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DISCUSSION

IPT nicely frames the situation of medically ill depressed patients. Some interesting issues arise in working with this population.

First, as depression begins to lift, many patients reframe the role transition of their medical illness as having a silver lining, “a blessing in disguise," as one patient described it. The illness gives them a chance to take a serious look inward, to evaluate, reconsider, and embrace their real needs. Some patients describe the illness as a turning point, after which they addressed aspects in their lives that they had previously avoided. Having a serious illness and facing the prospect of death is an opportunity to reevaluate life from a different, more introspective, and deeper perspective. Patients who have felt crushed by a role transition can feel resilient in having confronted and at least partially resolved it. This was obviously the case for Juana.

Another woman with breast cancer realized that she had been the stronger one in her relationship, and the financial and emotional caretaker for the whole family. When she got sick, she continued working, taking only a few days off for surgery. She had believed that she couldn’t take the time off because her family would not survive financially. After that experience, she started to reexamine her twenty-five-year relationship with her husband. She was able to recognize and understand her deep resentment and anger towards him. She started to make changes to take care of herself, giving herself permission to ask for things, set limits, and be vulnerable. Patients may see how numb their lives have been up to that point. A patient talked about a sense of “awakening," as if the illness were actually knocking on her door to force her to look at what had long been dormant or “dead," making her life dull and meaningless.

We may hypothesize that facing the possibility of one’s own death may alter one’s perspective, make one pay attention to what is really important in life, to one’s deepest desires and real fulfillment (Markowitz et al., 1995). Illness and the prospect of death may paradoxically provide a second chance to really live, leaving trivialities behind. Patients have frequently described this “now or never" attitude towards life. They felt they had to live fully; they dared to attempt what they never had done before. Having a serious illness pushed them to realize that life is not a dress

rehearsal.

Second, this reevaluation allows many patients to focus on the more positive and constructive aspects of enduring such a painful and frightening experience. From the therapist’s perspective, this was a surprise. I had anticipated difficulties in finding positive aspects of illness as a role transition. I was happily surprised to observe how patients regained a more positive outlook on life and on themselves as depressed symptoms decreased, and their ability to make changes towards a more fulfilled and richer emotional life.

A third interesting issue that arose involved understanding medical illness and depression from an interpersonal perspective. Addressing difficulties in social support and communication helped patients to assert themselves and advocate and negotiate for themselves in addressing medical decisions and postsurgical planning with medical staff.

During vulnerable times such as surgery or chemotherapy, patients face inevitable fears: of death, disability, disfigurement, the loss of health, fertility, youth, etc. This is an obvious time to ask for help and support from family and friends. Yet patients struggling with depression have difficulty feeling self-confident enough to assert their needs. They have trouble making decisions and plans. IPT, in focusing on interpersonal and communication problems, appears to be a good therapeutic approach to help these patients negotiate and better communicate their needs with their doctors, nurses, family, and friends. One patient vacillated about whether to stay with her abusive mother or go to her supportive daughter, whom she didn’t want to bother. She also did not feel comfortable asking her son because she did not want him to miss work.

Another patient struggled both with chemotherapy side effects and with fears of telling her doctor about them. Role-playing proved effective in validating her feelings and communicating her needs to her oncologist. Like Juana, she was finally able to switch to a medication with fewer side effects, and moreover felt more comfortable that her doctor understood her. This is a frequent theme for depressed medically ill patients: they often fear bothering or antagonizing their doctor or treatment team with questions, side effects, etc. One role of the IPT therapist is to help empower depressed patients to speak up. This has benefits both in treating depression (by improving self-assertion, control over one’s environment, and ideally the therapeutic relationship with the medical doctor) and improving medical treatment of the comorbid disorder.

Fourth, another important aspect of IPT treatment is that psychoeducation about depression helps depressed medical patients to feel less burdened as they understand that difficulty in making decisions, difficulty in advocating for themselves, and feeling self-doubt or lack of confidence stems from their depressive disorder. In our experience, patients learn to blame the depression instead of blaming themselves. This seems even more important than usual in IPT in working with a population experiencing two medical illnesses (e.g., breast cancer and major depression).

Finally, another aspect I discovered in working with these patients is the sense of their heroism in struggling with breast cancer. I started to feel (and see) Juana as a warrior with intensity, an unbeatable will, determined to survive and determined to make the right choices in her life. I felt connected to her and admired her. I told her how amazingly strong she was. I shared my admiration of having her in front of me, telling me her life story, trying to make sense of it, trying to express and share her pain and feelings in general. She had lost so much, and yet she was still fighting. What amazed me was her refusal to give up, even at the most difficult times. My only caveat would be that it is important not to rush to tell the patient this, to reflect it back after having developed a relationship and understood the full range of the patient’s life situation.

ACKNOWLEDGMENTS

Supported in part by National Cancer Institute grant R01 CA133050, “Interpersonal Psychotherapy for Depression in Breast Cancer," and NIMH grant R01 MH076051, “Improving the Effectiveness of Treatment for Depression in Hispanics" to Dr. Blanco; and support from the New York State Psychiatric Institute

SUGGESTED READING

Markowitz JC, Klerman GL, Clougherty KF, Spielman LA, Jacobsberg LB, Fishman B, Frances AJ, Kocsis JH, Perry SW: Individual psychotherapies for depressed HIVpositive patients. American Journal of Psychiatry 1995;152:1504-1509 Markowitz JC, Klerman GL, Perry SW: Interpersonal psychotherapy of depressed HIV-seropositive patients. Hospital and Community Psychiatry 1992;43:885-890

 
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