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Interpersonal Psychotherapy for Late-Life Depression

Past, Present, and Future

Received November 2, 2000; revised June 10, 2001; accepted June 18, 2001. From the Intervention Research Center for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Address correspondence to Dr. Miller, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213.

	ABSTRACTS

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
Interpersonal psychotherapy (IPT) has demonstrated efficacy in protecting against a recurrence of major depression in elderly subjects when used alone on a monthly basis and when combined with antidepressant medication. The authors summarize their experience using IPT over the past 10 years and discuss a variety of treatment correlates. In addition, preliminary results using IPT combined with paroxetine in depressed elders reveals no difference in remission rates between cognitively intact and cognitively impaired depressed elders.

Key Words: Interpersonal Psychotherapy (IPT) • Depression • Geriatric Psychiatry

	INTRODUCTION

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
The goal of this communication is to present a review of the major findings from 10 years of experience systematically applying IPT to individuals with late-life depression in a research setting, and to report on preliminary new findings applying IPT to a group of elders over age 70 that includes subjects with moderate cognitive impairment.

Interpersonal psychotherapy (IPT) is a manual-based, short-term psychotherapy originally designed for the treatment of depression.¹ The therapeutic focus in IPT is limited to current interpersonal relationships in four broad areas: abnormal grief, role transition, role dispute, and interpersonal deficits. Generally, IPT therapists contract with patients for 12 to 20 sessions of weekly, 50-minute face-to-face sessions. Techniques of exploration, clarification, encouragement of affect, communication analysis, and encouragement to attempt alternative coping strategies are used to bring about therapeutic change. IPT has been systematically taught to a range of healthcare providers, including psychiatrists, social workers, psychologists, and nurses.

The theoretical underpinnings for IPT are derived from multiple sources, including the work of Adolf Meyer,² Harry Stack Sullivan,³ and John Bowlby,^4,5 as well as empirical data based on the work of Brown and Harris on intimacy and social support,⁶ Pearlin and Lieberman on stressors inducing depression,⁷ and Weissman on the role of marital disputes in depression.⁸

The role of the IPT therapist is an active one in which extensive education about depression is provided to the patient, an interpersonal inventory of all important relationships is elicited, and transference interpretations are avoided. More detailed descriptions of IPT techniques are available elsewhere.^1,9

Since its inception, IPT has been adapted to a variety of disorders and subpopulations, including adolescents with depression,^10,11 patients with dysthymic disorder,¹² patients with bereavement-related depression,^13,14 HIV-seropositive patients,^15,16 midlife patients with recurrent depression,^17,18,19 and elderly patients with recurrent depression.^20,21

	ADAPTING IPT FOR LATE-LIFE DEPRESSION

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
The benefit of IPT as a maintenance treatment (alone and in combination with antidepressant medication) for midlife patients was initially demonstrated by Frank et al.¹⁹ In our experience, minimal changes were required to adapt IPT for use among elders.²¹ To accommodate illness, bad weather, or transportation problems, telephone sessions were used periodically. Hearing deficits required obvious accommodation. The vast majority of late-life research subjects became willing IPT participants despite a lack of prior experience with psychotherapy in most cases. We found that cognitively intact late-life patients, as a group, were able to engage, to establish a focus, to work through problems, and to try new approaches to solving problems.^13,19

	OVERVIEW OF THE PITTSBURGH MTLLD STUDY

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
The Maintenance Therapies in Late-Life Depression (MTLLD) study was designed to compare the efficacy of four maintenance therapies in prolonging recovery and preventing recurrence of major depression.²¹ Subjects age 60 or older with current major depressive disorder and at least one prior episode during the previous 3 years were recruited through print and electronic media, word of mouth, and physician referrals. Subjects were excluded if they met criteria for dementia, bipolar disorder, psychosis, or current substance abuse/dependence. The MTLLD study was carried out at a university-based geropsychiatric clinic in Pittsburgh. Over a 7-year period, 180 subjects were recruited and actually began treatment. Details of recruitment and medication management are available elsewhere.²¹

All subjects were initially treated with the antidepressant nortriptyline in combination with a minimum of 12 weekly IPT sessions. In the acute phase, all subjects received weekly 50-minute IPT sessions and nortriptyline with doses titrated to achieve steady-state blood levels of 80–120 ng/ml. For those subjects who achieved remission (defined as a Hamilton Rating Scale for Depression [Ham-D] score of 10 or less for 3 consecutive weeks), a 16-week continuation phase followed to ensure a stable recovery before randomization. During the continuation phase, IPT session frequency was reduced to twice monthly.

