Dynamic Interpersonal Therapy for U.S. Veterans in a Primary Care Setting

Short-term evidence-based psychotherapies have traditionally been used in primary care settings for patients with behavioral health concerns that warrant psychological consultation; however, not all patients benefit from the existing treatments (1, 2). Although the currently offered short-term psychotherapies are acceptable for many patients, a subgroup of patients do not respond to such treatment (e.g., they drop out or experience impactful residual symptoms posttreatment). Furthermore, some patients may not respond to the structure and outside work demanded by approaches such as cognitive-behavioral therapy or acceptance and commitment therapy (1, 2).

Although dynamic therapies may be offered as an alternative to traditional short-term psychotherapies, a range of concerns about them have been raised, including cost-effectiveness, lack of trained providers, and complications regarding treatment operationalization and fidelity. In addition, despite empirical support for the utility of dynamic treatments for a range of issues, some clinicians contend that there is little research to support their use (3). Particularly in medical centers, where evidence-based care is critical, these negative impressions of dynamic treatment have contributed to its underuse.

Brief dynamic interpersonal therapy (DIT) may address some of the negative impressions of traditional psychodynamic or psychoanalytic treatments. DIT, which was pilot tested in primary care, is a time-limited, manualized, 16-session treatment that formulates a patient’s symptoms of depression as responses to interpersonal difficulties or threats to attachment style (4). DIT attempts to collaboratively establish an interpersonal formulation for the patient’s depressive symptoms, helps the patient to recognize and shift relationship patterns tied to depression, and facilitates the patient’s capacity to reflect on their own experience and the experience of others. A randomized controlled trial (5) found that patients with major depressive disorder treated with DIT demonstrated outcomes comparable to those of cognitive-behavioral therapy, and treatment was significantly more effective than a low-intensity control intervention. DIT has also been shown to significantly reduce depressive and anxiety symptoms in a patient population at a U.S. Department of Veterans Affairs (VA) medical center (6).

DIT is particularly relevant for primary care settings, given the interpersonal relationships that exist between patients and medical staff as patients navigate comorbid behavioral health and general medical conditions. In these settings, interpersonal difficulties that have their basis in early attachment experiences can complicate the experience and navigation of chronic diseases in adulthood (7). These early experiences may affect how patients engage with the health care system and its providers, as well as their participation in disease management (8). Preliminary evidence exists to support the usefulness of psychodynamic psychotherapies, including DIT, for populations of patients who have comorbid general medical conditions, such as functional somatic disorders (9). The current study aimed to explore the usefulness of DIT within a VA primary care setting for a sample (N=30) of patients referred to DIT at a VA medical center.

Methods

This retrospective study of medical records was an extension of the VA Institutional Review Board–approved study, conducted by Chen et al. (6), of DIT for veterans. Participants (N=30) constituted a subset of veterans who were referred from primary care–mental health integration for DIT. DIT was provided by 21 psychology staff members and trainees between 2012 and 2019. Details about training and implementation of DIT have been published (6, 10).

The participants had a range of problems with a seemingly relational component and had characteristics, such as high insight or self-awareness, that would make them a good fit for dynamically oriented treatment. Providers referred primary care–mental health integration patients for DIT for one or more of the following reasons: chronic or broad interpersonal issues; clinical indication for longer, structured treatment versus brief, short-term treatment; early trauma (abuse, neglect); completion of and nonresponse to another evidence-based psychotherapy; lack of interest in traditional trauma-focused treatment; previous benefit from psychodynamic therapy; an expressed desire to understand perceived personal difficulties that arose within interpersonal contexts (including issues of self-esteem, self-confidence, and difficulties with conflict or assertiveness); or evidence of maladaptive relational or interpersonal themes.

Data were collected from VA medical records and included demographic information, general medical and psychiatric diagnoses, referral reason, attendance at DIT sessions, and patient-reported depression or anxiety. Outcomes for the latter were measured by using the nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalized Anxiety Disorder (GAD-7) questionnaire, respectively, which were administered at each session. Possible scores on the PHQ-9 range from 0 to 27, with higher scores indicating greater severity of depression; possible scores on the GAD-7 range from 0 to 21, with higher scores indicating greater severity of anxiety.

Descriptive statistics were used to summarize continuous variables (mean±SD) and categorical variables (frequency and percentage). For the repeated continuous outcome measures of PHQ-9 and GAD-7 scores, two separate generalized estimating equations (GEEs) were used to quantify between-session changes in depression and anxiety scores over the course of treatment for the subset of those (N=12) who scored above the clinical cutoff for depression (≥10 on the PHQ-9) and those (N=10) who scored above the clinical cutoff for anxiety (≥10 on the GAD-7) at the beginning of treatment (first available report at session 1 or 2). A compound symmetry working correlation structure was assumed for the GEEs. A two-sided p value <0.05 was considered statistically significant. Effect size was characterized by using Cohen’s d. All analyses were conducted with SAS, version 9.4.

