Transcript Low Intensity Comparators for Interpersonal Psychotherapy

Ellen Frank, Ph.D.
Jessica Levenson, M.S.
Yu Cheng, Ph.D.
University of Pittsburgh School of Medicine
Pittsburgh, PA USA
Disclosures
Ellen Frank, Ph.D.
• Advisory Board – Servier International
• Royalties – Guilford Press; American
Psychological Association
Advantages and Disadvantages of
Pharmacotherapy Comparators
• Answers an important question:
• “How does IPT compare to the most commonly
used treatment for depression?”
• Ecological validity? – tension between ‘real
world’ and ‘equating’ treatments for time
and attention
• Represents a choice with which clinicians are
often faced
• Rarely provides pharmacotherapy as it is likely
to be done in actual practice settings
Issues to Consider - I
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•
•
•
What drug(s)?
At what dose(s)?
Who provides the pharmacotherapy?
How often are pharmacotherapy visits
scheduled?
• How long do pharmacotherapy visits last?
Issues to Consider - II
• Do pharmacotherapists follow a manual?
• Are pharmacotherapy sessions monitored
via audio or video tape?
• Are other interventions allowed?
• Are patient preferences assessed?
Representative Depression
Studies with Pharmacotherapy
Comparators
• Klerman et al, 1974 (maintenance of acute
response)
• Weissman et al, 1979 (acute depression)
• Elkin et al, 1988 (acute depression)
• Frank et al, 1990 (maintenance of remission)
• Markowitz et al, 2005 (dysthymia)
• Blom et al, 2007 (acute depression)
• Frank et al, 2011 (acute depression)
Klerman et al , 1974 - I
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•
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•
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Drug – amitriptyline
Dose – 100-200mg
Pharmacotherapists – psychiatrists?
Frequency of visits – 1/month
Length of visits- 15 minutes (including
completion of rating scales)
Klerman et al, 1974 - II
• Pharmacotherapy manual – apparently not
• Pharmacotherapy sessions monitored via
audio or video tape – unclear
• Other interventions allowed – not
discussed
• Patient preferences assessed – not
discussed
Weissman et al , 1979 - I
•
•
•
•
•
Drug – amitriptyline
Dose – 100-200mg
Pharmacotherapists – psychiatrists?
Frequency of visits – not described
Length of visits – not described
Weissman et al, 1979 - II
• Pharmacotherapy manual – apparently not
• Pharmacotherapy sessions monitored via
audio or video tape – unclear
• Other interventions allowed – not
discussed
• Patient preferences assessed – not
discussed
Elkin et al , 1988 - I
•
•
•
•
•
Drug – imipramine
Dose – flexible; mean=185mg
Pharmacotherapists – psychiatrists
Frequency of visits – 1/week
Length of visits- 1st visit, 45-60min;
subsequent visits, 20-30min
Elkin et al, 1974 - II
• Pharmacotherapy manual – yes (Fawcett,
et al)
• Pharmacotherapy sessions monitored via
audio or video tape – yes
• Other interventions allowed – no
• Patient preferences assessed – not
discussed
Frank et al , 1990 - I
• Drug – imipramine
• Dose – flexible; mean = 216mg
• Pharmacotherapists – non-MD mental
health clinicians
• Frequency of visits – 1/month
• Length of visits- ~20 minutes
Frank et al, 1990 - II
• Pharmacotherapy manual – yes (adapted
from Fawcett, et al.)
• Pharmacotherapy sessions monitored via
audio or video tape – yes
• Other interventions allowed – no
• Patient preferences assessed – not
discussed
Markowitz et al , 2005 - I
•
•
•
•
Drug – sertraline
Dose – 112mg
Pharmacotherapists – psychiatrists?
Frequency of visits – weekly, then
biweekly (total of 10)
• Length of visits - initial visit 45-60min;
subsequent visits 20-30min
Markowitz et al, 2005 - II
• Pharmacotherapy manual – yes (Fawcett
et al)
• Pharmacotherapy sessions monitored via
audio or video tape – yes
• Other interventions allowed – not
discussed
• Patient preferences assessed – not
discussed
Blom et al , 2007 - I
• Drug – nefazodone
• Dose – mean=490mg
• Pharmacotherapists – psychiatrists or
psychiatric residents
• Frequency of visits – weekly?
