1. 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

2. PresenterCompanyProductResearchOther: Ellen PoleshuckNo disclosures Disclosure

3. Acknowledgements Mentor: 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 Funding: NIMH K23MH79347 Wynne Center for Family Research Private donation to URMC Dept. of Obstetrics & Gynecology Consultants Therapists Consultants Therapists Donna Giles, Ph.D.Beth Cerrito, Ph.D. 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. 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. Clinical Research Coordinators: Kelly Bellenger and Nicole Leshoure, M.S. Statistical Support: Xiang Liu, Ph.D., Naiji Lu, Ph.D., Silvia Sorensen, Ph.D. Statistical Support: Xiang Liu, Ph.D., Naiji Lu, Ph.D., Silvia Sorensen, Ph.D. Research StaffOther IPT-P Team Members Research StaffOther IPT-P Team Members Ayesha Khan, M.D.Gillian Finocan Kaag, Ph.D. Nicole Lighthouse, M.S. Stephanie Gamble, Ph.D. Jessica MarinoDanette 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) 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) 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) 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 Patients are presenting with pain concerns, not depression Multiple barriers to care Multiple barriers to care Implications for Implications for Engagement Engagement Conceptualization Conceptualization Adherence 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” 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 Directly address how pain is associated with depression and interpersonal functioning Improve accessibility Improve accessibility

7. Interpersonal Psychotherapy for 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 clinic Sessions are held in health care clinic Medical provider is integrated into delivery of care Medical provider is integrated into delivery of care Individualized pace of treatment Individualized pace of treatment Phone sessions as needed Phone sessions as needed

8. Sessions 1-2 Engagement, Conceptualization, and Developing a Plan Elicit pain story Elicit pain story Accept patient’s experience and focus Accept patient’s experience and focus Explore and address barriers Explore and address barriers Psychoeducation Psychoeducation Conceptualization Conceptualization Identify interpersonal problem focus area Identify interpersonal problem focus area “Change in healthy self” “Change in healthy self” Select strategies to target depression and pain Select strategies to target depression and pain

9. Sessions 3-7 Evaluate pain and depression at beginning of each session Evaluate pain and depression at beginning of each session Explore how changes in pain or depression may be related to changes in relationships Explore how changes in pain or depression may be related to changes in relationships Assess progress on goals Assess progress on goals Reinforce successes and self-care Reinforce successes and self-care Attend to treatment barriers Attend to treatment barriers

10. Final session Review strategies and reinforce gains Review strategies and reinforce gains Generalize strategies to other situations and unresolved concerns Generalize strategies to other situations and unresolved concerns Anticipate future difficulties Anticipate future difficulties Facilitate referral for on-going therapy if indicated 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 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 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 Randomized to IPT-P or E-TAU Masked assessments at 0, 12, 24, & 36 weeks Masked assessments at 0, 12, 24, & 36 weeks

12. Study Sample 61 women with MDD and pelvic pain 61 women with MDD and pelvic pain Mean age = 36.6 years (SD = 8.9) Mean age = 36.6 years (SD = 8.9) Race/ethnicity Race/ethnicity 44 (72.1%) African American 44 (72.1%) African American 11 (18.0%) non-Hispanic White 11 (18.0%) non-Hispanic White 6 (9.8%) Hispanic 6 (9.8%) Hispanic 42 (68.9 %) single/separated/divorced 42 (68.9 %) single/separated/divorced 39 (63.9 %) annual household income 39 (63.9 %) annual household income < US $20,000 annually

13. Chronic Pelvic Pain Dx n% Fibroids1219.7 Endometriosis1016.4 Unknown 813.1 Pelvic Inflam. Disease 5 8.2 Interstitial Cystitis 4 6.6 Other22 36.2

14. Co-Occurring Psychiatric Diagnoses IPT-PE-TAU TOTAL 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%) 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%)

15. Interim Analyses Generalized Estimating Equations controlling for age, baseline anti-depressant medication use, and session attendance Generalized Estimating Equations controlling for age, baseline anti-depressant medication use, and session attendance Interim analysis n’s Interim analysis n’s IPT-P E-TAUTotal 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 >0 sessions 23 (79.3%)13 (52.0%) 4.73.034 6+ sessions 13 (44.8%) 4 (16.0%) 5.98.018 6+ sessions 13 (44.8%) 4 (16.0%) 5.98.018

19. 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

20. Summary Many individuals who would benefit from IPT do not come knocking at our door 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 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 With minor additions, IPT was acceptable and helpful for underserved women with depression and pain