Interpersonal theory and adolescents with depression: clinical update.

Interpersonal psychotherapy (IPT) is a brief, time-limited therapy originally developed for use with adults diagnosed with major depression. During the past decade, IPT has been modified for use with many different age groups including adolescents diagnosed with depression. A number of empirical investigations have considered the use of interpersonal psychotherapy for adolescents (IPT-A) in the treatment of adolescents diagnosed with depression. This article provides mental health counselors with information about the prevalence and course of adolescent depression, other empirically tested treatments for adolescent depression, an explanation of IPT-A treatment protocol, and results of outcome studies on the effectiveness of IPT-A. Suggestions for future research investigations with IPT-A are offered.

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Depressive disorders among adolescents are not uncommon. The onset of major depression often occurs in adolescence and by late adolescence the prevalence rate for depressive disorders is estimated between 6% and 9% (Kutcher & Marton, 1996). The onset for major depressive disorders (MDD) appears most likely between the ages of 13 and 19 (Birmaher, Ryan, & Williamson, 1996). As with adults, females tend to be impacted by these disorders at the rate of 2:1 (Mueller & Orvaschel, 1997). Depressive symptomology in adolescence is also the most significant factor in predicting depressive symptomology in adulthood (Mufson & Moreau, 1997). Research suggests that depression may have more harmful effects for adolescents than for adults (Schraedley, Gotlib, & Hayward, 1999). These statistics reflect the need for intentional and culturally appropriate treatment developed specifically to meet the needs of adolesents diagnosed with depression. The question becomes, What treatment modalities can mental health counselors use to best meet this need?

Diagnostically, adolescent depression appears to mimic the characteristics of adult depression (Sands, 1998). Both adolescents and adults who are depressed appear to have chronic, recurring episodes, psychosocial impairments, disturbances in sleep and appetite, suicidal ideations, difficulties focusing, and depressed mood (Mufson & Moreau, 1997).

Some key clinical characteristics, however, distinguish adolescent depressive symptomology from that of adults (Birmaher, Ryan, Williamson, Brent, et al., 1996). Adolescents who are depressed tend to exhibit more helplessness, despair, lack of pleasure, hypersomia, and changes in weight (Birmaher et al., 1996). Depressive disorders in adolescence also tend to be more episodic, with stages of depression followed by stages of better functioning (Mufson & Moreau, 1997). Adolescent depression is characterized by significant impairments in academic performance and relationships with others (Birmaher, Ryan, Williamson, Brent, et al., 1996). Depressive symptomology among adolescents may be associated with future substance abuse and unwed pregnancy (Stanard, 2000). Eating disorders and violence may also be associated with adolescent onset depression (Modrican-McCarthy & Dalton, 1996). The ultimate violence towards oneself, suicide, is the most alarming difference between adolescent and adult depression. Research indicates that adolescents tend to have higher rates of lethality in their suicide attempts (Birmaher, Ryan, Williamson, Brent, et al., 1996). Among successful adolescent suicides, depression is the most common diagnosis (Kutcher & Marton, 1996).

Despite evidence that major depression is prevalent among the adolescent population, little empirical attention has been given to treatment with adolescents (Mufson et al., 1994). In comparison to the outcome studies related to treating adults diagnosed with major depression, there are few studies examining the effectiveness of treatment for adolescents with depression (Mufson, Weissman, Moreau, Garfinkel, 1999).

Psychopharmacological and cognitive-behavioral treatment approaches to the treatment of adolescents with depression have received some attention. The effectiveness of several antidepressants with depressed adolescents has been explored. However, these studies failed to demonstrate efficacy and have been criticized for poor research design (Mufson et al., 1999). Monoamine oxidase inhibitors (MAOIs) have been shown to be effective in the treatment of adult depression, but have not received a great deal of empirical attention for the treatment of adolescent depression (Kutcher & Marton, 1996). The use of tricyclic antidepressants in the treatment of adolescent depression has been explored in both open and controlled studies, but these studies have failed to demonstrate efficacy (Kutcher & Marton, 1996). Investigations of the use of serotonin-specific reuptake inhibitors (SSRI) have shown more promise in treating adolescent depression, but these studies have only been completed as open clinical trials (Kutcher & Marton, 1996). More research is needed examining the use of antidepressant medication in the treatment of depressed adolescents (Mufson, Moreau, & Weissman, 1996).