Those subjects who achieved a sustained remission were then randomly assigned for 3 years of monthly follow-up visits (maintenance phase) to either 1) combination treatment with nortriptyline and IPT; 2) placebo (PBO) plus IPT; 3) nortriptyline plus medication clinic (MC), a 15-minute one-way assessment of symptoms and side effects; or 4) PBO plus MC. We chose nortriptyline as the antidepressant because at the time MTLLD was begun (1989), it was considered to be the safest and most efficacious drug for late-life depression. Further details of the methodology are available elsewhere.²¹

	THE MAINTENANCE PHASE OF THE MTLLD STUDY

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
Those subjects randomized to placebo had their nortriptyline slowly tapered over 6 weeks under a double-blind condition. Subjects assigned to the medication maintenance clinic (no IPT) continued to see the same clinician they had seen during the acute and continuation phases to avoid a withdrawal-of-therapist effect. The MC visits generally lasted 10 to 15 minutes and were focused on a brief review of symptoms and side effects since the last visit, without any psychotherapist intervention except for a focus on medication compliance issues.

Subjects assigned to receive maintenance IPT were seen for 50-minute sessions on a monthly basis, during which time prior themes were revisited as necessary and new problems were addressed. Occasional crisis sessions were used when appropriate. Telephone calls from patients entailed brief assessments of the problem, with the expectation that lengthy discussions would be deferred until the next encounter.

To ensure the quality of IPT delivery, supervision was provided by videotaped weekly group supervision sessions with faculty throughout each phase of the study. Maintenance sessions were audiotaped and analyzed by unbiased raters to ensure the presence of IPT-specific elements in the IPT cells and their absence in the MC cells. The independent ratings of audiotaped maintenance sessions were ongoing throughout the study so that any detected drift from randomized treatment assignment to IPT or MC could be corrected with individual clinicians.

	SUMMARY OF MAJOR OUTCOMES OF THE MTLLD STUDY

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
This study built on the earlier work of Frank et al.¹⁹ on the maintenance treatment of nongeriatric adults. In the MTLLD study,²¹ however, there was a significant age effect on recurrence rates within treatment assignments, as described below.

One hundred eighty subjects were treated for major depression with combined treatment of IPT and nortriptyline. A remission rate of 78% (140/180) was observed defined by a Ham-D score of 10 or less for 3 consecutive weeks. Nineteen patients were nonresponders in the acute phase, and 21 others dropped out for other reasons (withdrawal of consent, medical reasons, noncompliance, adverse side effects, psychosis, mania, or death). Although 2 subjects dropped out stating that IPT was too difficult or traumatic, the vast majority of dropouts were due to medical problems, medication-related side effects, noncompliance, or refusal to continue.

Of the 140 subjects who remitted, 124 maintained remission for 4 months and were eligible to be randomized to the maintenance phase. The time to recurrence of a major depressive episode for all three active treatment groups was significantly better than for placebo.²¹ Recurrence rates over 3 years were as follows: nortriptyline plus IPT, 20% (95% confidence interval [CI], 4%–36%); nortriptyline plus MC, 43% (95% CI, 25%–61%); IPT plus PBO, 64% (95% CI, 45%–83%); and MC plus PBO, 90% (95% CI, 79%–100%). Combined treatment with nortriptyline and IPT was superior to IPT and PBO and showed a trend to superior efficacy over nortriptyline monotherapy (Wald ²=3.56, P=0.06). Subjects age 70 years and older had a higher and more rapid rate of recurrence than those ages 60 to 69.²¹ Among subjects age 70 and older, only the group that received combination therapy sustained their remission.