Results

In the overall sample (N=30), mean age was 44.2 years (additional demographic characteristics are summarized in Table 1). Overall, 97% (N=29) of the sample had one or more comorbid general medical conditions, 63% (N=19) had two or more, and 37% (N=11) had three or more. Common general medical issues fell within the domains of chronic pain (N=12, 40%), genitourinary (N=11, 37%), cardiovascular (N=7, 23%), obesity (N=6, 20%), sleep disorders (N=5, 16%), integumentary (N=5, 16%), gastrointestinal (N=4, 13%), and endocrine (N=4, 13%). The mean number of sessions completed was 12.3, with 77% (N=23) of the veterans completing treatment. Pearson’s correlation analyses were used to examine whether changes in anxiety or depression symptoms were associated with participant age, gender, or race; no statistically significant relationships were found.

In the subsamples of veterans with clinically elevated anxiety (N=10) or depression (N=12), large effect sizes were found for changes in PHQ-9 scores (d=1.36, 95% CI=−1.36 to 1.96, p<0.001) and GAD-7 scores (d=1.94, 95% CI=−1.94 to 1.96, p<0.001). Pretreatment GAD-7 scores (mean±SD=14.60±3.95, range 10–21) and PHQ-9 scores (mean=14.75±4.37, range 10–23) were compared with posttreatment scores (mean=8.50±5.25, range 0–16, and mean=8.50±6.20, range 1–17, respectively). After DIT, patients who initially met criteria for depression (PHQ-9 score≥10) reported a 42% reduction in PHQ-9 score. Patients who initially met criteria for anxiety (GAD-7 score≥10) reported a 42% reduction in GAD-7 score. In our sample, 40% (N=4) of patients who met criteria for clinical anxiety dropped beneath the clinical cutoff score after treatment. For patients who met criteria for major depressive disorder, 42% (N=5) dropped beneath the clinical cutoff score after treatment. Clinically meaningful improvement in symptoms was found early in treatment (by session 3) for depression and at the halfway mark (session 8) for anxiety.

Discussion

The results suggested that DIT may be a valuable treatment for patients in a primary care setting. DIT was associated with improvement in symptoms among this sample of patients with depression or anxiety and co-occurring general medical conditions.

In primary care in particular, the usefulness of DIT may extend beyond reduction of psychiatric symptoms to relational implications associated with the management of co-occurring general medical disorders. Development and expression of chronic health problems are affected by interpersonal relationships and attachment styles, which may influence how individuals respond to illness, including their care-seeking patterns, engagement with others in a health care system (providers, clerical staff, institutional transference), and treatment response. DIT’s emphasis on addressing problematic interpersonal patterns in patients’ lives may have implications for how patients manage the progression of disease processes and interact with health care staff and systems.

Early life experiences with caregivers shape individuals’ attachment styles and their views of self and others. These internal working models of relationships can affect the patient-physician relationship as well as the patient’s experience with the health care system. Awareness of these dynamics can inform how to work most effectively with patients to treat their specific general medical problems. Because these different attachment styles affect patient-physician relational dynamics in various ways, the work done in DIT can greatly affect this relationship. For example, DIT may help clinicians point out, address, and work through dynamics that emerge among patients with dismissive attachment styles who may have difficulty seeking help and who tend to be overly self-reliant. Even if a patient with this type of attachment style has debilitating chronic pain, for example, they may remain unlikely to seek care. DIT may help such patients learn to allow themselves to rely on others for support and care and may encourage them to interact with others in new, more effective ways.

The impact of a relational treatment, such as DIT, may be far-reaching, influencing health-related symptoms and engagement in the health care system and providing patients with an opportunity to work through institutional transference rooted in a particular attachment style. Because psychiatric and general medical symptoms operate in both interpersonal and psychological contexts, an interpersonal treatment that is acceptable to patients with complicated general medical conditions can be an important addition to current treatment options. An interpersonal dynamic treatment may not only heal psychological issues but also more broadly affect progression, expression, and management of general medical conditions or diseases.

Limitations of this study included its small sample size and lack of a control group. Furthermore, because of the sample size, the analyses were not controlled for confounding variables; thus, future work should explore potential moderators of treatment outcomes. In addition, symptoms were self-rated through patient-completed questionnaires. Future studies may benefit from evaluating symptom change through clinician-rated scales. Moreover, further research is needed on the hypothesized impact of participation in DIT treatment on engagement in and use of the health care system and on physiological processes or manifestations of illness (e.g., monitoring markers of inflammation before and after DIT). Finally, future work should continue to explore the nuances of the clinical process associated with DIT (11). Although our study showed strong results in support of DIT’s utility for the treatment of depression and anxiety among patients experiencing comorbid general medical conditions, outcomes data related to patient behaviors regarding the management of medical illnesses and engagement in care would be useful to further examine the value of DIT.

Conclusions

Our results suggested that DIT may be a useful and valuable treatment within a primary care medical setting for patients with depression or anxiety. These findings highlighted that treatment can be beneficial despite the presence of co-occurring general medical conditions. We also propose that DIT may be useful in influencing patients’ relationships with care providers and with the health care system at large, which may affect health care utilization as well as disease management and progression.