Transcript Psychosocial Treatment for Gynecology Patients with

Using IPT in Primary Care for
Underserved Women with
Depression and Chronic Pain
Ellen L. Poleshuck, Ph.D.
Associate Professor
Departments of Psychiatry and Obstetrics and Gynecology
University of Rochester Medical Center
Rochester, NY, USA
Disclosure
Presenter
Company
Ellen Poleshuck
No disclosures
Product
Research
Other:
Acknowledgements
Mentor: Nancy Talbot, Ph.D.
Co-mentors: Bob Dworkin, Ph.D., & Caron Zlotnick, Ph.D
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Funding: NIMH K23MH79347
Wynne Center for Family Research
Private donation to URMC Dept. of Obstetrics & Gynecology
Consultants
Donna Giles, Ph.D.
Carmen Green, M.D.
Wayne Katon, M.D.
Kurt Kroenke, M.D.
Holly Swartz, M.D.
Xin Tu, Ph.D.
Therapists
Beth Cerrito, Ph.D.
Natalie Cort, Ph.D.
Debra Hoffman-King, Ph.D.
Lucinda Hutton, M.S.
Lacy Morgan-Develder, M.S.
Tziporah Rosenberg, Ph.D.
Clinical Research Coordinators: Kelly Bellenger and Nicole Leshoure, M.S.
Statistical Support: Xiang Liu, Ph.D., Naiji Lu, Ph.D., Silvia Sorensen, Ph.D.
Research Staff
Ayesha Khan, M.D.
Nicole Lighthouse, M.S.
Jessica Marino
Amanda Pelcher
Melissa Parkhurst
Other IPT-P Team Members
Gillian Finocan Kaag, Ph.D.
Stephanie Gamble, Ph.D.
Danette Gibbs, M.A.
Louis Rosario-McCabe, N.P.
Chronic Pain and Depression
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Depression and pain are two of the most common
problems in primary care settings (CDC, 2009)
In the US, women, African Americans, Latinos, and
individuals with socioeconomic disadvantage are all
at increased risk for both difficulties (Gureje et al., 1998;
Narrow, 1998; Brown et al., 2003; Portenoy et al., 2004; Poleshuck & Green,
2008)
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Individuals with comorbid pain and depression have
poorer treatment adherence and outcomes (Mavandadi
et al., 2007; Karp et al; 2007; Kroenke et al., 2008; Bair et al., 2004)
Traditional Delivery of IPT not
an Optimal Fit
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Patients are presenting with pain
concerns, not depression
Multiple barriers to care
Implications for
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Engagement
Conceptualization
Adherence
Goals for Underserved Women with
Depression and Pain
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Relevance for women who are not seeking
treatment for depression and may not identify
themselves as “depressed”
Directly address how pain is associated with
depression and interpersonal functioning
Improve accessibility
Interpersonal Psychotherapy for
Depression and Pain (IPT-P)
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up to 8 sessions (modeled after Brief IPT)
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Sessions are held in health care clinic
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Medical provider is integrated into delivery of care
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Individualized pace of treatment
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Phone sessions as needed
Sessions 1-2
Engagement, Conceptualization, and
Developing a Plan
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Elicit pain story
Accept patient’s experience and focus
Explore and address barriers
Psychoeducation
Conceptualization
Identify interpersonal problem focus area
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“Change in healthy self”
Select strategies to target depression and pain
Sessions 3-7
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Evaluate pain and depression at beginning
of each session
Explore how changes in pain or depression
may be related to changes in relationships
Assess progress on goals
Reinforce successes and self-care
Attend to treatment barriers
Final session
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Review strategies and reinforce gains
Generalize strategies to other situations
and unresolved concerns
Anticipate future difficulties
Facilitate referral for on-going therapy if
indicated
RCT for women with CPP and
Depression
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Screen women for depression and pain in
women’s health and family medicine
clinics
Enroll women who meet criteria for major
depressive disorder on the SCID, HRSD of
> 14, and chronic pelvic pain for > 6
months
Randomized to IPT-P or E-TAU
Masked assessments at 0, 12, 24, & 36
weeks
Study Sample
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61 women with MDD and pelvic pain
Mean age = 36.6 years (SD = 8.9)
Race/ethnicity
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44 (72.1%) African American
11 (18.0%) non-Hispanic White
6 (9.8%) Hispanic
42 (68.9 %) single/separated/divorced
 39 (63.9 %) annual household income
< US $20,000 annually
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Chronic Pelvic Pain Dx
Fibroids
Endometriosis
Unknown
Pelvic Inflam. Disease
Interstitial Cystitis
Other
n
12
10
8
5
4
22
%
19.7
16.4
13.1
8.2
6.6
36.2
Co-Occurring Psychiatric
Diagnoses
56 (91.8%) met criteria for > 1 additional current diagnoses
Pain Disorder
Specific Phobia
PTSD
Panic Disorder
Hx of Substance
Abuse
IPT-P
E-TAU
TOTAL
n= 33
n=28
n=61
23 (69.7%)
19 (57.6%)
14 (42.4%)
10 (30.3%)
10 (30.3%)
21 (75%)
10 (35.7%)
12 (42.9%)
11 (39.3%)
9 (32.1%)
44 (72.1%)
29 (47.5%)
26 (42.6%)
21 (34.4%)
19 (31.1%)
Interim Analyses
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Generalized Estimating Equations controlling for
age, baseline anti-depressant medication use, and
session attendance
Interim analysis n’s
Baseline
12 weeks
24 weeks
36 weeks
IPT-P
33
24
15
22
E-TAU
28
26
19
18
Total
61
50
34
40
Retention
85%
69%
85%
Interim findings: Treatment
Engagement and Adherence
IPT-P (n=29)
E-TAU (n=25)
t
p
>0 sessions
23 (79.3%)
13 (52.0%)
4.73
.034
6+ sessions
13 (44.8%)
4 (16.0%)
5.98
.018
35
30
25
20
BDI E-TAU
BDI IPT-P
HRSD E-TAU
15
HRSD IPT-P
10
5
0
baseline
12 weeks
24 weeks
36 weeks
2
1.8
1.6
1.4
IIP aggression E-TAU
IIP aggression IPT-P
IIP sociability E-TAU
1.2
IIP sociability IPT-P
1
0.8
0.6
baseline
12 weeks
24 weeks
36 weeks
Interim Outcomes
Outcome Variable
β
SE
p
Hamilton Rating Scale for Dep
Beck Depression Inventory
MDD Diagnosis
-3.66
-4.23
-1.30
1.68 .029
2.15 .049
0.69 .059
IIP Aggression
IIP Sociability
-0.35
0.36
0.17 .041
0.18 .045
Summary
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Many individuals who would benefit from
IPT do not come knocking at our door
There are ways we can increase the
accessibility and relevance of IPT for
clinic-based “real life” populations,
including women with pain and depression
With minor additions, IPT was acceptable
and helpful for underserved women with
depression and pain