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Past Medical History

Generally healthy, with no history of thyroid disease or sexually transmitted infections. Alex was taking birth control pills, but no other non-psychotropic medication.

Mental Status Examination

Alex was an alert, petite, attractive, slim brunette woman, appearing her stated age, with appropriate makeup, dressed in blue blouse and skirt. Her movements were somewhat controlled, and her speech was fluent and unpressured, if somewhat monotonal and deliberate. Her mood was mildly to moderately depressed and anxious, with constricted affect for much of the interview. She gave way to tears briefly near the end of the interview but then resumed control. She showed no affective lability. Thinking was goal-directed, if somewhat obsessive and intellectualized. Alex denied psychotic symptoms and active suicidal ideation, conceding that life did not always feel worthwhile. She reported suggestions of obsessive-compulsive behaviors, such as having a favorite, magic number. In terms of her insight, she recognized being depressed and frustrated with past treatment, but had doubts about her prognosis. Sensorium was clear, with full orientation.

Impression

A thirty-year-old married businesswoman with longstanding, perhaps lifelong dysthymic disorder, with at least traits of and perhaps mild syndromal obsessive- compulsive disorder (Table 6.1). She was apparently functioning fairly well at work.

Alex has evidently never had aggressive trials of antidepressants, and might benefit from pressing the dosage higher. She appears a good candidate for IPT: she has relationships (a blessing for a chronically depressed patient, from the IPT perspective), and they are replete with conflict. IPT might focus on either a role transition or a role dispute.

Plan

As an initial plan, we discussed:

1. Discontinuing birth control pills, which might be worsening her mood and seemed unnecessary in the absence of sexual contact and her spouse’s requirement for other forms of contraception. She agreed to discuss this with her gynecologist.

Table 6.1 DSM-IV Diagnoses Axis I Dysthymic disorder (300.4)

Axis II Rule out Obsessive-compulsive personality disorder

Axis III Birth control pills

Axis IV Marital and family stress

Axis V 52-Global Assessment of Functioning score consistent with moderate

symptoms and impairment (1-100 scale where lower scores indicate lower functioning [APA, 1994])

  • 2. Checking her thyroid function, which had possibly never been previously tested
  • 3. Beginning venlafaxine, a medication she has not yet tried that has noradrenergic as well as serotonergic effects. We reviewed potential side effects, benefits, and likely course.
  • 4. Beginning a twelve-week course of IPT as a more focused antidepressant psychotherapy. We made an appointment for the following week. Despite an impressive income, she was concerned about cost, as her insurance covered only half my fee. She ambivalently agreed.

Session 2

Alex appeared promptly. She was somewhat brighter and less hopeless, although she reported persisting depressed and anxious mood, and her affect remained constricted and controlled. She had gotten her thyroid tests, which were normal, but had not yet contacted her gynecologist.

To my question, “How have things been since we last met?” she reported tolerating venlafaxine without side effects and feeling “maybe a few more ‘happy’ moments, it might be starting to work.” We agreed to increase the dosage. She volunteered that she had felt slightly more hopeful after the evaluation session, but quickly felt worse after Mike called and they struggled over weekend plans. I pointed out that her mood seemed connected to how she interacted with other people, which would be an important theme in our treatment.

We spent much of the session collecting an interpersonal inventory. Alex had a few friends from college, graduate school, and her job, but they really constituted extended acquaintances rather than people in whom she could confide. Her husband’s friends provided most of their social life, but she saw them as mostly distasteful immature types whose company she tolerated. She could confide in her mother, but feared burdening her because her mother was still more depressed than she (“I can handle it better”). Nor did she want to upset her younger brother, although they did have a warm relationship. Her father had never been approachable: he was always demanding, argumentative, and irritable; a provider, but emotionally disengaged from other family members. Because of his workaholic business career, he had rarely been around anyway. Alex agreed with my suggestion that there had been no one to talk to growing up, and that she had kept everything bottled up inside herself.

We resumed discussing her difficult relationship with her husband. Mike was no easy confidant himself. While she worked long hours, he had been coasting through his final two years of law school partying, spending their money, and taking numerous vacations with his school pals but without her. She conceded that the two of them were very different. She described them as “close, we love each other, but he hates New York and I love it, he’s for spending money while I would save,” etc. They had agreed that she visit him in New England every weekend while his school was in session in return for his eventually returning to New York after graduation.