In exploratory analyses of variables correlating with depression-free survival on maintenance IPT, we found that subjects with pre-treatment 17-item Ham-D scores of less than 20 were generally able to remain well on maintenance IPT plus PBO.²² Those subjects with pre-treatment Ham-D scores of 20 or greater required the addition of nortriptyline to remain depression-free.²² Subjects whose depression remitted rapidly on combined acute treatment with nortriptyline and weekly IPT (generally within 4 to 5 weeks), were able to survive depression-free for 3 years on monotherapy (IPT alone or nortriptyline alone), whereas those subjects who took longer than 6 weeks to remit on combined therapy in the acute phase required combination treatment in maintenance to remain depression-free for 3 years.²³

In addition, of those subjects who achieved a good subjective sleep quality measured by the Pittsburgh Subjective Sleep Quality Index during the continuation phase and were also randomly assigned to IPT plus PBO, 90% remained depression-free for 1 year compared with 30% of good sleepers assigned to MC plus PBO. Among patients with poor subjective sleep, 33% of those receiving monthly IPT with PBO and 17% of those assigned to MC with PBO survived without another episode of major depression in the first year of maintenance.²⁴

There was no difference in distribution and type of IPT foci between groups, or in the number of prior episodes of depression, length of index episode, time to recovery, or need for adjunctive medications such as lithium or lorazepam. We also did not detect any specific therapist effect in determining whether patients survived depression-free for 3 years or not.²¹

The advantage of continuing combined treatment throughout the maintenance phase was apparent not only in the lowest rate for recurrence of depression compared with the other groups, but also in the maintenance of gains in social adjustment. Subjects who were randomly assigned to combined treatment with nortriptyline and monthly maintenance IPT consistently demonstrated better scores on the Social Adjustment Scale than those randomly assigned to monotherapy (IPT alone or nortriptyline alone).²⁵ Subjects who received combined maintenance treatment showed better maintenance of gains in interpersonal functioning and lower interpersonal conflict during the first years of maintenance, compared with those subjects randomly assigned to monotherapy during the same period.²⁵

The most common foci of IPT in our subjects were role transition (43%), role dispute (37%), abnormal grief (19%), and interpersonal deficit (1.9%).²² Only one subject was deemed to have a primary focus of interpersonal deficit. This is not surprising given that patients in this group would be expected to have more personality disorder pathology and would be less likely to agree to consent to the rigors of research participation, particularly those with avoidant, antisocial, or paranoid personality features. The majority of subjects (57%) had a primary and secondary IPT focus, and 43% had a single focus.²⁶ Types of role transitions encountered included changes such as retirement, moving from one's home, and having the last child leave home. Role disputes, which generally involved a spouse or other family members, often emerged as a secondary focus after the presenting symptoms that were best categorized as a role transition were resolved. For example, the presenting difficulty may have been an adjustment to retirement—after which it became clear that a long-standing role conflict with the spouse was present and needed to be addressed. Case vignettes of IPT in late life are available elsewhere.^13,14,19,22

	MTLLD OUTCOMES RELEVANT TO CLINICAL PRACTICE

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
Monthly IPT sessions demonstrated efficacy as a monotherapy against a recurrence over 3 years of monthly follow-up and demonstrated added benefit when combined with antidepressant drug maintenance. We observed a significant age affect on recurrence rates across maintenance treatment assignments. Patients over age 70 required combination treatment with IPT and nortriptyline to be protected from a recurrence of depression, compared with either monotherapy.²¹ This finding argues for the greater need for elders to receive a psychosocial treatment in addition to pharmacotherapy to address the needs of this group and to maintain wellness from a recurrence of depression over the long term. Also, subjects with more severe depression at baseline who required longer than 6 weeks to remit required either combination treatment or nortriptyline to stay well long term. Patients with milder depression at baseline who remitted within 6 weeks were protected against a recurrence with monthly maintenance IPT.