Scientifically sound studies that consider the effectiveness of psychotherapies with this population are also lacking (Harrington, Whittaker, & Shoebridge, 1998). Studies have not met minimum scientific standards such as the use of homogeneous samples and random assignments to experimental and control groups (Mufson & Moreau, 1997). Psychotherapies for the treatment of adolescent depression have also been studied less extensively than somatic treatments (Kutcher & Marton, 1996).

The trend in counseling has been to adapt approaches for the treatment of adults with depression to adolescents (Kutcher & Marton, 1996). The treatments for adults that are commonly used for adolescents who are depressed include cognitive, psychodynamic, behavioral, and family approaches (Mufson & Moreau, 1997). These strategies, based on theoretical and clinical perspectives of adolescent treatment, seek to decrease depressive symptomology and increase psychosocial functioning of the adolescent (Mufson & Moreau, 1997).

There has been some empirical attention paid to the use of individual and group cognitive behavior therapy (CBT) with adolescents who are depressed (Mufson et al., 1999). Overall, the treatment outcomes for depressed adolescents have not been as promising as they are for adults (Kutcher & Marton, 1996). The empirical data available for CBT appears to suggest that CBT is more effective in treating adolescents with less intense depression and for those who are functioning better at intake (Kutcher & Marton, 1996).

Psychodynamic approaches to the treatment of adolescent depression have received little empirical investigation (Kutcher & Marton, 1996). There are no studies that meet minimum scientific standards available for the use of psychodynamic approaches with this population (Kutcher & Marton, 1996). One review did consider the use of this approach with adolescent depression and found it to be lacking in theoretical and procedural thoroughness (Kutcher & Marton, 1996).

Strict behavioral approaches to the treatment of adolescent depression have also not received much empirical attention (Mufson & Moreau, 1997). Behavioral techniques, however, have been used to treat depressive symptoms in adolescents with other diagnoses (Mufson & Moreau, 1997). In these cases, adolescents have responded to behavioral techniques that focus on self-control and social interactions (Mufson & Moreau, 1997).

Family therapy may be a promising treatment for adolescent depression since it has been linked in several studies to family problems (Kutcher & Marton, 1996). Little empirical attention, however, has been given to the use of family therapy in the treatment of adolescent depression (Kutcher & Marton, 1996). In one study, the use of systematic family therapy for treatment of adolescent depression was found to reduce depressive symptomology in adolescents, but an increase in parental depression was also found (Lantz, 1986).

One approach to the treatment of adolescent depression that looks promising based on outcome studies is the use of interpersonal psychotherapy. Interpersonal psychotherapy for adolescents (IPT-A) was developed to fill gaps in theoretical and empirical information available for the treatment of adolescent depression. Modifications to interpersonal psychotherapy (IPT) were made to meet the specific developmental and interpersonal needs of adolescents who are depressed (Moreau, Mufson, Weissman, & Klerman, 1991).

IPT is a brief, time-limited treatment originally developed and tested for use with adults diagnosed with a depressive disorder (Moreau et al., 1991). The goals of IPT treatment include reducing symptoms related to depression and identifying interpersonal problem areas connected with the start of depression (Moreau et al., 1991). No assumptions about the underlying origins of depression are made, rather the onset of depression is linked to one of four interpersonal problem areas. These areas are frequently associated with the beginning of depression in the adult population (Weissman & Markowitz, 1994). According to Weissman and Markowitz (1994), these problem areas are interpersonal deficits, role transitions, interpersonal role disputes, and grief. IPT theorists believe that discerning the interpersonal problems that contribute to depression and working to alleviate those problems is sufficient for the treatment of depression regardless of other biological or personality factors (Moreau et al., 1991). IPT therapy emphasizes the current interpersonal relationships and social contexts of the individual (Weissman & Markowitz, 1994). In the past decade, IPT has been modified for use with a host of different populations including adolescents who are depressed (Weissman & Markowitz, 1994).