This agreement amounted to a formal legal contract in their minds. She resented having to commute to his party weekends, but had already invested two years in doing so and at this point felt it would have been for naught if she reneged: he would then not have to honor his part of the deal. Indeed, most of their agreements had to be hammered out in lengthy debates in which she felt unsure, gave ground to his endless, withering arguments, and ended up feeling hemmed in and resentful. It was partly, she conceded, that he was a good debater, and partly her own self-doubt that was the problem. The arguments enraged her: Alex felt that she was probably right to feel taken advantage of, but couldn’t win the debates, was tired of fighting, and didn’t let herself feel her full anger “because it would be unbearable.”

I asked: “What’s wrong with being angry?” She related anger to her father’s drunken, screaming outbursts at her mother, a bad thing. “What good does it do?” she asked. Anger was disorganizing. She tried to keep things “civilized and rational,” taking a stolid, polite stance. We agreed that this didn’t seem to be working, and that her disputes with her husband left her frustrated and confused. “There’s something wrong with me, I know. I’m just defective,” she said. I ventured that the problem might not be that she was defective, but that chronic depression made her feel that way. That defective feeling was a symptom. Meanwhile, anger was a normal emotional response to having someone frustrate and bother you: “If a rational argument works, great; but if the other person doesn’t listen, what else can you do? It’s helpful to have more than one option for responding.” This led to a discussion of anger as a healthy signal of frustrating situations, and an emotion that could be put into words. I remarked that it often felt good to get frustrations off one’s chest, and that if she felt angry and didn’t express it, she was likely to feel uncomfortable, anxious, and perhaps more depressed. She cautiously if somewhat skeptically agreed.

Alex role-played expressing her frustration to her husband. “I know you have fun on weekends, Mike, and I want you to have fun, but it makes me angry that you expect me to drag myself to see you and join in when I’m exhausted after a week of work.” On review, we agreed that the content was what she wanted to communicate, but that her tone of voice was still very measured and “rational.” Although it meant stretching her usual affect, with further role-play she was better able to sound angry as well as to explain why she felt that way.

I suggested that this was a great time to take social risks. If they paid off, she was way ahead; and if they didn’t, at least she had tried, and we could discuss what had gone wrong and look for alternative approaches. She cautiously agreed.

Impression

This was an encouraging session. Alex remained depressed but seemed somewhat remoralized by the initial session. She took to role-play and was able to work on her constricted affect. Although she feared confrontations, which had been and remained painful to observe in her parents’ relationship, she seemed to understand the need to confront her husband, and seemed likely to do so.

Session 3

Alex was alert, prompt, and well groomed, in a more colorful outfit. She had normal movements, none involuntary, and fluent, unpressured speech. Her mood was less depressed (6-7 on a scale of 10, versus 2-3/10 at baseline) and mildly anxious, with controlled affect. She was half-smiling, giving way to controlled sadness and anger, and eyes welling by session’s end. Her affect was nonlabile and there was no thought disorder. She denied suicidal ideation and her sensorium was clear.

“How have things been since we last met?” Alex reported “doing okay” and denied venlafaxine side effects. She noted that her mood had improved somewhat, and mused that she was not sure if depression comes from biochemical vulnerability or life situation “or I guess it’s both.” She expressed doubts about whether her marriage was worth all the effort she had invested in it. Mike now wanted to go to a Colorado beer fest with his friends that coincided with her brother’s wedding. Alex said Mike knew how important this family occasion was for her, and he went drinking all the time—too much, perhaps. There would be other beer fests. Nonetheless, Mike argued that since he wanted her to come to the festival and she wanted him to come to the wedding, they were both equally disappointed and should keep their independent commitments.

This was a typical disagreement in which she felt in the right, yet emerged feeling indecisive, frustrated, and half-convinced by specious arguments. She expressed her sense of being a “weak” person in arguments, not sure whether Mike was not right. She said that her friends blindly supported her and her family already had a low opinion of Mike, so she resisted discussing their marital differences with them further. He’s “so childish, selfish! Even when he has compromised a little, it requires an exhausting effort.” Alex felt stuck, not wanting to be alone, “not wanting to feel I’ve wasted all this effort on marriage for nothing.” I validated her feelings, saying that they were understandable and something to weigh against what it would be like to continue this sort of relationship indefinitely. “And you’re also right that the marriage is contributing to your feeling depressed,” I said.