Self-reported sleep quality predicted who would benefit most from IPT as a maintenance treatment. The restoration of quality of sleep may be an indicator of a complete antidepressant response where brain function is completely normalized. In such cases, one would expect subjects with the most complete restoration of normal brain function to survive longer without a recurrence for any given treatment assignment. Subjects were, however, specifically selected for their history of recurrent depression, and therefore their risk for recurrence may have been higher than those with no prior history of depressive illness.

We observed that the use of IPT supported good compliance with the pharmacotherapy and that encouragement and extensive educational efforts were key to retaining subjects long enough for combination treatment to work.²⁶ This synergistic effect turned out to be particularly relevant for the over-70 group, who required combination treatment to remain well during maintenance.

The foci of IPT are germane to the needs of elderly patients—particularly role transition, grief, and role dispute. Patients with role dispute in advancing age often expressed the feeling of being trapped in difficult relationships where leaving was not an option for them. In such cases, a confidential forum for them to speak their minds and to explore alternative coping strategies provided hope and improved mood.

In the final analysis, IPT was user-friendly for older patients, many of whom had no prior experience with psychotherapy.

	GENERALIZABILITY OF MTLLD OUTCOMES

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
The contribution of the nonspecific aspects of research participation cannot be ignored in these results. Each patient interfaced with at least six concerned research team members on every visit. Factors such as the availability of a 24-hour answering service, the provision of medications by courier for shut-ins, visiting of patients who were hospitalized for medical reasons, ample opportunity for dealing with family members to explain depression, the fact that the treatment was free of charge, and the fact that many of the elders participated in research out of a sense of pride, loyalty, and altruism cannot be ignored. Many subjects were comforted by the fact that multiple "experts" agreed that their diagnosis was correct and that their treatment was on track, even if their progress was slow. These patients were comforted by the research milieu and the extensive support provided and were therefore more willing to accept adjunctive medication and research procedures, and to be tolerant of unpleasant side effects. These nonspecific elements, as a group, would not be present in a private practice setting, where outcomes would probably have been less robust.^27,28

	NEW RESEARCH USING IPT FOR LATE-LIFE DEPRESSION WITH COGNITIVE IMPAIRMENT

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
The population segment with the least data on treatment outcome for depression is the "old-old." We are currently investigating the use of IPT combined with the selective serotonin reuptake inhibitor paroxetine for maintenance treatment in subjects age 70 and older (MTLLD-2). In the MTLLD-2 study, we are treating depressed subjects with combined drug plus IPT for the acute and continuation phases and then randomly assigning remitters to monotherapy with IPT or paroxetine, or to a combination of both compared with placebo (four cells: IPT+paroxetine, IPT+PBO, MC+paroxetine, MC+PBO). In contrast to the original MTLLD-1 study, the MTLLD-2 study has no requirement for a prior episode and includes subjects with mild to moderate cognitive impairment (Mini-Mental State Examination²⁹ scores of 18 or greater). With the increased incidence of dementia with advancing age, we believe that including subjects with cognitive impairment enhances the generalizability of outcomes on the treatment of depression in the old-old.

The inclusion of depressed subjects with mild to moderate dementia, however, raises questions about the feasibility of subjects' receiving benefit from IPT in the face of memory loss or cognitive decline. A variety of possible cognitive deficits that could include memory loss or a decreased capacity for abstraction, insight, judgment, executive function, and problem-solving are recognized as potential limiting factors in a given subject's ability to participate in and benefit from IPT. After a great deal of discussion, we concluded that weekly face-to-face encounters between IPT therapists and subjects could, at the very least, be construed as supportive therapy sessions even though every effort would be made to engage subjects in IPT.

How could we determine whether IPT was in fact taking place, and not an attempt at providing IPT that, in reality, was more akin to supportive psychotherapy? We decided to make a concerted effort to engage each patient in IPT and to track the IPT therapist's ongoing subjective assessment of adherence to three areas: the subject's ability to engage, to focus, and to recall. Each IPT therapist was asked to fill out, after each visit, a simple questionnaire (a 5-point Likert-type scale, 0–4) that recorded the therapist's rating of a given patient's ability to engage in the therapeutic process, to collaborate on the establishment of a focus for the therapeutic interaction, and to recall material from previous sessions in order to build upon prior therapeutic work.

