Adaptations of IPT: What works for whom?

Interpersonal psychotherapy for depressed adolescents (IPT-A) is a time-limited (12–16 sessions) individual psychotherapy for adolescents ages 12–18 who are suffering from depression. IPT-A was adapted from interpersonal psychotherapy for depressed adults by Laura Mufson, Ph.D. and colleagues at Columbia University. While IPT-A recognizes that genetic, biological, and personality factors play a role in the development of depression, the focus of IPT-A is on how relationships impact mood and how mood impacts relationships and therefore play a big role in the onset or continuation of depressive symptoms.

Family Based Interpersonal Psychotherapy (FB-IPT) for Depressed Preadolescents is a primary intervention to reduce the burden of early-onset depressive disorders in children between the ages of 8-12 years, with a secondary focus on preventing or delaying depression recurrence in adolescence for this high risk group.    FB-IPT directly addresses two domains of interpersonal impairment associated with preadolescents’ depressive symptoms: parent-child conflict and peer impairment.  FB-IPT focuses on improving communication and problem solving skills in the parent-child relationship, the primary context for children’s social and emotional development to improve the quality of the parent-child relationship and to buffer depressed preadolescents from the effects of peer stress, as well as to rehearse effective interpersonal behavior with peers.

Adapted from IPT-A, FB-IPT includes several developmental modifications for 8-12 year-olds: 1) increased parental involvement and structured dyadic sessions, with individual meetings with parents and parent-child sessions for teaching and role-playing communication and problem solving skills, 2) an expanded Limited Sick Role, to shape parental expectations for depressed preadolescents’ performance across contexts and provide parenting strategies for decreasing conflict, and 3) an increased focus on comorbid social anxiety, to decrease depressed preadolescents’ interpersonal avoidance and to enhance their communication and interpersonal problem solving skills with peers.

As in adult and adolescent protocols, FB-IPT structures treatment around an identified “problem areas” temporally associated with the onset of depressive symptoms (loss, disputes, transitions, and interpersonal deficits) and structures treatment into 3 phases.  Initial Phase (sessions 1-5):  Sessions are divided between individual meetings with the preadolescent and the parent).  In meetings with preadolescents, FB-IPT therapists explore the relationship between depressive symptoms and negative experiences in family and peer relationships, and complete the Closeness Circle/ Interpersonal Inventory.  Parent meetings focus on psychoeducation about depression, helping preadolescents maintain routines with reasonable expectations for their performance, and parenting strategies for responding to increased irritability, interpersonal avoidance, and/ or anergia in preadolescents (“Parenting Tips”). Middle Phase (sessions 6-11):  Sessions are divided between individual meetings with the preadolescent and then with the parent-child dyad.  The primary interventions of FB-IPT include teaching communication and problem solving skills to preadolescents and parents.  During dyadic sessions, preadolescents and parents role-play communication and problem solving skills that are relevant to the identified problem area.  Termination Phase (sessions 12-14):  Sessions are divided between individual meetings with the preadolescent and then with the dyad to review progress and consolidate skills, discuss prevention strategies, and identify a plan for depression recurrence.

FB-IPT has been developed and tested with preadolescents diagnosed with depressive disorders and has demonstrated feasibility and acceptability with patients and their families in both an open treatment and randomized controlled trial (Dietz, Mufson, Irvine, & Brent, 2007; Dietz, Weinberg, Brent, & Mufson, 2015).  In our efficacy trial of 42 depressed preadolescents (Dietz et al., 2015), preadolescents receiving FB-IPT evidenced higher remission rates (60% vs. 30%) and significantly lower depression severity scores posttreatment than did depressed preadolescents receiving supportive therapy.  FB-IPT was also associated with large effect sizes for decreasing parent-child conflict (effect size of Cohen’s f2 = 1.3) and improving peer relationships (effect size of Cohen’s f2 = 0.7) as compared to supportive therapy.  Furthermore, decreases in interpersonal impairment with peers mediated the association between FB-IPT and preadolescents’ post-treatment outcomes (z = 1.92, p = 0.05), providing support for improving peer relationships as a mechanism of action of FB-IPT.