A number of empirical investigations into the efficacy of IPT-A with depressed adolescents have been undertaken (Mufson & Fairbanks, 1996; Mufson et al., 1994; Mufson et al., 1999; Rossello and Bernal, 1999; Santor & Kusumakar, 2001). This article identifies the treatment goals and modalities of IPT-A, examines outcome research that has been conducted on IPT-A, and makes recommendations for future research.

TREATMENT PROTOCOL

Overview

Moreau et al. (1991) asserted that the goals of IPT-A closely mirror those of IPT for depressed adults. Like IPT, IPT-A seeks to identify and change interpersonal problem areas associated with the onset of the adolescent's depression as well as alleviate depressive symptomology (Mufson et al., 1996).

The four interpersonal areas (interpersonal deficits, role transition, interpersonal role disputes, and grief) used by IPT in the treatment of adult depression are also addressed in IPT-A (Mufson & Moreau, 1998) A fifth problem area, single-parent families, has been added to IPT-A by Mufson, Moreau, and Weissman (1996) because of the frequency of single-parent families among depressed adolescents and the necessity to address the conflicts resulting from a parent's absence in the family.

Moreau et al. (1991) also emphasized that IPT-A has been designed to meet the unique developmental needs of adolescents. Issues addressed in IPT-A are specific to concerns and issues adolescents face (Mufson et al., 1996). Some issues identified in IPT-A include individuating from parents, peer pressures, romantic relationships, experiences with death, and issues of control and authority with parents (Moreau et al., 1991).

Treatment Techniques

IPT-A is a time-limited therapy that calls for a once weekly, 12-week treatment schedule (Mufson & Moreau, 1998). The goals of IPT-A are met by identifying interpersonal problem areas with which the adolescent is struggling and by focusing on how those problems are currently impacting their relationships (Mufson & Moreau, 1998). There are three treatment phases identified as part of the IPT-A model--initial, middle, and termination (Mufson et al., 1996). A more detailed discussion of IPT-A intervention strategies can be found in the IPT-A treatment manual (Mufson, Moreau, Weissman, & Klerman, 1993).

Initial Phase

The initial phase of IPT-A treatment described by Mufson & Moreau (1999) occurs during sessions one through four. During this phase, the goals of IPT-A are to conduct a complete diagnostic assessment and explain treatment options, obtain a complete history of current interpersonal relationships, identify the interpersonal problem area(s) that may have precipitated the onset of the depression, discuss goals and techniques of IPT-A treatment, and contract for treatment. During this initial phase evaluations for drug abuse and suicidal ideation are generally conducted because of the high co-morbidity of these problems with adolescent depression (Moreau et al., 1991).

Moreau et al. (1991) suggested bringing parents into counseling in initial sessions to be educated about their child's diagnosis, including information about its treatment, course, and prognosis. Contacts between the counselor and the adolescent's school may be made at this time so that the mental health counselor can educate the adolescent's teachers about the relationship between the adolescent's depression and his or her functioning in school (Mufson & Moreau, 1998).

In order to keep adolescents from withdrawing because of their depression and to keep parental support, adolescents who are depressed are also given the restricted "sick role" during initial sessions (Moreau et al., 1991). Mufson and Moreau (1999) suggested that when giving adolescents sick roles, the mental health counselors explain that clients have a mental health problem that might affect their ability to participate fully in everyday activities (Mufson & Moreau, 1999). They suggested that the mental health counselor encourage clients to continue to participate in day-to-day activities because it will help alleviate symptoms sooner. The sick role is given to encourage adolescents to continue participating in normal activities and to prevent parents from becoming overly impatient or critical of their child's performance (Moreau et al., 1991).