	PRELIMINARY RESULTS

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
To date, 70 subjects have been enrolled in the MTLLD-2 study and have completed at least 10 sessions of IPT. Table 1 illustrates demographics and preliminary findings on the IPT therapist ratings of the subjects' ability to engage, focus, and recall. Subjects are divided into three groups by cognitive status as measured more accurately by the Mattis Dementia Rating Scale.^30,31 We chose to limit the subsample to those having completed 10 sessions of IPT to ensure that an adequate "dose" of psychotherapy had been provided to be able to compare any difference across groups.

Tabulation of IPT therapist ratings of subject's ability to engage, focus, and recall on a 0–4 Likert-type scale showed a progressive decline with increased cognitive impairment. It is also noteworthy that the main scores in the cognitively intact group averaged well below the maximum score of 4 in all subgroups (Engage: ²=1,225, P<0.003; Focus: ²=13.78, P<0.001; Recall: ²=–19.53, P<0.0001).

Despite the apparent difference in the subjects' ability to utilize IPT, there was no difference between the cognitively impaired groups and the cognitively unimpaired group in the proportion that achieved remission or the time to remission among those subjects who received at least 10 sessions of psychotherapy in addition to paroxetine at a minimum dose of 10 mg per day and a mean of 22.4 (SD=10.3) mg per day.

Limiting the analysis in Table 1 to only those subjects who completed 10 sessions of psychotherapy neglects those who may have dropped out prior to completing 10 sessions. For comparison, Table 2 shows the proportion of dropouts and the proportion achieving full remission broken down by cognitive status in the entire sample at the time of this writing.

	DISCUSSION OF PRELIMINARY MTLLD-2 FINDINGS

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 
To our knowledge, there has been no prior attempt to systematically apply psychotherapy to cognitively impaired depressed elders in a randomized comparison to antidepressant medication and their combination. Because the MTLLD-2 study is ongoing, we can report only preliminary findings; thus far, we detect no differences between the cognitively impaired and unimpaired groups with respect to the proportion achieving remission or the time to remission in the acute phase, where all subjects receive paroxetine and weekly IPT for at least 10 weekly sessions. The interpretation of these preliminary findings merits caution, of course. IPT therapists' ratings of the subject's ability to participate fully in IPT decline with increasing cognitive impairment—and the existence of such a decline would raise the question of whether the achievement of remission is primarily a drug effect in which the addition of IPT (either fully or partially implemented) is superfluous. An alternative explanation is that the attempt to provide IPT to the more cognitively impaired subjects, even if the interaction would be better classified as supportive psychotherapy, is equipotent to fully implemented IPT. Thus, the combination of paroxetine with either IPT or supportive therapy could be equally effective for the treatment of late-life depression with and without mild to moderate cognitive impairment.

The future outcomes regarding the maintenance of recovery over 2 years of follow-up awaits the completion of this ongoing study. The stratification of subjects by cognitive status is intended to ensure that a balance will be achieved in randomized treatment assignment, thus allowing assessment of the differential effects of monotherapy with either drug, IPT, or their combination between groups with and without cognitive dysfunction. Specifically, the efficacy of the attempt to provide IPT, even if it more closely resembles supportive therapy, will be compared with fully implemented IPT during maintenance treatment.

	ACKNOWLEDGEMENTS

 
This work was supported by National Institute of Mental Health Grants P30 MH52247, R37 MH43832, and K05 MH00295.

	REFERENCES

Top ABSTRACTS INTRODUCTION ADAPTING IPT FOR LATE-LIFE... OVERVIEW OF THE PITTSBURGH... THE MAINTENANCE PHASE OF... SUMMARY OF MAJOR OUTCOMES... MTLLD OUTCOMES RELEVANT TO... GENERALIZABILITY OF MTLLD... NEW RESEARCH USING IPT... PRELIMINARY RESULTS DISCUSSION OF PRELIMINARY MTLLD... REFERENCES

 

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