In our experience, IPT in combination with nortriptyline shows a high degree of utility with depressed geriatric patients. We were impressed with the ability of our patients as a group to learn from the psychoeducational components of IPT, to become working partners in psychotherapy, often without prior experience, and to use IPT to modify interpersonal problems.
A shift of focus during IPT occurred in 57% of our subjects. In the case vignettes, Mr. A.'s job-related role transition and his wife's cancer diagnosis forced a confrontation with long-standing maladaptive behavior in his marital relationship. Mrs. B. revealed her long-standing resentments toward her husband only after exploring her difficulties adjusting to retirement. Mr. C. struggled with the grief of multiple losses through death before confronting his resentment toward various family members who assumed he would be their health care liaison. Perhaps a more crisis-oriented therapy with limited sessions would not have allowed for these secondary role disputes to emerge; however, in our view the secondary focus on role disputes is often the most important focus that is “saved for last”—after more temporary adjustments in coping have been made and after patients have developed the required rapport to approach more worrisome or deep-seated problems in their relationships. In other words, role transitions are easier to handle if important relationships are viewed as working well, and vice versa.
Regarding spousal role disputes, perhaps we are seeing an age cohort effect, since divorce would have been more frowned upon in the earlier years of these couples' marriages than in recent times. Couples with severe marital strains may have found ways to cope, however tenuous, only to find their tried and true strategies were failing as the stresses of late life accumulated. One-third of the patients with a primary focus of role dispute showed a secondary focus of role transition. Perhaps an unavoidable role transition precipitated a shift of a tenuously balanced relationship into one with a serious role dispute. It is not difficult to imagine the stresses of a new medical illness or the approach of retirement precipitating more disputes between spouses.
The clinical impressions of the 5 participating IPT psychotherapists treating these 180 patients over the past 7 years were that IPT required no major modification and was no more difficult to carry out than IPT with younger patients. There were certainly instances when financial, legal, medical, transportation, or housing problems arose and required exploration and sometimes practical recommendations for appropriate assistance. These instances were seen somewhat more frequently than with younger patients, but they did not significantly interrupt or overshadow the focal work in IPT. The reader should bear in mind that elderly subjects with significant memory loss or dementia, who would be expected to require even more assistance, were excluded from the protocol.
In preparing to work with depressed elderly patients, we found a review of principles of gerontology highly useful to familiarize ourselves with and be able to anticipate common problems and needs of elderly patients in general. A background course in gerontology or a year or more of experience working with elders is highly recommended for clinicians interested in applying IPT to elderly patients.
Although the use of nortriptyline with IPT, in our experience, has been a powerful antidepressant combination for elders with recurrent depression, we cannot comment on the differential effects of these two treatments as acute treatments. Report of the comparative efficacy of IPT, nortriptyline, and their combination as maintenance treatments will follow upon completion of the MTLLD protocol.