To date, FB-IPT is one of the few psychosocial interventions for depression in preadolescent children that has demonstrated superior outcomes when compared to an active comparison treatment condition.  As such, FB-IPT has promise as an efficacious intervention with readily measurable targets and mechanisms of action.  Future directions include implementation and effectiveness trials in community settings to expedite the dissemination of this promising intervention for depressed preadolescents.

Interpersonal Psychotherapy (IPT) was developed initially as an individual treatment for adult patients with major depressive disorder but later adapted for dysthymia, depressed adolescents and older patients, depression during pregnancy and postpartum period, as group treatment for depression and in brief formats for depression and distress. Designed for administration by experienced and trained mental health professionals, it can also be taught clinically to less trained persons. IPT has been used with and without medication for depression.

IPT is based on the idea that whatever the cause of depression, genes, inflammation, environment, it does not arise in a vacuum. The onset of depression is usually associated with something going on in the patient’s current personal life, usually in association with people they feel close to. Some common events are: a marriage breaks up, a dispute threatens an important relationship, a spouse loses interest and has an affair, a job is lost or in jeopardy, a move to a new neighborhood takes place, a loved one dies, a promotion or demotion occurs, a person retires, or a medical illness is diagnosed. IPT identifies and helps the patient learn how to deal with those personal problems and to understand their relationship to the onset of symptoms.

IPT views depression as having three parts:

Symptoms. The emotional, cognitive, and physical symptoms including depressed and anxious mood, difficulty concentrating, indecisiveness, pessimistic outlook, guilt, sleeping and eating disturbances, loss of interest and pleasure in life, fatigue, and suicidality.

Social and Interpersonal Life. Close attachments and relationships

Personality. Enduring patterns of behavior, for handling anger, self-esteem, assertiveness etc.

IPT does not treat personality and notes that many behaviors that appear enduring may be a reflection of the depression itself.

The elements of IPT, regardless of adaptation, include:

• Medical Model

You are a person with an illness, distress, symptoms, etc. It’s not your fault

• Sick Role

Take care of yourself. Who can help you?

• Interpersonal Inventory

Who is in your life now?

• Link symptoms to onset of problems. (Grief, Disputes, Transitions, Loneliness)
• Target symptom reduction and improved social functioning, not personality
• Set time limits
• Focus on current life and not the past

For details of the efficacy data, see Cuijpers, 2017. For the latest review of elements and adaptations, see Weissman, Markowitz & Klerman, 2018.

References

Cuijpers P. Four decades of outcome research on psychotherapies for adult depression: An overview of a series of meta-analyses. Canadian Psychology 2017; 58:7-19.

Weissman MM, Markowitz JM, Klerman GL. The Guide to Interpersonal Psychotherapy. Oxford Press 2018.

Using IPT for Older Individuals 

by Mark Miller, M.D.

IPT is well established as a practical treatment for helping depressed patients understand the triggers for their depression  in  an interpersonal context and to jointly explore  a course for change to reduce depressive symptoms and perhaps even prevent a recurrence by maintaining new and more effective coping strategies.  The same applies for older individuals with some important differences.

End- of-life awareness , losing key parts of  one’s support system  through death, declining physical health, growing dependency on others,  and declines in cognitive capacity and memory are themes more often seen in this group of patients.  Although IPT is designed as in individual therapy  (with some adaptations for marital dyad treatment or group formats),  the necessity of engaging and working with caregivers for the benefit of the older individuals is also a unique adaptation of IPT referred to as IPT-ci (for cognitive impairment).

Geriatric age is generally defined as those over age 60 but sometimes 65.  There can also be large differences in signs of aging that does not always match  chronological age and the difference between the “young old”  and the “old old”  (over age 85 ) can be considerable in terms of frailty,  medical burden and cognitive decline.  The good news about aging in America is that we are on verge living longer  due to advances in medical management and we spend more years in retirement  (often 30 or more)  than at any other time in history.  Many, but not all, older individuals also have accumulated assets allowing them to  enjoy travel and unprecedented leisure time in their “golden years”.