Mufson, Moreau, and Weissman (1996) indicated the initial stage of therapy concludes with the development of a treatment contract between the mental health counselor and client. This treatment contract specifically addresses the interpersonal problem area(s) to be addressed in treatment, limits of confidentiality, number and timing of sessions, what will be done in the case of missed appointments, and the role of the clients' parents' in the therapeutic process.

Middle Phase

The middle phase of IPT-A treatment consists of sessions five through eight and it is during this time that the mental health counselor and client begin to directly work on the interpersonal problem areas identified during the initial stages of treatment (Mufson et al., 1996). The main goal of the middle phase of IPT-A treatment is to associate these interpersonal problem areas to the depressive symptomology currently being experienced by the adolescent (Moreau et al., 1991). Five interpersonal problem areas are examined during this time: grief, interpersonal role disputes, role transitions, interpersonal deficits, and single-parent families (Mufson & Moreau, 1999). The focus of these interpersonal problem areas has been modified from IPT to meet the developmental needs and issues of depressed adolescents (Mufson & Moreau, 1998).

Grief. Adolescents who have lost a parent due to death may experience depression. Depression can often be the result of three types of abnormal grief--distorted, delayed, and chronic (Mufson & Moreau, 1998) Adolescents who are experiencing problems coping with grief may exhibit such symptoms as withdrawal, feelings of abandonment, substance abuse, sexual promiscuity, and reverting to earlier developmental stages (Mufson & Moreau, 1998). According to IPT-A, failure to successfully navigate through the stages of grief can lead to depression (Mufson & Moreau, 1999)

Mufson and Moreau (1999) noted that IPT-A treatment method seeks to help adolescents discuss and accept loss in their lives and identify feelings that coincide with that loss. There are several key factors that therapists are advised to attend to when dealing with the interpersonal problem area of grief. These factors include the social support system of the adolescents, their place in the family structure, psychosocial development, and the quality of the relationship lost.

Interpersonal role disputes. When there are different expectations between two individuals about their relationship, interpersonal role disputes are evident (Mufson & Moreau, 1999). Interpersonal role disputes are identified by Moreau et al. (1991) as common to the developmental issues of adolescents and may occur with parents over issues of sexuality, power, finances, and morals. Specific issues may include different expectations about premarital sex, curfews, allowances, and values about homosexuality.

Treatment of role disputes with adolescents often involves bringing in parents to discuss the disputes and to navigate the relationship (Mufson & Moreau, 1998). In addressing interpersonal role disputes, IPT-A counselors seek to help adolescents explain their expectations for the relationship, consider which expectations may be impractical, and help adolescents cope with non-negotiable expectations (Mufson et al., 1996). Several techniques are employed to meet these objectives including helping adolescents identify the dispute, negotiate options with parents, examine and change relationship expectations, and clarify and alter communication styles (Mufson & Moreau, 1998).

Role transitions. Role transitions are another frequent problem area for adolescents with depression (Moreau et al., 1991). Some role transitions are common to the developmental levels of adolescents. Transitions that can prove problematic for adolescents include initiation of romantic relationships, puberty, parting from parents and family, and transition into work or higher education (Mufson & Moreau, 1999). Problems arise in this area when the adolescent is unable to cope with the role transition or when the parents are unable to handle the new role of their child (Mufson et al., 1996).

If parents are involved in the adolescent's struggles with role transitions, then they may also be included in some of the counseling sessions (Moreau et al., 1991). The mental health counselor's function in these sessions is to help the family adjust to the adolescent's new role and to elicit support and encouragement from the parents in the adolescent's attempts to adjust to the new role (Mufson & Moreau, 1999). Mental health counselors working with adolescents who are experiencing problems with role transitions might also help adolescents to process their old roles and associated feelings and identify why the transition is necessary (Moreau et al., 1991).

Interpersonal deficits. Interpersonal deficits are particularly important to address during the adolescent years, because these deficits can have a great impact on adolescents' achievement of developmental tasks (Moreau et al., 1991). Developmental tasks that can be impacted by adolescents' interpersonal deficits include making friends, beginning romantic relationships, forming social ties, and making choices about romantic commitment, vocation, and sexuality (Mufson & Moreau, 1999). Lack of interpersonal skills may lead to adolescents becoming socially isolated from their peers (Mufson et al., 1996). As a result of being ostracized from peers, adolescents may withdraw, leading to a further delay in the acquisition of appropriate social skills (Mufson & Moreau, 1999).