At this point it was tempting to dig further into the marriage, but I felt I should give Alex a formulation in order to structure the remainder of treatment:

therapist: Can we pause for a moment? You’ve given me a lot of helpful information so far; I want to make sure I’ve gotten the picture of what’s going on with you. From what you’ve told me, you’ve been depressed for about as long as you can remember, long before when the depression worsened in your freshman year in college. We call that kind of lingering depression dysthymic disorder, and it’s a treatable, medical problem that’s not your fault. In fact, we’re going to try to make it better in just the next nine weeks. There are already some hopeful signs that you’re improving, although I expect you to be skeptical until you’re really feeling better, and perhaps have felt so for a while. Both medication and psychotherapy can be helpful in treating dysthymic disorder.

This kind of chronic depression has the kind of symptoms we’ve already been talking about: self-doubt and self-criticism, indecisiveness, sleeping problems, and a discomfort with feelings like anger and your own wishes that makes it hard to be in confrontations. (It doesn’t help that your husband is such an arguer!) Feeling this way with dysthymic disorder makes it hard for you to stand up for yourself in interpersonal encounters: the “weakness” and “defectiveness” are dysthymic symptoms. We know that there’s a connection between how you’re feeling and how you handle situations with other people: depression makes it hard to handle situations, and when encounters with other people go badly, it’s depressing, right? alex: Right.

therapist: And yet if you’ve always felt this way, it’s hard to tell what’s depression and what’s you, where the depression is getting in your way. What we’re going to do over the remainder of this twelve-week treatment is to help you through a role transition, to help you see what’s the healthy you and what’s the depression. If you can learn to trust your healthy emotions and use them to handle encounters with Mike and other people better, things should go better, and you should feel better. At the same time, we’ll be giving the medication a chance to work. So it’s a transition from thinking this is the way you are to feeling better. Does all that make sense to you?

It did. She agreed to the formulation, and we scheduled a next session.

Impression

Another encouraging session: Alex is a little rigid but a quick learner. Her symptoms seem to be improving—whether from the medication, IPT, or both doesn’t really matter at present. I opted for an iatrogenic role transition despite the presence of clear role disputes—with both her husband and father—because Alex’s symptoms so long predate her marriage and she seems so clearly to be struggling over which of her feelings and symptoms she should trust.

Plan

We increased the venlafaxine dosage as she was having no side effects.

Session 4

Alex arrived looking generally brighter but still self-doubting. We began by repeating her Ham-D, which had dropped to 11. She was slightly surprised but pleased to see this progress, on which I congratulated her. She reported “doing okay. Still some problem sleeping, but that may just be from the depression.” She said she generally felt okay “when not thinking about my marriage”

Alex raised her concern that she is too compulsive and not flexible enough, a criticism her husband had made. She reported having gone home following our last session and noticing she was upset. She wrote Mike a long email—“in direct conversation things tend to get too emotional”—in which she clearly spelled out feeling hurt about the wedding situation. To his credit, Mike came home early from work so that they could have a long discussion. She emphasized a point we had discussed, that she really needs to have him acknowledge her feelings if the relationship is to work. He then agreed to attend the wedding, saying he “didn’t realize it was so important to you”! (Alex and I agreed this was a remarkable explanation, given their long arguments about this.) He then complained that she was not emotionally available, too compulsive and inflexible.

We briefly discussed her mild obsessive-compulsive symptoms. She then conceded that it was hard for her to be emotionally available, having accumulated lots of anger at Mike over the years. I agreed that she had a lot to be angry about:

therapist: And it’s never simply resolved: even when Mike concedes a point, he doesn’t just apologize, but comes back with conditions, etc. It sounds exhausting.

alex: It is. But my choices seem to be to keep working to make baby steps [to improve the relationship] or to give up. therapist: That maybe true.

We reviewed her options for accelerating improvement in the relationship. Both rational proposals and angry arguments had been unsuccessful. I asked if she had ever given him an ultimatum. She had, several years before, after moving to New York, “but I guess not since”—and never about their sexual difficulties. She noted that “it would be very frustrated to have invested so much energy in this relationship and not have it work out.”

therapist: Yes, that’s true. You’re being very patient. The fact that you have to invest so much energy to get so little return . . . When do you think he’s going to really get it?

alex: I don’t know. Maybe it’s hopeless.

