Examining Stress Outcomes Among Depressed Mothers Treated with IPT Jill M. Cyranowski, Ph.D.

1. Examining Stress Outcomes Among Depressed Mothers Treated with IPT Jill M. Cyranowski, Ph.D. Assistant Professor of Psychiatry and Psychology Western Psychiatric Institute and Clinic University of Pittsburgh Medical Center

2. Overview • PMBC-related research goals • Aims of pilot study • Feasibility outcomes: recruitment, retention and compliance • Pilot study results •  Acute physiological and emotional • reactivity to child-focused interpersonal • stressor •  Examining correlates of the cortisol • response to waking among depressed and • never-depressed moms

3. Depression And Interpersonal Life Stress Major depression associated with perturbations in neuroendocrine and autonomic stress response  Importance of understanding depression- related HPA/SAM dysreguation within a social/interpersonal context  Evidence of interactions between depression and recent life stress or early childhood trauma

4. IPT as a Research Platform MOOD • If you improve interpersonal function… • alleviating interpersonal problems • increasing social support • … decrease depressive symptoms • Role of stress • Interpersonal problems engender stress • Social support buffers one from the negative effects of life stress Interpersonal Events

5. Stress Outcomes Study (SOS): Study Goals • Use of non-invasive physiologic procedures that could be implemented in outpatient depression clinic •  Salivary cortisol •  Cardiovascular reactivity •  Continuous EKG for Heart Period Variability (HPV) • Obtain dynamic assessment of stress system that examined stress reactivity within a social context • Examine the feasibility of study procedures •  Would mothers be willing and able to participate? •  Incorporation into clinic procedures

6. Stress Outcomes Study (SOS): Study Goals  Incorporate thorough psychosocial assessment  Perceived stress, early life trauma  Social support, social function Could we incorporate a proxy evaluation of levels of expressed emotion (EE) displayed by mothers when talking about their children

7. Study Participants • Depressed mothers recruited from parent treatment trial (MH64518, Holly Swartz, PI) •  Age 18-60, mother of child aged 6-18 being • treated in a WPIC child psychiatric clinic •  Met SCID MDD criteria, HRSD > 15 •  Randomly assigned to receive either • IPT-MOMS or TAU (treatment as usual) • Control mothers matched on age and ethnicity • Timing of baseline (“early treatment”) assessment •  Goal: within 4 weeks of entry into parent study •  IPT mothers had received an average of 4 • sessions prior to baseline assessment

8. Feasibility: Recruitment Reasons for not enrolling: ▪ 2 - Not interested ▪ 1 - Interested, but did not FU ▪ 1 - Travel too difficult ▪ 3 - Felt “overwhelmed” ▪ 1 - Work conflict 36 Approached 27 Enrolled 12 TAU 5 Withdrawn 22 Matched 10 IPT Reasons for withdrawal: ▪ 1 did not enter parent study ▪ 2 early d/c from parent study ▪ Time 1 assessment out of window ▪ 1 would not complete questionnaires

9. Feasibility: Retention & Compliance

10. In-Clinic Stress Reactivity Task: Examining Acute Physiological and Emotional Reactivity to a Child-Focused Interpersonal Stressor

11. Speech Stress Give speech about “an interpersonal situation with your [son/daughter] that made you feel angry or stressed.” ■ Describe the situation ■ How did you deal with the situation? ■ How did you feel about the situation and the people involved? ■ How well do you think you handled the situation? How satisfied are you with the way it all turned out? ■Told that speech would be video taped and that their performance would be rated at a later time

13. In-Clinic Reactivity Task 2 min Speech Prep 5 min Free Speech 10 min Habituation Recovery 1 (20 min) Recovery 2 (20 min) 10 min Resting Baseline 4 min Speech Stress POMS assessment Series of 2-3 BP assessments

14. Study Participants: Demographics

15. Study Participants: Clinical Variables IPT vs TAU group comparison: ** p < .01, * p = .06

16. Mood Reactivity: POMS Depression Scale

17. Mood Reactivity: POMS Depression Scale

18. Mood Reactivity: POMS Depression Reactivity Scores

19. Physiological Reactivity: Diastolic Blood Pressure

20. Physiological Reactivity: Diastolic Blood Pressure

21. Physiological Reactivity: Diastolic Blood Pressure Reactivity Scores

22. Physiological Reactivity: Heart Rate

23. Physiological Reactivity: Heart Rate

24. Physiological Reactivity: Heart Rate Reactivity Scores Group effect, controlling for: marital status, smoking status, menopausal status, psychotropic med use, and cardiovascular med use, F (2,41) = 4.74, p = .01

25. Examining Correlates of the Cortisol Response to Waking Among Depressed And Never-Depressed Moms

26. Ambulatory Cortisol Assessment Protocol • Focus on feasibility of implementation •  Asked to obtain samples for 2 day period •  5 samples per day 1 - First wake • 2 - 30-mins post-wake • 3 - 11:00 AM • 4 - 3:00 PM • 5 - 8:00 PM •  Patients given pre-programmed timers, watches, • and diary/instruction cards (“spit kit”) •  Used MEMSCAPS for electronic verification

29. Determining Cortisol Data Integrity • Examined reliability of sample timing using MEMSCAP data and diary cards  2 waking samples – within 10 minutes •  11 PM, 3:00 PM, 8:00 PM – within 60 minutes • Eliminated any subjects/samples where • Wake time > 11:00 am • Subject taking corticosteriod (Advair) • Subject indicated problem in comment section  Sample outside of temporal assessment window • Used Day 1 samples if: •  Day 1 was weekday, and •  First two morning samples were good •  Otherwise, used Day 2 samples

30. Blunted Cortisol Response to Awakening Among Depressed Women From Stetler & Miller (2005), Journal of Abnormal Psychology

31. Ambulatory Salivary Cortisol Outcomes: Initial Assessment

32. Self-Reported Early Trauma In Depressed and Never-Depressed Women 27% of Controls scored above group Md 73% of Depressed scored above group Md

33. LES Life Events Reported in Past Year In Depressed and Never-Depressed Women ** p < .01

34. Stability of AM Rise Indicator over 16 Week Study Period

35. Associations With AM Cortisol Rise: Early Life Trauma

36. Associations With AM Cortisol Rise: Impact of Past Year Life Events (LES)

37. Depressed Group: Early Trauma (ETI) x Recent Life Events (LES) Main effect for LES, F(1,14) = 5.80, p < .05

38. Conclusions • Pilot work supports the feasibility of incorporating assessment of physiologic stress reactivity and diurnal regulation within outpatient treatment trials • Importance of examining stress outcomes within an social/interpersonal context •  Current social function and social stress •  Early life trauma • IPT trials represent an ideal platform for examining relationship among stress, depression and interpersonal function over time •  IPT conceptual model provides ideal fit •  IPT provides non-pharmacologic probe to • examine relationships over time

39. Acknowledgements Holly Swartz Tara Hofkens Ellen Frank Heather Spielvogle Janet Amico Kristen Frey Anna Marsland Lynda Rose Kathy Light Patty Houck Pete Gianaros John Scott DMDPP staff Deb Stapf Grant Support: National Institute of Mental Health grants MH64144 (Cyranowski) and MH64518 (Swartz) Pittsburgh Mind-Body Center WPIC Mental Health Intervention Research Center