Deficits identified in the IPT-A approach are those that result from depression rather than from inherent personality traits (Mufson et al., 1996). There are several techniques used to address interpersonal deficits (Mufson & Moreau, 1999). Some approaches include helping adolescents identify what specific role deficits have played in current and past interpersonal relationships, consideration of what deficits need to be changed, and encouragment of those changes in significant relationships (Mufson & Moreau, 1999). Role-plays are often used to help adolescents identify their interpersonal deficits and to help them practice new skills (Mufson et al., 1996). Asking adolescents to practice new behaviors outside of counseling sessions may also help them generalize new skills to other situations (Moreau et al., 1991).

Single-parent families. Single-parent homes are identified as another common problem area for many depressed adolescents. Mufson and Moreau (1999) suggest that the conflicts a single-parent home can engender can lead to depression among adolescents. Typically, factors such as the finality of the parting of the parent, its abruptness in happening, and whether a parent has parted before can impact the severity of the adolescent's depression. When considering the nature of the adolescent's depression, the mental health counselor also needs to be cognizant of the adolescent's relationship with both the custodial and absent parent.

IPT-A has developed six treatment goals for addressing this problem area with adolescents (Moreau et al., 1991). First, mental health counselors help adolescents recognize the impact the exit of the parent had on their life (Mufson et al., 1996). Secondly, adolescents receive help processing their feelings of bereavement, rejection, desertion, and/or punishment resulting from the parting of the parent (Moreau et al., 1991). Mental health counselors also help adolescents' process hopes for a relationship with the missing parent (Mufson et al., 1996). Fourth, mental health counselors facilitate development of an effective relationship with the remaining parent (Moreau et al., 1991). Fifth, if possible, the establishment of a relationship with the absent parent may be explored (Mufson et al., 1996). Sixth and finally, mental health counselors help adolescents understand and accept the finality of the situation (Moreau et al., 1991).

Termination

The termination phase of IPT-A occurs between sessions nine through twelve (Mufson & Moreau, 1999) Termination should be discussed throughout the counseling process (Moreau et al., 1991). In the termination phase, adolescents are helped to individuate from the mental health counselor and to gain a sense of efficacy for coping with future problems (Mufson & Moreau, 1999). During the termination session, mental health counselors and adolescents process what has occurred in counseling, discuss possible areas that could cause future problems, and explore problem-solving strategies related to those areas (Moreau et al., 1991). IPT-A also includes considerations for termination that are specific to working with adolescents (Moreau et al., 1991). These considerations include terminating work with family members who have been involved in the counseling process and discussing with those members modifications in family interactions that have occurred since counseling began (Mufson et al., 1996).

Moreau et al. (1991) indicated termination in this model also includes discussion of symptoms and conflicts within four categories. These categories include symptoms related to depression, secondary symptoms, areas of conflict that are lasting and represent pervasive personality patterns, and areas of discord between adolescents and their families. Families and adolescents need to be educated about the possibility of a recurrence of symptomology for a short time after counseling has been terminated, and indications that suggest the need for future treatment should also be discussed.

OUTCOME STUDIES

From 1994 to the present, several outcome studies have been conducted on the use of IPT-A for adolescents with depression (Mufson et al., 1994; Mufson & Fairbanks, 1996; Mufson et al., 1999; Santor & Kusumakar, 2001). Although results of these studies have been promising, much more empirical attention is needed. The empirical studies have several design flaws that need to be addressed in future research. The ensuing discussion will provide an overview of these studies, their outcomes, and limitations.

