Using IPT in Primary Care Using IPT in Primary Care for Underserved Women for Underserved Women

with Depression and with Depression and Chronic PainChronic Pain  Ellen L. Poleshuck, Ph.D.Ellen L. Poleshuck, Ph.D.

Associate ProfessorAssociate ProfessorDepartments of Psychiatry and Obstetrics and GynecologyDepartments of Psychiatry and Obstetrics and Gynecology

University of Rochester Medical CenterUniversity of Rochester Medical CenterRochester, NY, USARochester, NY, USA

Presenter Company Product Research Other:

Ellen Poleshuck No disclosures

Disclosure Disclosure

AcknowledgementsAcknowledgementsMentor: Mentor: Nancy Talbot, Ph.D.Nancy Talbot, Ph.D.

Co-mentors: Co-mentors: Bob Dworkin, Ph.D., & Caron Zlotnick, Ph.DBob Dworkin, Ph.D., & Caron Zlotnick, Ph.D

Funding: Funding: NIMH K23MH79347NIMH K23MH79347 Wynne Center for Family Research Wynne Center for Family Research Private donation to URMC Dept. of Obstetrics & Gynecology Private donation to URMC Dept. of Obstetrics & Gynecology

ConsultantsConsultants TherapistsTherapists Donna Giles, Ph.D.Donna Giles, Ph.D. Beth Cerrito, Ph.D.Beth Cerrito, Ph.D.

Carmen Green, M.D.Carmen Green, M.D. Natalie Cort, Ph.D.Natalie Cort, Ph.D.Wayne Katon, M.D.Wayne Katon, M.D. Debra Hoffman-King, Ph.D.Debra Hoffman-King, Ph.D.

Kurt Kroenke, M.D.Kurt Kroenke, M.D. Lucinda Hutton, M.S.Lucinda Hutton, M.S.Holly Swartz, M.D.Holly Swartz, M.D. Lacy Morgan-Develder, M.S. Lacy Morgan-Develder, M.S. Xin Tu, Ph.D.Xin Tu, Ph.D. Tziporah Rosenberg, Ph.D.Tziporah Rosenberg, Ph.D.

Clinical Research Coordinators: Clinical Research Coordinators: Kelly Bellenger and Nicole Leshoure, M.S.Kelly Bellenger and Nicole Leshoure, M.S. Statistical Support: Statistical Support: Xiang Liu, Ph.D., Naiji Lu, Ph.D., Silvia Sorensen, Ph.D.Xiang Liu, Ph.D., Naiji Lu, Ph.D., Silvia Sorensen, Ph.D.

Research StaffResearch Staff Other IPT-P Team MembersOther IPT-P Team MembersAyesha Khan, M.D.Ayesha Khan, M.D. Gillian Finocan Kaag, Ph.D.Gillian Finocan Kaag, Ph.D.Nicole Lighthouse, M.S. Nicole Lighthouse, M.S. Stephanie Gamble, Ph.D.Stephanie Gamble, Ph.D.Jessica MarinoJessica Marino Danette Gibbs, M.A.Danette Gibbs, M.A.Amanda Pelcher Amanda Pelcher Louis Rosario-McCabe, N.P.Louis Rosario-McCabe, N.P.Melissa ParkhurstMelissa Parkhurst

Chronic Pain and Chronic Pain and DepressionDepression

Depression and pain are two of the most Depression and pain are two of the most common problems in primary care settings common problems in primary care settings (CDC, 2009)(CDC, 2009)

In the US, women, African Americans, In the US, women, African Americans, Latinos, and individuals with socioeconomic Latinos, and individuals with socioeconomic disadvantage are all at increased risk for disadvantage are all at increased risk for both difficulties both difficulties (Gureje et al., 1998; Narrow, 1998; Brown et (Gureje et al., 1998; Narrow, 1998; Brown et al., 2003; Portenoy et al., 2004; Poleshuck & Green, 2008)al., 2003; Portenoy et al., 2004; Poleshuck & Green, 2008)

Individuals with comorbid pain and Individuals with comorbid pain and depression have poorer treatment adherence depression have poorer treatment adherence and outcomes and outcomes (Mavandadi et al., 2007; Karp et al; 2007; (Mavandadi et al., 2007; Karp et al; 2007; Kroenke et al., 2008; Bair et al., 2004)Kroenke et al., 2008; Bair et al., 2004)

Traditional Delivery of IPT Traditional Delivery of IPT not an Optimal Fitnot an Optimal Fit

Patients are presenting with pain Patients are presenting with pain concerns, not depressionconcerns, not depression

Multiple barriers to careMultiple barriers to care Implications forImplications for

EngagementEngagement ConceptualizationConceptualization AdherenceAdherence

Goals for Underserved Women Goals for Underserved Women with Depression and Painwith Depression and Pain

Relevance for women who are not seeking Relevance for women who are not seeking treatment for depression and may not treatment for depression and may not identify themselves as “depressed”identify themselves as “depressed”

Directly address how pain is associated with Directly address how pain is associated with depression and interpersonal functioningdepression and interpersonal functioning

Improve accessibilityImprove accessibility

Interpersonal Interpersonal Psychotherapy for Psychotherapy for

Depression and Pain (IPT-P)Depression and Pain (IPT-P) up to 8 sessions (modeled after Brief IPT)up to 8 sessions (modeled after Brief IPT)

Sessions are held in health care clinicSessions are held in health care clinic

Medical provider is integrated into delivery Medical provider is integrated into delivery of careof care

Individualized pace of treatmentIndividualized pace of treatment

Phone sessions as neededPhone sessions as needed

Sessions 1-2Sessions 1-2Engagement, Conceptualization, Engagement, Conceptualization,

and Developing a Planand Developing a Plan

Elicit pain storyElicit pain story Accept patient’s experience and focusAccept patient’s experience and focus Explore and address barriersExplore and address barriers PsychoeducationPsychoeducation ConceptualizationConceptualization Identify interpersonal problem focus areaIdentify interpersonal problem focus area

