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Katagiri et al. Interpersonal Psychotherapy for Depression

create conversation time between the patient and wife, which at the time was non-existent. During the process, the wife was dissatisfied that the patient would not discuss difficulties with her during challenging times at work, and that she did not agree with the division of child-rearing work between them. The gridlock gradually disappeared as the patient’s comprehension of the wife’s characteristics and expectations deepened, and he obtained communication skills. A cooperative relationship between work support and child-rearing was formed as a result of renegotiation between the two individuals. The wife began to cooperate with the patient in starting a new business, and at this stage in February 2019, the 16 IPT sessions were concluded. The patient also succeeded in starting his own business in June of the same year.

Case 2

The patient had experienced major changes from her conventional living environment, had major decreases in motivation, and was unsure of what to do. The patient initially blamed others and thought that the cause of her depression was that people around her did not support her. She felt that the treatment strategy of IPT, which resolves present problems that impact mood (e.g., workplace and lifestyle troubles) with a focus on interpersonal relationships, was refreshing and felt motivated for treatment.

The patient began IPT while on leave in October 2018, and the MADRS score was 4. Although the MADRS score was very low, as the course of the disorder was prolonged with recurrence, employment was not stable, and the patient felt strong distress over her decreased social function. We thought that IPT would be useful for the patient because her employment was not stable even if the rating scale did not indicate depression. Interpersonal patterns involving a small number of people and minimal emotional interaction were observed in the patient; the problem lies in the fact that the patient was unable to request support from others. Another issue was that the workplace required closer and more emotional interpersonal relationships. The goal of acquiring communication skills where necessary support can be obtained from surrounding people, even under stressful conditions, was set, and the patient consented.

The patient felt stuck because she was unsure about how to negotiate the issues of organizing multiple lessons, such as ballroom dancing, which became a burden because the patient could not just quit, and of helping at the office where she was commuting as part of rehabilitation. Therefore, adjustments were made while conducting roleplay, and we sought to improve communication skills. The patient also suffered from continuous sleep cycle disturbances because she was making a livelihood from part-time work, and an increased tendency of depressive symptoms was seen for several days after partying with her friends at weekend events and returning home late at night, so social rhythm therapy was also introduced. This process improved her depressive symptoms, and she returned to work in March 2019.

There was a stressful event even after returning to work where a colleague had taken a high-handed attitude, but the patient’s emotions and ways of expressing her thoughts were examined

during roleplays and implemented. The patient still had struggles facing her strong-minded seniors, but she was able to discuss with her superiors when she felt emotional struggles, and the 16 IPT sessions were concluded in May 2019.

Case 3

The patient has ongoing unstable relationships with her mother, partner, and other close individuals, and she perceived difficulties in intimate relationships, but the issues were unclear. The patient was able to deepen her understanding of her weaknesses in interpersonal relationships after obtaining visual information from a drawing test (House-Tree-Person-Person test) conducted during testing and hospitalization feedback. She demonstrated interest in IPT.

The patient began IPT in May 2018, and the MADRS score was 19. She would occasionally be involved in part-time work and had no regular employment. She always had a poor relationship with her mother, did not have strong emotional interactions with other family members, and had attachment issues. Problems in human relationships have caused strong confusion in patients. She lived with her significant other but decided to return home after discord with her partner. The goals of understanding the mismatched expectations with her mother and significant others, and learning appropriate self- expression without being excessively concerned about other people’s judgment, and learning communication skills were set, and the patient consented to this goal. She began to sort her mother’s personal issues and her own issues while accepting her anger toward her mother, which allowed her to gradually put an appropriate distance between them; this resulted in less emotional instability due to her relationship with her mother. However, the patient’s depressive symptoms worsened after a verbal argument with her significant other in October of the same year, and she was admitted to our hospital for 9 days. We set up sessions that also involved her significant other during this hospitalization period, and we sought to repair the mismatched expectations by having the two individuals share what they wanted from the other partner, and establish a number of rules to continue their relationship. Subsequent stabilization of her relationship with her partner resulted in a gradual stabilization of her mood, and she began to show more motivation toward work. She finished her 12 sessions in December of the same year. She was hired as a full-time employee in March 2019.

Case 4

The patient had always been aware of his awkwardness in interpersonal relationships, but he had little insight as to how this affected his depressive symptoms. These problems were objectively exhibited during testing and hospitalization feedback, and deepening the understanding of the associations between improved interpersonal skills and depressive symptoms served as a motivation for conducting IPT.