Mufson et al. (1994) conducted two studies of IPT-A on adolescents with depression. The phase one study was designed to examine the clinical dimensions for adolescents with depression and to highlight areas needing revision based on the results. The population sample for this study was small, consisting of five adolescents who were classified as having major depression, depression not otherwise specified, dysthymic disorder, or adjustment disorder with depressed mood. The first author of this study was also the therapist applying the IPT-A treatment to the participants. No assessment measures were used in this study to monitor treatment effects. Instead, cases were evaluated clinically for regularity of appointments, amount of sessions attended, length of therapy, and temperament after conclusion of therapy.

Several modifications were made to the IPT-A treatment model after this first study. One modification was the addition of the single-parent family as an interpersonal problem area. Counseling sessions were modified to meet the developmental and contextual concerns of adolescents. Discussions of parental and cultural conflicts were also added to address issues of concern for adolescents. The length of therapy was shortened from 16 weeks to 12 weeks and short telephone sessions were also added.

Although this study was designed to help the authors make adjustments and changes to the IPT-A treatment manual, there were some design flaws in this initial study. The sample was extremely small and consisted of all female adolescents. Studies designed to solidify the treatment guidelines for a particular therapy should use a larger and more diverse population so the uses of the treatment can be generalized to a larger population. This study also used only one therapist. Therefore, it is indistinguishable whether the treatment effects were due to the application of the IPT-A treatment or to the therapeutic skills of the therapist. Given the demographic makeup of participants, it is unclear if the modifications made to the IPT-A model apply to only the treatment needs of female adolescents, or if the modifications made can be effective when working with male adolescents.

Mufson et al.'s (1994) second study was designed to test the IPT-A treatment manual in an open clinical trial and to make further adjustments to the manual as a result. This study was small and consisted of 14 adolescents who met the same diagnostic criteria as in the phase one study. Participants in this clinical trial attended 12 therapy sessions conducted by a child psychologist. This study did use specific assessment measures for evaluating the impact of this therapy on the participants.

The results of this study indicate there was a substantial reduction in depressive symptomology and improvement in the general functioning of participants. At the conclusion of the study, none of the participants met the criteria of the DSM-III-R for any depressive disorder. There were, however, some noteworthy limitations to this study. The sample size was small and consisted of mostly female adolescents. There were only two males included in this study. The participants in this study were mostly Hispanic with three participants being of African-American origin. Given the demographic makeup of participants in this study, it is unclear whether or not the treatment effects would be valid for other populations such as Caucasian male adolescents. Another limitation of this study was that the counseling was conducted by only one counselor, which makes it unclear whether the treatment effects were a result of the counselor's skills or the actual IPT-A treatment. Finally, there was no control group in this study. It is not known whether or not the depression would have improved without any therapeutic treatment.

Mufson and Fairbanks (1996) conducted another study on the effectiveness of IPT-A with depressed adolescents. Unlike the previous two studies, this study considered the relapse rates of those adolescents who had previously received IPT-A therapy for their depression. The participants for this study were drawn from the phase two study discussed earlier. Of the 14 original participants, only 10 elected to participate in this study. All of the participants in this study were female with seven individuals of Hispanic origin and three African Americans. Assessment measures were used to measure current depressive symptomology and social functioning.

The results of this study suggested the treatment effects from the initial IPT-A therapy were maintained over a one-year period directly following the conclusion of therapy. The results of this study also indicated that the participants were experiencing better relations with their families. The participants' overall global impairment, however, appeared to be worse at follow-up. This finding may have been due to methodological problems. One third of the participants had received additional treatment following IPT-A therapy. It is unclear whether the results of this study were due to the IPT-A treatment effects or other treatment used in the year following the completion of IPT-A therapy.

Like the previous two studies, this study also had limitations. The sample size was small and included no males. Without further research, these treatment effects cannot be generalized to adolescents of other demographic backgrounds. Also, because this was a naturalistic follow-up study, there was no control for other treatment the adolescents may have had after the completion of IPT-A therapy. Finally, there was no control group in this study. Therefore, it is not known whether these findings would have been similar in adolescents who did not receive IPT-A treatment for depression.