Sigmund Freud’s contention that older individuals are less able to benefit from psychotherapy because they are “too set in their ways” has been decisively   refuted by practitioners of many schools of psychotherapy including IPT.  No significant changes  in technique are required to  provide IPT to this group other than being more flexible in making accommodations for hearing impairment (place chairs to favor their best ear or use amplification),  acknowledging  transportation difficulties and possibly accommodating  chronic pain that limits sitting for full sessions.  Using the telephone to maintain weekly sessions can help  maintain  psychotherapeutic momentum when inclement weather, physical illness or transportation problems are encountered.  The time limited aspect of a fixed number of   IPT sessions fosters motivation for working hard in IPT  at any age before  the allotted time runs out.  This conscious and unconscious pressure is sometimes magnified  when working with older clients who feel that time is also running out on their life.  Being retired with more flexible schedules can also mean that attendance is  more  consistent  compared to younger clients with many more scheduling conflicts related to family and work responsibilities.  Loneliness and shrinking support systems can also make the empathic aspects of  a psychotherapeutic relationship rise in importance compared to other age groups.   Some older patients who are virtual shut-ins  sometimes  refer to their therapy visit is the high point of their week.

IPT is user friendly and particularly suited to the needs of older clients because it feels like a conversation with a caring individual and three of the four foci of IPT easily relate to common themes faced by this group.  For example, role  transitions  such retirement, downsizing, confronting an “empty nest”,  facing limitations due to physical  or cognitive decline, financial insecurity,  declining support systems,  embracing increased dependency and realizing that death is approaching are commonly seen.  Role disputes can occur at any age but marital strain sometimes exacerbates with the forced proximity of retirement or caregiver burden due to medical illness in  either the identified patient or in their spouse.  Cognitive impairment in a spouse can be extremely challenging to manage particularly if the identified patient  has  their own  burdensome medical issues or disabilities.  Degenerative brain disease can also bring personality change to the point of  “losing “ one’s spouse without them actually dying.   Caregivers of dementia victims often complain of feeling lonely, of losing their conversation partner, their lover, or the one to share hobbies or common interests with.   Seeking   to maintain interests through activities with non-demented others can sometimes   bring guilt feelings or feelings  of betrayal or abandonment. Romantic connections to others can also be a temptation  when  spouses are severely demented.  Caregiver burden for medical or mental health reasons would be categorized as a role transition in IPT terms as would a decline in the identified patient’s own health or cognitive function  causing a transition from a healthier self to a less healthy  or capable one.   Grief due to the death of loved ones or members of one’s   support system is, of course, more common with advancing age.  Approaching death in a loved one is sometimes , but not always,  anticipated with advancing age as denial of it’s approach is one possible coping mechanism.  The death of a loved one who is a key support   might also trigger a host of  secondary  role transitions such  as the need to change one’s domicile,  find alternative means of transportation, get help with financial management, or learn how to hire help for the first time if one’s late spouse handled those things exclusively.   Learning to manage on one’s own after a spouse dies inevitably means also confronting whether to seek or accept the offer of new attachments   which can precipitate  a range of emotions  facing this additional  role transition.

Applying IPT in the traditional  12-16 contracted session is often adequate to work through adjustment to grief or the role transitions or disputes described above.   Interpersonal deficits in later life, as in younger individuals  sometimes  reflect  co-morbid personality disorders or  traits.  Some  cluster B traits  soften or mellow with age but those with Cluster C traits often face crises when the are confronted with  increasing dependency or disability that cannot be remedied with intensified effort or when the finality of death is clearly approaching.

Age per se should not be seen as a limiting  factor in  successfully completing  a course of IPT .

Interpersonal and Social Rhythm Therapy (IPSRT), based on Interpersonal Psychotherapy (IPT), is an evidence-based psychotherapy for individuals suffering from bipolar disorder (Frank, 2005). Developed by Ellen Frank, Ph.D. and colleagues at the University of Pittsburgh, this treatment combines a behavioral approach to increasing the regularity of daily routines (social rhythms) with an interpersonal approach to coping with the stresses of bipolar illness itself, with interpersonal life stress and with social role problems (Frank et al., 2005). Refinements and adaptations include IPSRT for bipolar II disorder (Swartz, Levenson, & Frank, 2012; Swartz, Rucci, et al., 2018), group IPSRT (Swartz et al., 2009), IPSRT for youth with bipolar disorder (Hlastala & Frank, 2006; Hlastala, Kotler, McClellan, & McCauley, 2010),  IPSRT for high risk offspring of parents with bipolar disorder (Goldstein et al., 2014), and an online version of IPSRT (Swartz, Rollman, Frank, & Mohr, 2018).