• Length of visits- initial visit 30min;
subsequent visits 15min
Blom et al, 2007 - II
• Pharmacotherapy manual – yes (adapted
from Fawcett et al)
• Pharmacotherapy sessions monitored via
audio or video tape – yes
• Other interventions allowed – oxazepam
• Patient preferences assessed – not
discussed
Frank et al , 2011 - I
• Drug – escitalopram
• Dose – mean=490mg
• Pharmacotherapists – psychiatrists at
Pisa; non-MD MH professionals at
Pittsburgh
• Frequency of visits – weekly
• Length of visits- 20-30min
Frank et al, 2011 - II
• Pharmacotherapy manual – yes (adapted
from Fawcett et al)
• Pharmacotherapy sessions monitored via
audio or video tape – yes
• Other interventions allowed – low-dose
benzodiazepines for sleep
• Patient preferences assessed – yes
IPT v. Pharmacotherapy ESs and NNTs
Author
Design
Duration
Depression
Measure
Effect
Size1
Klerman
150 women
et al., 1974 with
‘neurotic’
depression
6 ‘maintenance’ tx
conditions: drug, PBO or
no pill crossed with ‘low
contact’ v.
‘high contact’ (IPT
precursor)
8 months
Cumulative
chance of relapse
ES= -.12
NNT= -25
Weissman Acute
et al., 1979 depression
IPT (n=17) v. IPT+AMI
16 weeks
(n=23) v. NST (n=21) v. AMI
(n=20)
Time to sx failure ES =.33
NNT=7.1
(Raskin > 9)
Elkin
Acute
et al., 1988 depression
IPT (n=61) v.
CBT (n=69) v.
IMI-CM (n=57 ) v. PBO-CM
(n=62)
ES=.02
BDI, HSCL-90
NNT=100
HRSD-17, GAS
Recovery: yes/no
Recovery: yes/no
by severity
1ES
Populatio
n
16 weeks
calculated comparing IPT alone to pharmacotherapy alone based on arcsin transformations of two proportions, NNT the
inverse of the difference in two proportions
IPT v. Pharmacotherapy ESs and NNTs
Author
Population
Design
Duration
Frank
et al., 1990
Recurrent
depression
3 years
Markowitz
et al., 2005
Dysthymia
Blom
et al., 2007
Acute
depression
5 maintenance tx
conditions:
IPT-M (n=26) ,
IPT-M +PBO (n=26),
IPT-M+IMI (n=25),
CM+PBO (n=23),
CM+IMI (n=28)
IPT (n=23)
v. BSP (n=26)
v. SERT (n=24)
v. IPT+SERT (n=21)
IPT (n=50)
v. IPT+PBO (n=47)
NEF (n=47)
v. IPT+NEF (n=49 )
1ES
Depression
Measure
Time to
recurrence
Effect
Size1
ES= -.77
NNT = -2.7
16 weeks
HRSD-24,
BDI,CDRS,
IIP, SAS
ES = -.47
NNT= -4.3
16 weeks
HRSD-17*,
MADRS, CGI
ES2=.09
calculated comparing IPT alone to pharmacotherapy alone based on arcsin transformations of two proportions, NNT the
inverse of the difference in two proportions
2ES calculated comparing IPT alone to pharmacotherapy alone based on the t statistic
IPT v. Pharmacotherapy ESs and NNTs
Author
Population
Frank
Acute
et al., 2011 depression
Design
Duration
IPT (n=160) v.
ESCIT (n=158 )
12 weeks
Depression
Measure
Time to
remission
Effect
Size1
ES= -.14
NNT=-14.3
Note: treatment
preference had no
effect on outcome
1ES
calculated comparing IPT alone to pharmacotherapy alone based on arcsin transformations of two proportions, NNT the
inverse of the difference in two proportions
Summary
• IPT has generally fared reasonably well in
comparison to pharmacotherapy of acute
depression
• More chronic conditions (recurrent depression
and dysthymia) generally had somewhat
better outcomes with pharmacotherapy
• Study designs have shown increasing
sophistication over the 30+ years of research
on IPT and pharmacotherapy, but no perfect
design exists
• Clear tensions exist between ecological
validity and research design rigor