Interpersonal Psychotherapy for Dysthymic Disorder

In this slender volume, Markowitz presents a lucid, candid description of interpersonal psychotherapy, one of the two most researched short-term therapies for depression, the other being cognitive behavior therapy as described by Beck et al. (1). Both of these therapies have been shown to be effective in major depression, generally of the milder variety. This volume focuses on treating patients with dysthymia, whose sufferers are a major constituency in office-based psychiatric practices. The author has worked extensively with Klerman, Weissman, and colleagues, whose original volume on interpersonal therapy and depression goes into greater depth regarding general principles of the treatment (2).

A key premise of the book is that the chronicity of the disorder should not be mistaken for the personality of the patient. After treatment, many dysthymic patients no longer have the morose, pessimistic, self-defeating qualities that were considered traits but were actually part of an illness pattern. This point deserves particular attention for the treatment-naive patient, as well as for those who have had aimless or otherwise fruitless therapies.

The author’s nondoctrinaire approach includes pointing out the importance of medication as a first-line treatment for many dysthymic patients, interpersonal therapy’s inclusion of the nonspecific factors Jerome Frank (3) defined as necessary in any successful psychotherapy, and the fact that interpersonal therapy has its share of failures. The importance of the optimistic therapist is emphasized. Through his understandable explanations of why interpersonal therapy works, specific suggestions, and illustrative case vignettes, Markowitz convinces the reader of interpersonal therapy’s utility.

The book begins with a basic review of dysthymic disorder and its treatment. The overview of interpersonal therapy packs a lot of information into a few pages, which has the advantage of brevity but the disadvantage of curtailing discussion of some topics, such as differential therapeutics. The overview chapter also defines the four areas of focus of the therapy: grief, role dispute, role transition, and interpersonal deficits. These areas are elaborated on in the chapter that deals specifically with treatment of the dysthymic patient, leading to some redundancy.

The category of interpersonal deficits is the most questionable theoretically and the most problematic therapeutically, as the author acknowledges. It encompasses patients who are isolated, have poor social skills, and lack connection with others. The author advises steering clear of this area, if possible, and choosing another focus with the patient. Many of the interpersonal therapy failures are with patients who have interpersonal deficits. The author emphasizes the need to try different approaches when failure occurs. He should have included the need to review the diagnosis. Unsuccessful outcomes are often caused by misdiagnosis. I suspect that in addition to having axis II features, as the author suggests, some patients with interpersonal deficits may have social phobia.

Markowitz acknowledges that combined psychotherapy and pharmacotherapy is ideal but accepts the premise that its general use is too expensive, advocating it only for difficult situations. Too expensive for whom? Lost opportunities and adverse effects on the patient as well as economic and emotional travail for those around the patient are rarely taken into account when costs are considered.

Psychotherapy research can confirm the utility of a treatment for a given diagnosis but may not tell us what to do with a given patient. Any successful treatment must enable the patient to change maladaptive behaviors, but we still do not know enough to match the type of therapy with variables such as the cognitive styles, temperaments, and beliefs of the patient and therapist, which highlights the need for flexibility and more than one approach. In this regard, if the only treatments used are those whose outcomes can be measured, we may be sure that other useful treatments will be bypassed because ways of measuring them may not yet exist. Tension between treatment approaches is necessary for the discovery of new methods, which is how current short-term treatments emerged.

The limits of a one-size-fits-all approach to psychotherapy may be particularly evident in short-term treatment approaches, which lack the luxury of time for the patient and therapist to develop a synchronous operating mode. The psychiatric generalist sees a wide variety of patients and needs competence in more than one type of psychotherapy, as well as in psychopharmacology, unless patients are to be constantly referred to colleagues. This excellent book will urge an expanded repertoire on the experienced psychiatrist and provide trainees and less experienced therapists with an introduction to interpersonal therapy. Now, if we could only teach therapists how to be creative in applying their skills.