 Origins of Interpersonal and Social Rhythm Therapy

An instability model of bipolar I disorder assumes that individuals with bipolar disorder are fundamentally (biologically) vulnerable to disruptions in circadian rhythms. It posits that for biologically at-risk individuals, recovery from even slight perturbations in schedules is difficult. While those who do not possess this vulnerability can relatively quickly “rebound” from external threats to their circadian integrity, individuals with mood disorders quickly move from mild circadian variations to maladaptive patterns which then potentially lead them from euthymia to mood episodes. For instance, when an individual misses a night of sleep because they are working late to complete a work deadline, they experience disturbances in their circadian integrity. In individuals without mood disorders, this disturbance is transient and easily corrected by a night or two of restorative sleep. In contrast, an individual with bipolar disorder is very sensitive to these changes and is likely to be unable to return to a regular pattern of sleep without considerable effort. After a several nights of disturbed sleep, this individual is at much higher risk for episode recurrence. A direct consequence of this model is the hypothesis that helping patients learn to lead more orderly lives should promote circadian integrity and thereby improve symptomatic outcomes. IPSRT was developed in response to this hypothesis.

Treatment Principles

IPSRT was built on the idea that helping patients to regulate social rhythms and to more effectively manage their interpersonal relationships will help vulnerable individuals reduce the risk of developing both depressive and (hypo)manic mood symptoms. IPSRT fuses three distinct strategies, interpersonal psychotherapy, psychoeducation, and social rhythm therapy, to accomplish these goals.  The therapist moves seamlessly among the strategies, according to the particular needs of the patient at the time

Social Rhythm Metric

The backbone of Social Rhythm Therapy is the Social Rhythm Metric (SRM) (Monk, Flaherty, Frank, Hoskinson, & Kupfer, 1990). The SRM is a pencil and paper assessment that patients complete each week to record the time at which they complete each of 5 daily activities: out of bed, first contact with another person, start regular daily activity (school, work, etc.), dinner, and in bed.   An app version of the SRM is in development.  Individuals are also asked to evaluate the degree of involvement of other people in these activities: “0” means that no one was present; “1” means that someone was present but not very involved; “2” means that someone was present and interacting with the individual to a moderately stimulating degree; and “3” means that someone was present and interacting on very stimulating level. In addition to recording the timing of daily activities and levels of stimulation, the patient also records average mood and energy levels on a scale of minus five to plus five. The SRM is used as both an outcome measure and a therapeutic tool. Improvement in scores has been associated with favorable outcomes with IPSRT. In individual sessions, the IPSRT therapist reviews SRMs to help the patient achieve more regular rhythms. In addition, the SRM is used to help the patient track the links among rhythm stability (or instability) and mood and energy states, ultimately coming to recognize that disruptions in schedule will likely lead to dysregulated mood and energy states and, conversely, that dyregulated mood and energy states may contribute to changes in daily rhythms. Identification of these patterns represents the first step in regulating them.

For more information about IPSRT, visit the online training website at www.ipsrt.org

References

Frank, E. (2005). Treating bipolar disorder: A clinician’s guide to interpersonal and social rhythm therapy. New York, NY: Guilford Press.

Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., . . . Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry, 62(9), 996-1004. doi:10.1001/archpsyc.62.9.996

Goldstein, T. R., Fersch-Podrat, R., Axelson, D. A., Gilbert, A., Hlastala, S. A., Birmaher, B., & Frank, E. (2014). Early Intervention for Adolescents at High Risk for the Development of Bipolar Disorder: Pilot Study of Interpersonal and Social Rhythm Therapy (IPSRT). Psychotherapy: Theory, Research, Practice, Training, 51(1), 180-189. doi:Doi 10.1037/A0034396

Hlastala, S. A., & Frank, E. (2006). Adapting interpersonal and social rhythm therapy to the developmental needs of adolescents with bipolar disorder. Development and Psychopathology, 18(4), 1267-1288. doi:10.1017/S0954579406060615

Hlastala, S. A., Kotler, J. S., McClellan, J. M., & McCauley, E. A. (2010). Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial. Depression and Anxiety, 27(5), 457-464. doi:10.1002/da.20668

Monk, T. H., Flaherty, J. F., Frank, E., Hoskinson, K., & Kupfer, D. J. (1990). The Social Rhythm Metric: An instrument to quantify the daily rhythms of life. Journal of Nervous & Mental Disease, 178(2), 120-126.