Mufson et al. (1999) completed an outcome study of the efficacy of IPT-A therapy with depressed adolescents. There were 48 participants in this study, all of whom met the DSM-III-R criteria for major depressive disorder. Again, the majority of participants in this study were of Hispanic background and were female. This study did, however, use a control group. The control group received clinical monitoring biweekly for 30 minutes, whereas the IPT-A group were seen weekly for 12 weeks. All of the therapists in this study were trained and supervised in the IPT-A treatment method. Results of this study indicated that IPT-A treatment in comparison with clinical monitoring was significantly more effective in diminishing depressive symptomology and increasing the social functioning of participants. The drop out rate, however, in the clinical monitoring group was 54% as compared to 12% in the IPT-A group. The attrition rate of the clinical monitoring group indicates that IPT-A may be more effective in treating adolescent depression than a biweekly review of the adolescent's symptoms. Participants in the IPT-A group also reported increased abilities to problem solve at the completion of treatment.

While the results of this study are promising there are limitations. Although the sample size of this study was much larger than the previous studies of IPT-A, the sample size (N = 48) was still relatively small. Participants in this study were again mostly Hispanic females. Therefore, the results of this study cannot be generalized to adolescents of other demographic backgrounds. This study also used therapists who had received formal training in using the IPT-A treatment model. The therapists in this study were receiving supervision from individuals highly trained in IPT-A themselves. It is indistinguishable, therefore, whether the results of this study would be found with counselors who had not received formal training or supervision in IPT-A. There was also a significant attrition rate in the control group, which makes it difficult to compare results to the treatment group. The nature of the control group itself was also troublesome. Participants in the treatment group spent more time with their therapists and therefore may have developed a more effective therapeutic relationship than individuals in the clinical monitoring group. The control group received no therapy, only clinical monitoring. It is unclear whether the treatment effects are due to the time spent in therapy and the development of a therapeutic relationship or receiving IPT-A treatment.

A recent study investigated the use of IPT-A with adolescents who were moderately to severely depressed (Santor & Kusumakar, 2001). This study used therapists who did not previously have formal skills or training in using the IPT-A treatment model. Participants in this study included 25 adolescents, 23 of whom were female. All of the participants in this study met the criteria for major depression as outlined in the DSM-IV Nine therapists were used in this study and all completed a 3-day instruction seminar on IPT-A treatment protocol. Participants in the study received 12 IPT-A treatment sessions with one of the nine therapists. Several assessment measures were used to evaluate participant progress throughout the study.

The results of this study suggested that depressive symptomology was significantly reduced and global functioning was increased after participants received IPT-A treatment, indicating that IPT-A treatment may be effective for adolescents who are moderately to severely depressed. This study also indicated that individuals who have had little or no prior experience using the IPT-A method could successfully apply IPT-A therapy with short-term intensive training.

Although the results of this study are promising there are limitations. The participants in this study were predominantly female, which leaves unclear whether these treatment effects would be found in depressed male adolescents who were treated with IPT-A. The participants in this study also had comorbid diagnoses, and the treatment effects indicated in this study may be specific to one of the other diagnoses rather than the depression. Because there was no follow-up data collected, it is unclear how long the treatment effects lasted. This study cannot therefore predict rates of relapse after receiving IPT-A treatment.

The most recently completed study on the effectiveness of IPT for depressed adolescents compared the use of this method with cognitive-behavioral therapy (CBT; Rossello & Bernal, 1999). This study used the original IPT treatment protocol instead of IPT-A, resulting in issues of single parent families not being addressed. Participants in this study included 71 Puerto Rican adolescents who met the diagnostic criteria for major depressive disorder, dysthymia, or both. The sample was well balanced by gender consisting of 54% female and 46% male participants. This study also used a wait-list control group. Both treatment groups met with the participants individually, once a week for 12 weeks. Each session lasted one-hour. Several outcome measures were used to assess participant progress throughout the study.

The results of this study indicated that both IPT and CBT are efficacious treatment modalities for adolescents with depression. IPT participants, however, were statistically better functioning than the CBT participants at the conclusion of treatment. The results of this study demonstrate that IPT may be an effective modality for treating Puerto Rican adolescents who are depressed.