We discussed the pros and cons of in-person communication over email: she agreed that email might allow her to control affect better but also was less direct and more open to misinterpretation. We role-played both the content and tone in which she might address Mike, during which she raised the stakes by saying, “You know, I can’t put up with this forever.”

Impression

Alex is improving steadily, tolerating venlafaxine well, and really trying to address the marital thorn in her side despite her doubts. She sees the wedding concession as a victory, albeit one too hard to win, and is voicing clearer anger at Mike (which I’m normalizing) and less at herself. Good signs are that she is generally insightful and quick to convert our discussions into interpersonal actions. She sounds clear, if deliberate, in her communication. The prognosis appears good for her, if not for the marriage.

Session 5

Alex is alert, prompt, and well groomed. She has normal movements, none involuntary, and fluent, unpressured speech. Her mood is mildly depressed and anxious, with reactive, nonlabile affect. There is no thought disorder. She denied suicidal ideation. Sensorium is clear.

She reported feeling a little worse. “My brother’s wedding is next week, and Mike will come, after all, but it was a struggle. He seemed to get it, and is also willing to go to take a future weekend beach vacation because he knows it’s something I like. He does seem to be trying.” On the other hand, achieving these victories had again seemed Pyrrhic: it required hours of discussion, and he criticized and caviled even as he conceded these decisions, leaving her with a bad taste in her mouth. Alex reiterated that she loved Mike, but she found their relationship exhausting. He continued to avoid sex.

Alex reported tolerating medication without side effects except possible exacerbation of chronic sweating. She was willing to continue the medication and to increase it to 225 mg daily. On the whole, she concluded, she is feeling less depressed, but Mike gets her really upset. She seemed angrier and sadder as she recognized that she is right to be upset about her marriage.

Session 6

therapist: How have you been since we last met?

alex: Good. The wedding was nice, although I had to intercede between Mike and my father. Both of them can be so difficult, and I’m always caught in the middle. I have to protect Mike from my Dad.

This led to a discussion of continuing tension with Mike, as well as her father’s irritable, critical, and unsociable behavior. Mike had now reneged on the beach plans, saying that he hadn’t realized that her family might join them, and that that voided their contract. Alex sighed: “Everything’s an argument, everything’s a negotiation with him.”

We discussed whether she was being overly reasonable and placating with Mike rather than fully expressing how angry his pattern of argument and criticism made her. He continued to see their marriage as a formal legal “contract” and was constant “litigating” with her. She had had it. “I keep thinking: if only I could explain it right, maybe he would get it.” I suggested that she seemed clear in her communication on her part, whereas Mike seemed to like to argue but not really to listen or communicate. She related her anger that in their one attempt at couples therapy, the therapist seemed so evenhanded, never contradicting Mike:

alex: Why didn’t she tell him he was being an asshole? . . . I try to listen to him but he doesn’t listen to me. It makes me so angry! therapist: You’re right to be angry. You need to trust your own feelings, although depression can make it hard to do so. It’s not nice that Mike plays on your depressed doubts to his own advantage. Do you do that to him?

No, she did not. Alex was sounding angry in a fuller, less controlled (but nonlabile) way than before. Mike never made sacrifices for her, whereas she frequently sacrificed for him.

alex: I want him to make things up to me. He’s kind of conceding he’s been wrong in the past, but wants to start over with an even scorecard, and I’m just too angry to do that right now. therapist: Have you said that to Mike?

She had not. We then role-played how she might communicate this to him. I commented: “You know, you’re really sounding much less controlled, much more appropriately angry.” Instead of getting obsessionally stuck in the argument of the moment, she recognized her objection to Mike’s more general argumentative strategy: she listened thoughtfully, whereas he played to win. We spent the rest of the session reviewing what she wanted to say to Mike and in what tone. By the end of the session

Alex had reached an ultimatum: “I’m not ready to take this kind of behavior for much longer!” She was going to give him until the end of his term to get his act together.

Impression

Further progress: Alex is doing well at the halfway mark. I reminded her that we were halfway through treatment as a further spur to her tackling of her marriage.