Swartz, H. A., Levenson, J. C., & Frank, E. (2012). Psychotherapy for Bipolar II Disorder: The Role of Interpersonal and Social Rhythm Therapy. Professional psychology, research and practice, 43(2), 145-153.

Swartz, H. A., Maihoefer, C., O’Toole, K., Buck, N., Kiderman, H., Henschke, P., . . . Frank, E. (2009). Group Interpersonal and Social Rhythm Therapy across the continuum of care in routine practice settings. Bipolar Disorders, 11, 84-85.

Swartz, H. A., Rollman, B. L., Frank, E., & Mohr, D. (2018). Rhythms And You (RAY): an online intervention for managing bipolar disorder in primary care (P-195). Bipolar Disorders, 20, 63-141.

Swartz, H. A., Rucci, P., Thase, M. E., Wallace, M., Carretta, E., Celedonia, K. L., & Frank, E. (2018). Psychotherapy Alone and Combined With Medication as Treatments for Bipolar II Depression: A Randomized Controlled Trial. The Journal of clinical psychiatry, 79(2)

Rationale and Empirical Evidence for IPT and Brief IPT for Perinatal Depression

Because depression during pregnancy appears to be strongly related to lack of perceived support from significant others, particularly the spouse or partner (O’Hara & Swain, 1996), an interpersonal approach to treatment and prevention of antenatal depression, therefore, may be not only judicious, but also critical.  IPT has demonstrated efficacy in many domains, including the acute treatment of postpartum depression.  O’Hara, Stuart, Gorman, & Wenzel (2000) conducted a randomized trial of 120 mostly White, well-educated, married or cohabitating women who experienced an onset of major depression postpartum and who were successfully treated with 12 sessions of IPT.

IPT also has a role in preventing postpartum depression by reducing antenatal depression because it targets the specific symptoms and interpersonal problem areas (especially role transitions and interpersonal conflicts) experienced by depressed women not only during the postpartum period Steuart & O’Hara, 1995) but also during the pregnancy. A number of studies have evaluated the effects of IPT intervention for high-risk women with antenatal major depression. Spinelli (1997) added to IPT the special role transition of “complicated pregnancy,” which encompasses current medical problems during pregnancy and a history of perinatal loss, medical problems, and sexual trauma. Results from a pilot study (Spinelli, 1997) showed that 16 weekly session of IPT significantly decreased depressive symptoms in 9 pregnant women (mostly Hispanic and White) with major depression. Subsequently, Spinelli and Endicott (2003) conducted a randomized, controlled 16-week trial of IPT for 50 pregnant women with major depression and found that women in the IPT group, compared to those in a parent education group, reported a greater decrease in depressive symptoms.  Recently, Spinelli et al. (2016) found that among women with moderate levels of depression during pregnancy, IPT was more effective in reducing depression than the parent education condition.

Given that the dropout rate is so high in low-income, minority individuals in need of treatment for depression (J. Miranda & Dwyer, 1993), a brief, effective treatment for depression may increase treatment engagement by alleviating the burden of attending numerous sessions (Swartz et al., 2008).  Brief IPT (8 sessions) seems particularly applicable for treating depression in pregnant, low-income, racially and ethnically diverse women. Along with alleviating the burden of numerous treatment sessions, the time pressure afforded by Brief IPT fits with pregnant women’s motivations to feel better as quickly as possible before their baby is born, and it appears to be an effective alternative to pharmacological treatment. Moreover, the idea that depression takes place in an interpersonal context (Klerman et al., 1984) seems to be culturally consonant with the collectivist worldviews of diverse racial/ethnic minority groups (Hall, 2001).