The results of this study support the efficacy of IPT for adolescents with depression, however, there were limitations to this study that need to be addressed in future studies. Some of these limitations include a small sample size, restricted measures of functioning, use of only self-report outcome measures, loss of contact with wait-list control group at follow-up, lack of investigation in to co-morbidity of diagnoses, and the larger proportion of participants diagnosed with major depression in the CBT group. This study was also limited because it only considered the use of this method with Puerto Rican adolescents. It is therefore unclear whether or not the same results would be applicable to adolescents of different cultural backgrounds.

CONCLUSIONS AND RECOMMENDATIONS

IPT was originally developed as a short, time-limited therapy to treat adults diagnosed with major depression (Mufson et al., 1991). Within the last decade, IPT has also been adapted for use with many different populations and different clinical diagnoses (Weissman & Markowitz, 1994). IPT-A is one of the modifications that has been made to IPT and is designed to meet the developmental and contextual issues of adolescents with depression (Mufson et al., 1991). Recent empirical investigations of the use of IPT-A with adolescents who are depressed demonstrate encouraging results (Mufson et al., 1994; Mufson & Fairbanks, 1996; Mufson et al., 1999; Rossello & Bernal, 1999; Santor & Kusumakar, 2001).The number of participants in these studies, however, has been limited (Mufson et al., 1994; Mufson & Fairbanks, 1996; Mufson et al., 1999; Rossello & Bernal, 1999; Santor & Kusumakar, 2001). The empirical findings of these studies, therefore, cannot be generalized to populations of adolescents with depression from varying demographic backgrounds. Treatment effects in these studies are also unclear based on research design problems (Mufson et al., 1994; Mufson & Fairbanks, 1996; Mufson et al., 1999; Santor & Kusumakar, 2001). It is difficult to discern whether treatment effects were due to the actual IPT-A treatment or other factors that were inherent in the research design.

Future empirical investigations are needed to address the limitations of previous studies if mental health counselors are to have confidence in the ability of IPT-A to effectively treat adolescents with depession. Future empirical investigations should use larger and more demographically diverse participant samples. Studies that include more males and individuals from other cultural backgrounds are needed. Future empirical investigations may also want to further examine whether counselors need a great deal of training in IPT-A to have successful treatment effects with depressed adolescents. IPT-A also needs to be examined in comparison to other methods of treatment for adolescent depression. Studies that compare IPT-A treatment to pharmaceutical treatment or that examine the use of pharmaceutical treatment along with IPT-A might be helpful in discerning what treatments could be most effective for treating adolescent depression. Studies are also needed to investigate the long-term effects of IPT-A treatment for adolescents with depression. This is especially important given data that suggests adolescent depression often leads to depressive episodes in adulthood (Weissman et al., 1999). Finally, many of the studies completed on IPT-A have examined its effects with adolescents who are only diagnosed with depressive disorders. Adolescents who had co-morbid diagnoses were often times excluded from the studies (Mufson et al., 1994; Mufson & Fairbanks, 1996; Mufson et al., 1999). Given that adolescent depression is often co-morbid with other clinical diagnoses (Nolen-Hoeksema & Girgus, 1994), additional empirical attention needs to be given to the use of IPT-A with adolescents who have a depressive diagnosis in conjunction with another DSM-IV diagnosis.

Given the promising results of initial empirical investigations into the efficacy of IPT-A with adolescent depressive disorders, the need for future research is substantiated. Future research could clarify IPT-A's treatment effects with adolescents of differing demographic backgrounds, compare the efficacy of IPT-A with other treatments for adolescent depression, clarify whether IPT-A can be used by novice counselors, and could demonstrate IPT-A's efficacy with adolescents with co-morbid diagnoses.

REFERENCES:

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996)., Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427-1439.

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Elizabeth A. Mellin is a doctoral student and Patricia M. Beamish, Ed.D., is an associate professor. Both are with the Department of Counseling and Higher Education, Ohio University, Athens. Email [e-mail] and [e-mail]