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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. Disclosure .

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Using IPT in Primary Care for Underserved Women with Depression and Chronic Pain

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  1. 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

  2. Disclosure

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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%)

  15. 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%

  16. 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

  17. 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

  18. 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

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