Brief IPT has received empirical support in a number of studies of socio-economically disadvantaged, racially and ethnically diverse pregnant women with depression (Grote et al; 2004; 2009; 2016; Lenze et al., under review). Brief IPT consists of 8 individual sessions provided over 8 or more weeks. It retains the core features of standard IPT, such as strengthening social supports, building on patient strengths and coping strategies, and resolving interpersonal problems. At the same time, brief IPT offers several advantages over standard IPT. First, it reduces the treatment burden for overwhelmed, pregnant or parenting women with multiple acute and chronic stressors. Second, to promote a quicker treatment response, brief IPT techniques have been expanded to include behavioral activation strategies that can be shared with family members/friends and assigned as weekly homework with an interpersonal focus.

Brief IPT can be supplemented with IPT Maintenance to prevent postpartum depressive relapse or recurrence.

Exposure therapies have dominated the treatment of posttraumatic stress disorder (PTSD). Although effective, they do not benefit all patients, and many patients (and therapists) refuse to do them because of the grueling requirement to face and relive traumatic memories in order to habituate to them.  IPT offers a non-exposure-based approach to PTSD. IPT acknowledges the impact of trauma on the patient’s life, but rather than attempting to reconstruct the traumatic events, it aims to repair the damage trauma does to interpersonal trust and social functioning. Trauma can isolate patients from the social supports that protect against developing and help in recovery from PTSD.

Among the consequences of PTSD are affective numbing, interpersonal hypervigilance, and social withdrawal (1). Numbness, an avoidance particularly of negative affect, makes it hard to read one’s interpersonal environment. Thus in adapting IPT for PTSD, we devote the early part of treatment to affective reattunement: helping patients to identify their emotions and to recognize them as helpful social signals rather than as bad or dangerous. Once patients can read their feelings, they can put them to use to handle relationships better, deciding whom they can trust and whom they can’t.  IPT for PTSD tends to focus on role transitions, which are usually inherent having been traumatized (2).

Krupnick and colleagues (3) showed that group IPT reduced PTSD and depression in badly and repeatedly traumatized women relative to a waiting list control. Campanini et al. reported that adding IPT to pharmacotherapy reduced PTSD symptoms more than pharmacotherapy alone (4). Markowitz and colleagues (5) found 14 weeks of individual IPT non-inferior to Prolonged Exposure, the best tested exposure therapy, and that IPT had advantages for patients with comorbid major depression (5) or sexual trauma (6). Dropout was non-significantly lower in IPT (5): 15% versus 29%. Apparent personality disorders often resolved with treatment of PTSD (7). Patients also preferred IPT to exposure therapy (8). Gains in IPT persisted at three month follow-up (9). Further research is needed to replicate these findings, particularly for military PTSD.

References

1. Bleiberg KL, Markowitz JC: Interpersonal psychotherapy for posttraumatic stress disorder. Am J Psychiatry 2005;162:181-183
2. Markowitz JC: Interpersonal Psychotherapy for Posttraumatic Stress Disorder. New York: Oxford University Press, 2016
3. Krupnick JL, Green BL, Stockton P, Miranda J, Krause E, Mete M: Group interpersonal psychotherapy for low-income women with posttraumatic stress disorder. Psychother Res 2008; 18:497-50
4. Campanini RF, Schoedl AF, Pupo MC, Costa AC, Krupnick JL, Mello MF: Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial. Depress Anxiety 2010;27:72-77
5. Markowitz JC, Petkova E, Neria Y, Van Meter P, Zhao Y, Hembree E, Lovell K, Biyanova T, Marshall RD: Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. Am J Psychiatry 2015;172;430-440
6. Markowitz JC, Neria Y, Lovell K, Van Meter PE, Petkova E: History of sexual trauma moderates psychotherapy outcome for posttraumatic stress disorder. Depress Anxiety 2017 Apr 4 [Epub ahead of print]
7. Markowitz JC, Petkova E, Biyanova T, Ding K, Suh EJ, Neria Y: Exploring personality diagnosis stability following acute psychotherapy for chronic posttraumatic stress disorder. Depress Anxiety 2015;32:919-926
8. Markowitz JC, Meehan KB, Petkova E, Zhao Y, Van Meter PE, Neria Y, Pessin H, Nazia Y: Treatment preferences of psychotherapy patients with chronic PTSD. J Clin Psychiatry 2016;77:363-370
9. Markowitz JC, Choo T, Neria Y: Do Acute Benefits of Interpersonal Psychotherapy for Posttraumatic Stress Disorder Endure? (submitted for publication)