Interpersonal Psychotherapy for Adolescents – Dr Roslyn Law

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  • 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.
  • Interpersonal Psychotherapy for Adolescents – Dr Roslyn Law

    1. 1. INTERPERSONAL PSYCHOTHERAPY FOR ADOLESCENTS (IPT-A) Dr Roslyn Law IPT-A Module Lead for UCL/KCL and University of Reading
    2. 2.        IPT-A CYP IAPT Structure and treatment objectives Collaborative Routine outcome monitoring Evidence based Case management and supervision Challenges of IAPT
    3. 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)
    4. 4. CYP in IAPT Evidence based Collaborative IAPT Case management and supervision Routine outcome monitoring
    5. 5. NICE Guidelines recommended Explicitly collaborative in session and between agencies IPTA Collaborative practice and supervision protocol Weekly symptom review and Interpersonal goals
    6. 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. 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. 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. 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. 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
    11. 11. Collaboration       Diagnosis and role in therapy Interpersonal review Formulation Goal setting With parents and carers With other professional
    12. 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. 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. 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?
    15. 15. Siste r, Louis e Friend, Michelle Mum B’friend, Tom Friend, Joanne Dad
    16. 16. IPT-A Focal areas: select one
    17. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

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