Session 7

Alex arrived late, having called ahead to say she was stuck in terrible traffic. She was perhaps overly apologetic. That aside, she seemed bright, euthymic, and more emotionally engaged. She denied depression, seemed just slightly hesitant and anxious, but on the whole looked proud of herself.

alex: Well, things have been good. [She had learned the IPT method: I didn’t even have a chance to ask my opening question.] Things have been good. I practiced what we discussed and really told Mike how I felt. He seemed to get the point. In fact, he’s now talking about starting therapy himself, which I take as a good sign. It’s a concession that not everything’s my fault. therapist: That’s great! Tell me all about how you did this!

She recounted having said to Mike pretty much everything we had discussed in the prior session. “When he saw I wasn’t hesitating, he really backed off. The funny thing is that I did still feel a little unsure inside, but I went for it anyway, and it really worked. I do feel like I got a lot off my chest.” I validated her emotional response and reinforced her ability to assert herself with her husband. From her description, the interchange was unlike any they had had before.

Session 8

We repeated the Ham-D at the start of the session, which was now at 5. I noted that this constituted remission: she really had the depression under control. Alex denied meaningful side effects on venlafaxine 225 mg daily. She reported feeling euthymic but a little worried about whether it would last. She also described, and showed in her affect, sadness and anger.

alex: I’m still angry, wary, not sure how much Mike owes me for all his past mistreatment. We can’t just start things over as if nothing had happened in 6 years. And the romance, the erotic vibe is still missing. He is trying, at last, and yet I’m too mad to show appreciation at times. Last weekend I went up to see him at law school, and when I came in the door his cell phone rang, and he spent fifteen minutes on the phone talking to his buddies rather than greeting me. I was furious. Then he said he was disappointed that I hadn’t appreciated how he cleaned up the house for me, and that he was at home rather than in a bar. He had some points, those were nice things he didn’t usually do, but I was too angry to really give him credit.

therapist: Why was that?

alex: Because his ignoring me for a stupid frat-boy conversation made that hard to appreciate. Was I wrong? therapist: What do you think?

alex: As usual, Mike has an argument, with some pieces of evidence to back him up. But I think I have a point, too. He’s so selfish, he always putting himself first and not stopping to think of my feelings.

therapist: That’s where you are right now. You need to trust how you feel. I certainly understand why you felt angry. So did you tell him? alex: Yes, I think you’d be proud of me. I told him that his ignoring me ruined the other things he had done, which is unfortunate: I could see he had tried, but then why did he have to undo the positive by acting as if I hadn’t arrived? That he really hurts my feelings when he treats me like I’m not even there. And furthermore, I said I really needed him to get his act together by the time he graduates, which is less than six months away. That means his stopping carping about everything, to really listen to what I’m saying and pay attention to my feelings. That also means our having a sex life. I said this forcefully [as she was saying it now] but not too shrilly, just the way I wanted it to come out. It sounded good, and I felt good. And he heard it.

therapist: That sounds great! No wonder you’re feeling good.

Alex raised her doubts about whether Mike was really capable of changing. She then went on to talk about her wish to confront her father, who also intimidated her and ignored her feelings.

At the end of the session I reassured her that while her mood might shift in response to life circumstances, she was likely to remain better—although it might take some time feeling euthymic for her to believe it. I encouraged her that creating a “new track record” while euthymic, taking advantage of her gains to build further momentum, would increase her self-confidence over time.

Impression

Euthymic and doing well interpersonally. She has a real question of whether her husband, whatever his intentions, is capable of meeting her halfway.

Session 9

Alex was alert, prompt, and well groomed, with more relaxed movements and fluent, unpressured speech. Her mood was euthymic and mildly anxious, with more reactive, nonlabile affect. She had no thought disorder. Sensorium was clear.

Mike had sent her a long email complaining that she was ignoring his attempts to change things. Alex brought this in to discuss: she disagreed with much that he said, found it self-serving, and yet remained confused as to how to move forward. She noted Mike’s insistence on developing a contract of rules for starting over in their relationship, of which his letter was an example. Mike complained that therapy was making her a more difficult, angrier, and less pliant wife, and wanted to know: “Do you promise you’ll be the same after tomorrow’s session?”

She described herself as needing a moral compass but increasingly feeling vindicated in her own feelings. We role-played how she might handle Mike when he asked about her feelings after the session.

Impression

Alex continues to feel better while also feeling a little overwhelmed by the changes she is making. I kept putting the ball in her court, emphasizing she has to be the one to decide things.

Session 10

Alex reported still feeling euthymic, and seemed a little more confident that this improved state might persist.

