is an affect-based therapy. It focuses on the identification and validation of affect, with the aim of improving communication of emotions to others.
- Based on biopsychosocial/cultural/ spiritual model formulation: IPT conceptualises an individual’s experience and presentation in the context of biological factors (e.g. genetics and physiology); social factors (e.g. social relationships and support); psychological factors (e.g. disposition and attachment style); cultural and spiritual factors. IPT acknowledges that mental health difficulties are determined by a range of different factors, however the experience of mental health difficulties themselves impair an individual’s motivation towards, participation in, and experience of interpersonal relationships. Therefore, the core premise of IPT is that by resolving interpersonal maintaining factors contributing to an individual’s distress, or enhancing supportive relationships that mental health difficulties will improve.
- Time limited: In the acute phase, IPT is typically delivered over 16 weekly sessions, with the potential of maintenance sessions post therapy to support ongoing symptom remission.
- Limited feedback on therapeutic relationship: IPT’s key focus is on relationships that are outside of the patient-therapist relationship. Transference, which ensues during therapy, provides the therapist with key information about an individual’s communication and expectations of relationships. The patient-therapist relationship is not the focus of IPT; however, this platform enables the therapist to hypothesise about interpersonal functioning outside of therapy, and can support tentative interpersonal feedback with the aim of seeking parallels in 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:
- Initial phase: Delivered over sessions 1-4 and includes assessing the presenting problems, providing psychoeducation about presenting symptoms, introducing the recovery role, creating a timeline and conducting an interpersonal inventory. The initial phase will culminate in the development of an interpersonal formulation in which the focal area is identified and agreed and further IPT sessions are contracted.
- Middle phase: Delivered over sessions 5-12 and aims to resolve the interpersonal problem aligned with one of four IPT focal areas.
- Final phase: Delivered over sessions 13-16 and aims to bring a good conclusion to the treatment
Fidelity
IPT for depression should be delivered by accredited IPT practitioners. UCL competencies for IPT by Lemma, Roth and Pilling (2008) highlight that practitioners delivering IPT should be able to draw on existing key knowledge of depression. IPT should be delivered as per validated manuals, and content and structure are adhered to ensure consistency in delivery of intervention. 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. The IPT adherence and quality scale (https://iptinstitute.com/ipt-training-materials/ipt-quality-adherence-scale/) is a validated scale used as a measure of adherence to treatment.
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 16 sessions, however, an 8-session brief format has been evaluated. 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.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Supports
Implementation Support
Implementation support for IPT for depression 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.
Start-up Costs
Costs for IPT training include costs for the 5-day standard IPT training course (approx. £1500), with additional costs (£2600) for supervision of clinicians who will work towards accredited IPT practitioner status. There are additional yearly IPT UK membership fees. Please see the IPT-UK site for details of costs (https://www.iptuk.net) as well as the International Society for IPT https://interpersonalpsychotherapy.org/ Some funded training places are available through NES (to IPT practitioner and supervisor status) for those clinicians working in CAMHS or adult mental health services nominated by their respective health boards.
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, BPS CAAP register), 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. The first two cases need to be in depression, however further casework could be in an evidence-based model for other mental health problems. Accreditation certificate is issued when the required criteria are met. Once individuals are an accredited practitioner, monthly supervision is required to maintain practice. This can be with practitioner peers in a group setting.
To be an IPT-UK accredited supervisor, practitioner need to complete NES training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/) and specialist IPT supervision training components: specifically, two further IPT cases under accredited supervision, an IPT-UK accredited supervision course and an assessment of supervision of at least one case.
Supervision Requirements
Accreditation is conducted under regular supervision with an IPT-UK accredited supervisor. Supervision is provided weekly, with at least 12 of the 16 sessions attended per case. Supervisees 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.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
The IPT model can be explained by the following theories:
- 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.
- 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
Some of the available evidence for IPT for depression management in CYP include meta-analytic studies. These are described below.
The first was a meta-analysis that evaluated the effectiveness of psychological interventions in youth depression (1). The meta-analysis included 55 studies, of which 5 studies involved IPT. Participants were aged 4-18 years with a depressive disorder diagnosis (DSM or ICD) or elevated symptoms.
The second was a network meta-analysis conducted to evaluate the comparative efficacy of psychotherapies for depression in CYP (2). The meta-analysis included 52 studies (n=3805) 9 psychotherapies, and 4 control conditions. Of the 52 studies, 8 of them evaluated IPT. Participants were children and adolescents (aged from 6 to 18 years), with diagnosis of major depression, minor depression, intermittent depression, or dysthymia.