““Change in healthy self”Change in healthy self” Select strategies to target depression and Select strategies to target depression and

painpain

Sessions 3-7Sessions 3-7 Evaluate pain and depression at Evaluate pain and depression at

beginning of each sessionbeginning of each session Explore how changes in pain or Explore how changes in pain or

depression may be related to changes depression may be related to changes in relationshipsin relationships

Assess progress on goalsAssess progress on goals Reinforce successes and self-careReinforce successes and self-care Attend to treatment barriers Attend to treatment barriers

Final sessionFinal session

Review strategies and reinforce gainsReview strategies and reinforce gains Generalize strategies to other Generalize strategies to other

situations and unresolved concernssituations and unresolved concerns Anticipate future difficultiesAnticipate future difficulties Facilitate referral for on-going Facilitate referral for on-going

therapy if indicatedtherapy if indicated

RCT for women with CPP RCT for women with CPP and Depressionand Depression

Screen women for depression and pain in Screen women for depression and pain in women’s health and family medicine clinicswomen’s health and family medicine clinics

Enroll women who meet criteria for major Enroll women who meet criteria for major depressive disorder on the SCID, HRSD of depressive disorder on the SCID, HRSD of >> 14, and chronic pelvic pain for 14, and chronic pelvic pain for >> 6 months 6 months

Randomized to IPT-P or E-TAURandomized to IPT-P or E-TAU Masked assessments at 0, 12, 24, & 36 Masked assessments at 0, 12, 24, & 36

weeksweeks

Study SampleStudy Sample

61 women with MDD and pelvic pain61 women with MDD and pelvic pain Mean age = 36.6 years (SD = 8.9)Mean age = 36.6 years (SD = 8.9) Race/ethnicityRace/ethnicity

44 (72.1%) African American44 (72.1%) African American 11 (18.0%) non-Hispanic White11 (18.0%) non-Hispanic White 6 (9.8%) Hispanic6 (9.8%) Hispanic

42 (68.9 %) single/separated/divorced42 (68.9 %) single/separated/divorced 39 (63.9 %) annual household income 39 (63.9 %) annual household income

< US $20,000 annually< US $20,000 annually

Chronic Pelvic Pain DxChronic Pelvic Pain Dx

nn %%

FibroidsFibroids 1212 19.719.7

EndometriosisEndometriosis 1010 16.416.4

UnknownUnknown 8 8 13.113.1

Pelvic Inflam. DiseasePelvic Inflam. Disease 5 5 8.2 8.2

Interstitial CystitisInterstitial Cystitis 4 6.6 4 6.6

OtherOther 2222 36.2 36.2

Co-Occurring Psychiatric Co-Occurring Psychiatric DiagnosesDiagnoses

IPT-P E-TAU TOTAL

Pain DisorderSpecific PhobiaPTSDPanic DisorderHx of Substance Abuse

23 (69.7%) 21 (75%) 44 (72.1%)

19 (57.6%) 10 (35.7%) 29 (47.5%)

14 (42.4%) 12 (42.9%) 26 (42.6%)

10 (30.3%) 9 (32.1%) 19 (31.1%)

n= 33 n=28 n=61

56 (91.8%) met criteria for > 1 additional current diagnoses

10 (30.3%) 11 (39.3%) 21 (34.4%)

Interim AnalysesInterim Analyses

Generalized Estimating Equations controlling for Generalized Estimating Equations controlling for age, baseline anti-depressant medication use, and age, baseline anti-depressant medication use, and session attendancesession attendance

Interim analysis n’sInterim analysis n’sIPT-PIPT-P E-TAU E-TAU TotalTotal Retention Retention

BaselineBaseline 33 33 28 28 61 61

12 weeks12 weeks 24 24 26 50 85% 26 50 85%

24 weeks24 weeks 15 19 34 15 19 34 69% 69%

36 weeks 22 18 40 85%36 weeks 22 18 40 85%

Interim findings: Treatment Interim findings: Treatment Engagement and AdherenceEngagement and Adherence

IPT-PIPT-P (n=29) (n=29) E-TAU (n=25)E-TAU (n=25) t t p p

>0 sessions>0 sessions 23 (79.3%) 23 (79.3%) 13 (52.0%)13 (52.0%) 4.73 .0344.73 .034

6+ sessions6+ sessions 13 (44.8%) 13 (44.8%) 4 (16.0%) 4 (16.0%) 5.98 .0185.98 .018

Interim OutcomesInterim Outcomes

Outcome Variable Outcome Variable ββ SE SE ppHamilton Rating Scale for DepHamilton Rating Scale for Dep -3.66-3.66 1.68 1.68 .029 .029

Beck Depression InventoryBeck Depression Inventory -4.23 2.15 -4.23 2.15 .049 .049

MDD DiagnosisMDD Diagnosis -1.30-1.30 0.69 .059 0.69 .059

IIP AggressionIIP Aggression -0.35-0.35 0.17 0.17 .041 .041

IIP SociabilityIIP Sociability 0.36 0.36 0.18 .045 0.18 .045

SummarySummary Many individuals who would benefit Many individuals who would benefit

from IPT do not come knocking at our from IPT do not come knocking at our doordoor

There are ways we can increase the There are ways we can increase the accessibility and relevance of IPT for accessibility and relevance of IPT for clinic-based “real life” populations, clinic-based “real life” populations, including women with pain and including women with pain and depressiondepression

With minor additions, IPT was With minor additions, IPT was acceptable and helpful for underserved acceptable and helpful for underserved women with depression and painwomen with depression and pain