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

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.

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.

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.

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.

The authors thank Mia Silvan-Grau, B.A., Madeline Ehrenberg, B.A., Elizabeth Duran, M.A., and Fayel Mustafiz, B.A., for assisting with the research.