He retired in May 2018, as decided before the introduction of the IPT was considered. The patient began IPT in June 2018, and the MADRS score was 24. It was observed that family functions were inadequate, there was little emotional interaction, and he had only superficial relationships when he was a high

Frontiers in Psychiatry | www.frontiersin.org 6 April 2021 | Volume 12 | Article 617305

Katagiri et al. Interpersonal Psychotherapy for Depression

school student. The patient wanted interpersonal relationships but had few opportunities to cultivate communication skills, and it was also thought that attachment issues were causing awkward interpersonal relationships. The patient was unable to take the necessary communicative steps in various social settings even after employment and exhibited maladaptive habits. The patient started a new job at another company shortly after starting the sessions. Here, the goal of being able to address personal and professional issues while learning interpersonal skills to continue stable employment was set, and sessions were continued. Other individuals who could provide support, such as his brother and workplace seniors, were recruited, and we sought to develop communication skills in the patient by conducting roleplays in various difficult settings. The patient was able to stabilize emotionally as a result of creating allies in the workplace, and he was able to address issues even when they arose in the workplace. Sufficient improvements in depressive symptoms were also observed when his responses in the workplace improved. The patient was able to obtain sufficient information needed for IPT introduction during testing and hospitalization interviews, so the six IPT sessions were concluded in November of the same year.

DISCUSSION

In this study, various tests were conducted on TRD patients, indications for IPT were examined based on these findings, and the course of four patients was summarized. Our results revealed that all four patients were able to return to work, and it was shown that IPT was effective when indicated for TRD patients. Each patient had favorable motivations for conducting treatment according to the formulation, and there were no patients who suspended treatment. The intervention period and the number of sessions varied, but all patients returned to work and found stable employment either during IPT treatment or within 6 months of concluding treatment.

Refractory to treatment is subjective and often does not correspond to objective measures. The four patients in this study also participated in testing and hospitalization for TRD to resolve the distress of their dissipating depressive symptoms and unstable working conditions. Based on the results of each test, a multidisciplinary conference was held, and interpersonal problems were considered to be a major factor in the lack of improvement in social functioning. Therefore, IPT, another treatment option, was proposed and agreed upon. Although the outcome of this study is the social function of employment, there is a lack of data on objective measures of depressive symptoms, social adjustment, and quality of life pre-post treatment. The lack of such data is a major limitation of this study. Second, in Cases 2, 3, and 4, it cannot be denied that the effect of increasing the dose of the drug may have contributed to the outcome, which is a limitation of this study. Third, baseline social functioning prior to individual IPT implementation is not uniform and can be considered a confounding factor.

In this study, we considered why IPT results in improvements in TRD and employment status for the four patients. A common factor across all four patients was difficulty in their work

and personal lives. IPT revealed the subject individuals who they struggled with, and the issues in their own relationships with significant others were clarified. The patients were able to achieve self-realization. Being able to recognize that the problems they face were caused by relationship issues with themselves and significant others was the trigger for escaping their TRD. Patients were able to receive the necessary support from significant others through this process and move toward improvements in depressive symptoms and stable employment. It is generally difficult for patients to feel resistance against IPT because its formulation focuses on recovering social function while remaining close to the patients’ own emotions. The various objective feedback of the test results, as was done in this report, was thought to enable a more specific and objective understanding of the relationship between the patient and interpersonal relationship patterns. This was thought to be a major motivation for treatment. Although the effect of IPT on typical depression has been demonstrated in previous studies, few studies have investigated the effect of IPT with a focus on TRD. Souza randomly assigned 40 patients with TRD between the standard treatment and IPT groups in a randomized controlled trial to compare the degree of improvement in depressive symptoms. Human development and social relations (HDSR), Beck Depression Inventory (BDI), and Clinical Global Impression (CGI) improved at 8, 12, 19, and 24 weeks in both groups, but there were no significant differences between the groups at any time point (10). The 2018 Cochrane Database Systemic Review also tested a variety of psychotherapies for TRD and showed that the addition of psychotherapy, including IPT, to usual care, could help improve short-term symptomatic response and remission rates. Most evidence on medium-term and long-term usefulness comes from a single trial, and no clear conclusions are available (11). Therefore, it is difficult to say that the usefulness of IPT for TRD is still established. The background to this is that there are diverse elements that contribute to the intractability of depression, including problems in interpersonal relationships, and it is thought that uniform improvements with an identical treatment method are difficult. Of the obtained TRD test results, we excluded patients with psychiatric symptoms or intellectual problems from indications of IPT, as well as patients who had little awareness of interpersonal relationship problems (e.g., those with autism spectrum disorders, schizoid personality traits) and those in whom other treatment methods are desirable considering future communication abilities. Psychological tests are useful in understanding the characteristics of such interpersonal relationships. The House-Tree-Person-Person Test (HTPP) is a projectionmethod and is amodified version of the figure painting in the HTP test developed by Buck (12), which is a psychological test that depicts both male and female figures in addition to pictures of a house and tree (13). The analysis of these results extracts the level of awareness of interpersonal relationships and unstable interpersonal relationship patterns (e.g., important people who impact the patient and the emotions associated with them, the method by which those emotions are expressed), based on Takahashi’s references. Projection methods such as HTPP have conventionally been used as assessment tools and for