As predicted, Mike immediately wanted reassurance after our last session. “I confronted him, said this wasn’t going to work, and he gave in. He is seeing a therapist, although I’m not sure what he’s doing in those sessions. . . .What’s cool is, I’m handling things differently than in the past. We’re no longer having exhausting fights, and I’m also not giving up and letting him win rather than fight. I told him I could meet with him and his therapist if he’d like.”

We discussed her continuing shift in feelings towards her husband. “I’m not depressed, but I’m unsure where I’m going and our marriage is going, confused at times . . . I’ll have to see how I feel, I guess, but I can’t just forgive him instantly. He does seem to be making a little progress, but it’s not clear that he’s really going to be able to have sex or really learn to communicate. On the other hand, it would be sad to give up after having invested so much time, effort, and suffering, blood, sweat, and tears in him.”

Why had she put up with this for so long? She spontaneously linked her marriage to her parents’ difficult relationship, and not wanting to separate as they had. She blamed both her father and to some degree her mother for the bad parental marriage. “And Mike always projected such certainty that he was right about things . . . but I’m not buying that any longer.”

We again discussed and role-played her wish to express her feelings to her parents about how she had felt growing up, and how their marriage had affected her. She had never really confronted her father for not being around and for being so hurtful. She worried it might ruin their already tenuous relationship. “Or strengthen it. You’re on a roll!” I commented. We did, however, review contingencies for what might go wrong in such a talk, and how she might broach this to her parents.

We then broached the topic of acute treatment termination and what Alex would like to do. I emphasized that she had already made great progress, achieving the goal of acute treatment of euthymia. I noted that some patients liked ongoing contact, sometimes at reduced frequency, to consolidate their gains, but that she should decide what she wanted to do. (Given her sensitivity to men imposing conditions on her, this stance seemed important.) Alex raised questions about the cost of therapy and said she would think about it. She paused, then thanked me, saying that she had gotten a lot out of treatment already. I mentioned that the idea of separation could evoke sadness, but that sadness differed from depression.

Session 11

Alex reported that her mood remained good. Work was going particularly well and she might qualify for a bonus. Moreover, things were going better with Mike. He was less frustrating in discussions, seemed to make an effort to ask her how she felt at times. Nonetheless, he was still avoiding sex, saying he was worried about pregnancy despite contraception. It wasn’t clear that he was really discussing this with his therapist—he refused to discuss it. Much as she didn’t want to give up on the relationship, she mused about whether he was really capable of change, whether she was wasting her time.

She had in the meantime confronted her father, with partial success. She had set up a time to speak to him, and he had listened more than usual as she told him that she’d like to have a better relationship, but that she was hurt and angry at the way he had treated the whole family growing up. He denied that much bad had happened, at which point she said that if he took this stance, they couldn’t have much of a discussion. He was initially angry, taken aback, but then said he would think about it. The next day he had called and said it was helpful she had confronted him.

We agreed that she was continuing to find alternatives to either going along with the other person’s rules or fruitlessly arguing. I noted that she seemed less bound by her dysthymic outlook, more confident and more secure in her own feelings. She had “changed the equation” with Mike, and perhaps could do so with her father as well.

Session 12

Alex was as usual prompt to the session, well groomed and bright. Her Ham-D was now 4. Her mood was euthymic and very mildly anxious; her affect was still slightly constricted at points, but on the whole far fuller than twelve weeks earlier.

Nothing much had changed in her marriage. Mike still seemed to be trying hard to be conciliatory, and he was seeing his therapist more often. She felt less angry at him but more dubious that things would really improve. They had had sex only twice during the interval of therapy, both times at her urging. He continued to shrink from intimacy, telling her he was “just really fucked up” Although this was better than his blaming Alex for all their difficulties, it was still discouraging.

She thanked me for having helped her to this point. I said it had been a pleasure working with her, that I had been impressed by her fortitude, by her bravery in taking interpersonal risks, and by the considerable progress she seemed to have made in understanding and trusting her feelings, communicating them to others, and improving relationships. She asked whether we could continue to meet every two to three weeks for maintenance treatment. I agreed, asking her what goals she had in mind. She talked about resolving her marital situation, improving her family relations, and perhaps building some other social supports, noting that she did not have a lot of friends to turn to.

