Academic journal article American Journal of Psychotherapy

Interpersonal Counseling (IPC) for Depression in Primary Care

Academic journal article American Journal of Psychotherapy

Interpersonal Counseling (IPC) for Depression in Primary Care

Article excerpt

INTRODUCTION

The implementation of the Affordable Care Act brings increasing interest in patient-centered, cost-effective models of care that expand access to mental health services for diverse populations. Broadened eligibility for Medicaid benefits and new subsidies for private coverage of low and moderate income people will bring large numbers of previously uninsured depressed people into primary care (Garfield et al., 2011). Meeting the mental health care needs of these newly insured individuals will require expanding access to evidence-based, though currently underutilized, approaches to the primary care management of depression. Primary care will remain a major resource for screening and treating depression, especially for patients with low incomes (Cooper et al., 2003; Mojtabai & Olfson, 2008) because of high prevalence, substantial morbidity, and adverse effects of depression on management of chronic medical conditions (Murray et al., 2010; Lerner & Henke, 2008; Wang et al., 2004; Kendler et al., 2009; Olfson et al., 2002; Hankerson et al., 2011; Weissman et al., 2004; Mann et al., 2004; Ormel et al., 2008). Under the traditional model of primary care treatment of depression, primary care physicians often struggle without support to manage the mental health problems of their patients. Their well-intentioned efforts are too often undermined by competing clinical imperatives to treat acute and chronic medical conditions and deliver preventive care. Moreover, primary care physicians in the United States neither have training in psychotherapy nor the time to deliver psychotherapy.

Interpersonal counseling (IPC), a brief, patient-centered approach to managing depression, lowers the burden on primary care physicians by having a mental-health worker located within the primary care setting. Interpersonal counseling is derived directly from interpersonal psychotherapy (IPT), an evidence-based psychotherapy that has undergone numerous efficacy studies, and been translated and adapted for cross-cultural use (Klerman et al., 1984; Weissman et al., 2000, 2007; Markowitz and Weissman, 2012; Barth et al., 2013). This paper describes the rationale for using IPC in primary care, offers alternative models of care, and summarizes the development, evidence of efficacy, and basic structure of IPC. The paper concludes with an illustrative case vignette.

RATIONALE FOR USING IPC IN PRIMARY CARE

Interpersonal Counseling (IPC) is a brief manualized evidence-based treatment for evaluating and triaging patients with depressive symptoms to appropriate levels of care. It fills the gap between screening and referral of patients who may need more sustained care, while offering support, identifying resources and clarifying the psychosocial triggers that may have brought on the depressive episode. Because symptoms of depression are often a transient reaction to life stress, many patients do not require sustained treatment, and the symptoms will remit after 3 to 5 (or even fewer) sessions. Other patients may require watchful waiting, and a small number may require triage to sustained treatment with medication, longer term psychotherapy, or both.

Primary care patients with depression usually receive medication but if given the option, generally prefer to talk to someone about their problems (Vidair et al., 2011 McHugh et al., 2013). Less than 40% of adults entering psychotherapy ever receive more than 3 to 5 sessions. Whether the brevity of treatment episodes is primarily driven by patient preference or economic considerations is unclear, but short treatment is the norm and imposes constraints on the feasibility of traditional psychotherapy approaches in this setting. Throughout this paper we may refer to IPC as three sessions but the need for flexibility is recognized as will be noted.

The principle underlying IPC is that a systematic, but brief, evaluation, support, and triage may help to allocate a scarce commodity-full outpatient mental health treatment-to those patients who might derive the greatest benefit and for whom it may be most appropriate. …

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