A key limitation of these meta-analyses is that they have both incorporated a preventative model of IPT (IPT-AST) which explicitly excludes young people who meet diagnostic threshold for depression. To address this Duffy et al (3) conducted a systematic review and meta-analysis of IPT-A for adolescent depression. Twenty studies were identified (10 RCT’s and 10 open trials/case studies).
Finally in a network meta-analysis (4) of 331 RCT’s of psychotherapies for depression in individuals across the age range (34,385 participants). Thirty-five studies (10%) explored IPT. Depression was established via a diagnostic interview or by a score above a cut off on a validated self-report measure.
Young People - Rating: 5
Children and Young People Outcomes
Compared to control conditions, i.e. waitlist, no-treatment, treatment-as-usual, or psychological placebo, the following outcomes were observed;
- Significantly reduced depressive symptoms at post-treatment (1-3) short-term (1 to 6 months) (2,3) and long-term (6 to 12 months) follow-up (2,3).
- At post treatment, significantly reduced interpersonal difficulties with a medium effect and significant improvement in general functioning with a very large effect (3).
Adults - Rating: 5
Adult Evidence and Outcomes
There is evidence to support the delivery of IPT in depression. These include meta-analytic reviews. Some of these are described below.
The first study was a meta-analytic review conducted to evaluate the effectiveness of IPT in the management of mental health conditions (5). The review included 90 studies with 11,434 participants (of any age) presenting with different mental health conditions including depression, anxiety, and eating disorders. Of the 90 studies, 62 studies included people with depression.
The second study was a meta-analysis conducted to examine the effects of psychotherapies for adult depression (6). The meta-analysis included 23,908 participants in 256 randomized trials with 332 comparisons made between psychotherapy and inactive control groups. Of these comparisons, 24 delivered interpersonal psychotherapy. Participants were adults (aged 18 years and above) who met diagnostic criteria for depression.
The third study was a meta-analytic review conducted to evaluate the effectiveness of IPT in depression, including dysthymia (7). The review included IPT delivered as an acute treatment or as maintenance therapy after successful recovery from a depressive disorder. Thirty-eight RCTs consisting of 4,356 adult and adolescent participants were included in the review. Six of the 38 studies were conducted in adolescents. Participants had a diagnosis of unipolar depressive disorder or presented with elevated depressive symptoms.
Finally in a network meta-analysis (4) of 331 RCT’s of psychotherapies for depression in individuals across the age range (34,385 participants). Thirty-five studies (10%) explored IPT. Depression was established via a diagnostic interview or by a score above a cut off on a validated self-report measure.
Adult Outcomes for Depression
Compared to inactive control group (e.g. waitlist, usual care, or placebo), the following outcomes were observed;
- Significantly reduced depression symptoms at post-treatment (4-7) maintained at up to 12-months follow-up (4).
Need
Comparable Population
IPT has also been shown to be effective in the treatment of depression in children, young people and adults.
- Is this comparable to the population your service would like to serve?
Desired Outcome
IPT has been shown to effectively reduce depression and reduce interpersonal difficulties.
- Is delivering IPT for the treatment of mental health disorders including depression a priority for your organisation?
- Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Interpersonal psychotherapy (IPT) is a time-limited psychological intervention for the treatment of depression and other mental health presentations. 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 and interpersonal theory.
- Do the underpinning theories and the underlying mental health conditions addressed by the intervention align with the requirements of your organisation?
Priorities
IPT addresses interpersonal problem areas that are linked to distress and symptoms of depression. IPT has been delivered in individual and group formats.
- What population will your service be offering IPT to?
- In what format will this intervention be delivered?
Existing Initiatives
- Does your service currently deliver interventions to treat mental health disorders including depression?
- Are existing initiatives practicable and effective?
- Do existing initiatives fit current and anticipated requirements?
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
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 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 methods of recording sessions for accreditation purposes is helpful.
- 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 review?
Administrative Support
IPT is typically delivered over 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 IPT be delivered?
- Does your service have a venue to deliver IPT sessions?
- Can administrative supports needed to deliver this intervention be provided?
Financial Support
The 5-day standard IPT course costs £1500, with an additional £2600 for accredited supervision for practitioners working towards accredited practitioner status. 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?
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