Impression

Euthymic at the end of acute treatment. The iatrogenic role transition to euthymia appears accomplished. Alex’s marital role dispute is somewhat improved, and she really did as much as could be expected to improve it; much of the problem appears to lie with her husband. Mild obsessive-compulsive traits persist at a diminished level.

Plan

Begin maintenance IPT, meeting every two to three weeks for the next year, and have her continue venlafaxine 225 mg qd.

Follow-up

Over the next year, Alex continued antidepressant medication and IPT, the latter generally at three-week intervals. Her business career flourished, her relationships with her mother and brother improved, and she began to develop some friendships at work. Despite intermittent attempts to approach her father, they remained fairly distant. Mike graduated from law school and moved back to New York. Although less argumentative, he was unable to tolerate much intimacy despite individual therapy and a couples/sex therapy the couple began. She did report feeling more confident, and more assured that her good mood would persist.

Five months after the graduation deadline, having repeatedly weighed her feelings and her options, Alex stuck to her ultimatum and sadly told Mike that it just wasn’t going to work. He was first angry and recriminating, but Alex held her ground, and they both ended up tearfully agreeing that things were not satisfactory. After moving out, she initially worried that she was getting depressed and shifted IPT frequency to every two weeks, but soon stabilized again, and felt stronger having learned she could tolerate such changes. Like many chronically depressed patients, euthymia took some time to feel secure, and led her then to look back sadly on lost years of depression and decreased productivity. She adjusted, however, mourned the past (a completion of a role transition), and focused on moving ahead.

An attractive and intelligent woman who now showed far more emotional range and appropriate self-assertion, she began dating a few months later and started a new, healthier relationship. This relieved her fears that it was “too late” to start over. At the end of the one-year follow-up, her obsessive traits seemed greatly diminished (cf., Cyranowski et al., 2004). She then opted to continue medication and to check in every six months with me. She remained euthymic, had remarried, and (having briefly stopped her antidepressant) had a healthy young child at a further three-year follow-up.

DISCUSSION

Chronically depressed patients can be discouraging, but the combination of antidepressant medication and IPT may provide a potent intervention that literally gives them a new lease on life. The case of Alex proceeded relatively smoothly, and her outcome was excellent. Whether her initial mood improvement resulted from medication, psychotherapy, or the combination, IPT was obviously instrumental in helping her learn to tolerate and understand her affects and to use them to improve her relationships. She tried to resolve and eventually dissolved her role dispute while successfully navigating the role transition to euthymia.

Not all chronically depressed patients respond so easily, but many will respond to combined pharmacotherapy and IPT. Combined treatment has never shown less efficacy than monotherapy for depression (Manning et al., 1992; Rush & Thase, 1999). An advantage of the current case was Alex’s marriage: in IPT, we prefer a bad relationship to the absence of relationships. Many chronically depressed patients are single and isolated and would have to be mobilized to find relationships, whereas here the marriage provided a ready laboratory for Alex to explore her interpersonal options. Alex also quickly remoralized in treatment, her hopelessness fading. She showed a readiness to risk change in order to improve her situation. Therapists always hope for such patient qualities, and treatment is obviously more difficult—but still rarely impossible—in their absence. For some chronically depressed patients, an occupational gain, such as asking for a raise, may provide a less threatening initial treatment focus than interpersonal intimacy. Work has a job description patients can understand, whereas dating and other relationships can seem overwhelming, uncharted territory for chronically depressed individuals. An initial success experience (Frank, 1971) at work that helps the patient achieve euthymia may provide greater confidence for subsequent gains in relationships.

Under all circumstances, the therapist must remain encouraging and therapeutically realistic, keeping in mind that the patient is chronically hopeless and waiting to see the therapist give up, as others around him or her have. It is helpful to think ahead both pharmacologically and psychotherapeutically: If this medication is ineffective, what should the next step be? Where does the therapy appear to be heading? Which affects and relationships is the patient avoiding? When the patient sees that you are not giving up, that you really believe the prognosis is good, and that other options remain, it provides an important model for the patient’s own outlook.

SUGGESTED READING

Markowitz JC: Psychotherapy of the post-dysthymic patient. Journal of Psychotherapy Practice and Research 1993;2:157-163

Markowitz JC : Interpersonal Psychotherapy for Dysthymic Disorder. Washington, D.C.: American Psychiatric Press, 1998

Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks MH: A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients. Journal of Affective Disorders 2005;89:167-175

 
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