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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 .

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using ipt in primary care for underserved women with depression and chronic pain

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

acknowledgements mentor nancy talbot ph d co mentors bob dworkin ph d caron zlotnick ph d
AcknowledgementsMentor: Nancy Talbot, Ph.D.Co-mentors: Bob Dworkin, Ph.D., & Caron Zlotnick, Ph.D
  • Funding: NIMH K23MH79347 Wynne Center for Family Research Private donation to URMC Dept. of Obstetrics & Gynecology
  • Consultants Therapists

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

Carmen Green, M.D. Natalie Cort, Ph.D.

Wayne Katon, M.D. Debra Hoffman-King, Ph.D.

Kurt Kroenke, M.D. Lucinda Hutton, M.S.

Holly Swartz, M.D. Lacy Morgan-Develder, M.S.

Xin Tu, Ph.D. 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 Other IPT-P Team Members

Ayesha Khan, M.D. Gillian Finocan Kaag, Ph.D.

Nicole Lighthouse, M.S. Stephanie Gamble, Ph.D.

Jessica Marino Danette Gibbs, M.A.

Amanda Pelcher Louis Rosario-McCabe, N.P.

Melissa Parkhurst

chronic pain and depression
Chronic Pain and Depression
  • 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)
  • 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
Traditional Delivery of IPT not an Optimal Fit
  • Patients are presenting with pain concerns, not depression
  • Multiple barriers to care
  • Implications for
    • Engagement
    • Conceptualization
    • Adherence
goals for underserved women with depression and pain
Goals for Underserved Women with Depression and Pain
  • 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
Interpersonal Psychotherapy for Depression and Pain (IPT-P)
  • up to 8 sessions (modeled after Brief IPT)
  • Sessions are held in health care clinic
  • Medical provider is integrated into delivery of care
  • Individualized pace of treatment
  • Phone sessions as needed
sessions 1 2 engagement conceptualization and developing a plan
Sessions 1-2Engagement, Conceptualization, and Developing a Plan
  • Elicit pain story
  • Accept patient’s experience and focus
  • Explore and address barriers
  • Psychoeducation
  • Conceptualization
  • Identify interpersonal problem focus area
    • “Change in healthy self”
  • Select strategies to target depression and pain
sessions 3 7
Sessions 3-7
  • 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
Final session
  • 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
RCT for women with CPP and Depression
  • 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
Study Sample
  • 61 women with MDD and pelvic pain
  • Mean age = 36.6 years (SD = 8.9)
  • Race/ethnicity
    • 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

chronic pelvic pain dx
Chronic Pelvic Pain Dx

n %

Fibroids 12 19.7

Endometriosis 10 16.4

Unknown 8 13.1

Pelvic Inflam. Disease 5 8.2

Interstitial Cystitis 4 6.6

Other 22 36.2

slide14

Co-Occurring Psychiatric Diagnoses

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

IPT-PE-TAUTOTAL

n= 33 n=28 n=61

Pain Disorder

Specific Phobia

PTSD

Panic Disorder

Hx 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%) 11 (39.3%) 21 (34.4%)

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

interim analyses
Interim Analyses
    • Generalized Estimating Equations controlling for age, baseline anti-depressant medication use, and session attendance
  • Interim analysis n’s

IPT-P E-TAU Total Retention

Baseline 33 28 61

12 weeks 24 26 50 85%

24 weeks 15 19 34 69%

36 weeks 22 18 40 85%

interim findings treatment engagement and adherence
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

interim outcomes
Interim Outcomes

Outcome Variable β SE p

Hamilton Rating Scale for Dep -3.66 1.68 .029

Beck Depression Inventory -4.23 2.15 .049

MDD Diagnosis -1.30 0.69 .059

IIP Aggression -0.35 0.17 .041

IIP Sociability 0.36 0.18 .045

summary
Summary
  • 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