Frontiers in Psychiatry | www.frontiersin.org 7 April 2021 | Volume 12 | Article 617305

Katagiri et al. Interpersonal Psychotherapy for Depression

evaluative objectives of treatment methods, but positioning them as decision materials for indicating psychiatric treatments as was done in this study is a new initiative. Although all four patients who took up had conflicts with their interpersonal relationships and communication ability, these problems were not linked with their own symptoms or social functioning problems. In a follow- up survey of Japanese workers returning to work after an episode of major depressive disorder 1 year later, 50.5% continued to work, but the reason for their sick leave included relapse, retiring for personal reasons (e.g., interpersonal relationships, work environment stress, and family relations), being laid off or fired (14). Moreover, patients with TRD had worse work productivity and social functioning than non-TRD patients (2). Two years have passed since the end of IPT, and all cases have continued to work, suggesting that the specific approach to interpersonal relationships and social functioning through IPT, which had not been intervened in the past, was effective.

Various testing feedbacks are thought to be useful as a motivator for psychotherapy. It has been reported that highly motivated patients with generalized anxiety disorder were able to benefit significantly more from psychosomatic therapy during their hospital stay compared to less motivated patients (15). A study on depression also reported that patients with relatively high levels of depressive symptoms who were motivated early in their treatment could benefit significantly more from psychosomatic therapy than patients with low levels of motivation (16). Furthermore, psychotherapy, which focuses on motivation, is also widely known (17). All four patients had feelings of insufficiency in their own life situations and thought that the issue lay in others when their pathology was communicated using objective test results. It was suggested that the patients’ understanding was deepened by not only words but also numerical values, figures, and explanations using the drawing drawn by the patients themselves. The patients were then able to be introduced to IPT with high motivation from the initial stage of treatment. The supportive and cooperative involvement of many staff members during the examination may have served as the basis for change. This may have resulted in the smooth introduction of the “medical model” used by IPT, which was that “the current condition is due to symptoms, and what is needed is therapy,” increased motivation toward treatment, and higher treatment effects.

Research on employment and interpersonal relationships began in the United States in the mid-1970s, and a recent meta-analysis of studies involving healthcare professionals has shown an association between burnout and working conditions, interpersonal and professional conflicts, mental distress, and poor social support (4). These studies reported correlations between interpersonal relationships and employment in the workplace, but two of the patients in our study did not address interpersonal relationships in the workplace during the sessions. This was probably because the improvements in attachment problems and communication skills brought by IPT resulted in coping skills when associating with people other than significant others, which were learned through treatment. All four patients underwent therapeutic interventions for relationships with their significant others in the process of changing their social roles (gained necessary support in the process of coping with

interpersonal conflicts in the family andworkplace, and stabilized employment). As noted above, IPT is a treatment that deals with social support itself, so improving symptoms with IPT and restoring social function may be of constant relevance. Reports on IPT that compared treatment as usual (TAU) and group sessions of workplace-related interpersonal psychotherapy (W-IPT) among 27 depression patients have shown that it has significant effects on depressive symptoms as well as in subjective work performance, self-efficacy to return to work, and insomnia (18). A randomized trial that compared eight sessions of W-IPT and TAU in 28 patients with depression exhibited significant improvements and the effectiveness of W-IPT in reducing depressive symptoms, work-ability (WAI), return-to- work attitude (RTW-SE), and the effort-reward ratio (ERI) (19). We anticipate further accumulation of evidence relating to employment and interpersonal relationships.

CONCLUSION

We reported four cases of TRD in which IPT was conducted, which resulted in patients returning to work and finding stable employment. The results of various tests performed to formulate the treatment plan, the detailed indications for IPT discussed at the conference, and the motivation for IPT through feedback of the results are the features of this study. IPT, which focuses on relationships with significant others, is a treatment method that not only improves symptoms but also intervenes in social functions, and it can be an effective option when considering support to return to work. With medication control and assessment of depressive symptoms over time, more precise study on the correlation between interpersonal relationships, depressive symptoms, and employment is expected in the future.

DATA AVAILABILITY STATEMENT

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

ETHICS STATEMENT

The studies involving human participants were reviewed and approved by Faculty of Medicine Research Ethics Committee, Kyorin University. The patients/participants provided their written informed consent to participate in this study.