Randomized controlled trial of interpersonal psychotherapy versus enhanced treatment as usual for women with co-occurring depression and pelvic pain

https://doi.org/10.1016/j.jpsychores.2014.07.016Get rights and content

Highlights

  • Two approaches to treating women with depression and chronic pelvic pain are compared.

  • Study participants reported both treatments to be acceptable.

  • Interpersonal Psychotherapy showed positive outcomes using causal modeling.

Abstract

Objective

Our study assessed the effectiveness of Interpersonal Psychotherapy (IPT) tailored for biomedical patients with depression and pain. IPT was compared to enhanced treatment as usual (E-TAU) among women with co-occurring depression and chronic pain presenting for care at a women's health or family medicine practice. We hypothesized that women presenting to urban medical practices with depression and chronic pain would benefit from IPT tailored to address their needs to a greater degree than from E-TAU.

Methods

We conducted a randomized controlled psychotherapy trial of 61 women from 2 urban medical practices who met criteria for major depressive disorder and chronic pelvic pain. Participants were assigned to receive either 8 sessions of IPT or a facilitated psychotherapy referral to a community mental health center, and assessed for depression, social interactions, and pain at 0-, 12-, 24-, and 36-weeks, with score on the Hamilton Rating Scale for Depression as the primary outcome. Both intent-to-treat (ITT) and causal modeling analyses correcting for treatment attendance were conducted.

Results

ITT analyses were not significant. In causal modeling analyses, participants assigned to IPT showed significantly more improvement for depression and social interactions, but not for pain.

Conclusion

IPT may be a viable option as part of a comprehensive treatment program for women in medical practices with depression and chronic pain.

Clinical Trials Registration: Clinical Trials.gov, www.clinicaltrials.gov, NCT00895999.

Introduction

Reproductive-aged women are among those at greatest risk for both depression [1] and chronic pain [2]. Mood disorders and pain-related chronic medical conditions are the two leading causes of decreased quality of life [3], with annual costs of chronic pain and depression estimated at $215 billion and $80 billion respectively in the United States [4], [5]. Moreover, treatment engagement, adherence, and outcomes consistently are worse for those with depression and pain than for those with depression alone. Specifically, patients with depression and chronic pain have more severe depression, longer time to remission, poorer remission rates, and more partial response rates [6], [7], [8], [9], [10], [11], [12], [13] compared to patients with depression only. Women who have the added burden of socioeconomic disadvantage face poverty, low educational attainment, multiple life stressors and limited resources, in addition to factors likely interfering further with their treatment engagement and response, such as trauma exposure, chronic life stress, and poor health [14], [15], [16]. To meet these challenges, tailored approaches that are responsive to the complex, concurrent difficulties facing women with pain and depression are required.

Women living with socioeconomic disadvantage and African American women often report using their medical doctors as their primary resource for both physical and mental health care [17], [18], and indicate a preference for psychotherapy over medication for treatment of depression [19], [20], [21]. Interpersonal Psychotherapy (IPT) is an evidence-based, time-limited psychotherapy that focuses on interpersonal issues associated with both the onset and maintenance of depression [22], [23]. IPT is an effective treatment for individuals with physical illnesses [24], [25], [26], [27], and patients in primary care and women's health settings [28], [29], [30], [31]. IPT also has been found to be an excellent fit for low-income women and women of color with multiple social adversities and limited support [29], [30], [32]. Given the strong outcomes for IPT among socioeconomically disadvantaged women with health related concerns, we conducted a preliminary study for women with depression and pain, using specific treatment adaptations to address pain and treatment engagement [33], Interpersonal Psychotherapy for depressed patients with pain (IPT-P). Results from the study showed improvements in depression and social function [34], leading us to our next step: a controlled trial of our adapted IPT, with an active comparison condition.

In the current study, we compared IPT-P to enhanced treatment as usual (E-TAU), in which participants were provided with facilitated referrals for psychotherapy in a community mental health center. We hypothesized that IPT-P would prove more effective than E-TAU for depression outcomes among women with depression and pain presenting to primary care and obstetrics and gynecology practices. Our primary outcome was the severity score on the Hamilton Rating Scale of Depression. We also hypothesized that IPT-P would yield significant improvements in social interactions, pain, and daily function compared to E-TAU.

Section snippets

Settings and participants

Women from two urban medical practices (obstetrics and gynecology and family medicine) were recruited between February, 2009 and September, 2011. We targeted women with chronic pelvic pain for several reasons: their elevated risk for under-treatment of depression [35], [36]; the lack of studies assessing what treatments are effective among women with pelvic pain [37]; to reduce the heterogeneity of the types of pain interference experienced among participants; and because of the focus on

Participants

A total of 200 of 3224 (6.2%) women had positive screens and were referred for a baseline assessment (Fig. 1). Of those, 85 (42.5%) failed to complete the baseline assessment and were not enrolled, and 24 (12.0%) declined to participate.

Of the remaining 93 women, 31 (33.3%) were excluded due to subthreshold depression symptoms (n = 20), psychotic or bipolar symptoms (n = 4), substance dependence (n = 3), or distance from the hospital interfering with their ability to attend regular psychotherapy

Discussion

In sum, patients assigned to receive IPT-P demonstrated greater satisfaction and significantly better outcomes for depression and social interactions than patients assigned to receive E-TAU after correcting for variability in treatment attendance; no significant differences were found for pain outcomes. Moreover, results suggest that IPT-P can be used effectively for patients who traditionally are under-represented in treatment: women with chronic pain presenting to medical settings and not

Conclusions

Study findings demonstrate that IPT-P was acceptable and generate the hypothesis that it was effective for the improvement of depression and social interactions among patients with depression and chronic pain. The study findings therefore suggest that IPT-P may be a viable option as part of a comprehensive treatment program for this patient population. These findings are also important because untreated depression can interfere with adherence and response to pain treatments [55], [56]. Thus, by

Competing interest statement

“All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare that (1) [authors] received support from [name of company or other competing interest] for the submitted work; (2) [authors] have [specify relationships] with [name of companies or other competing interests] in the past three years that could be perceived to constitute a conflict of interest; (3) spouses, partners, or children of [authors] have [specified] financial

Acknowledgments

This work was supported by grant K23-MH079347 from the National Institute of Mental Health. We are grateful to Catherine Cerulli, JD, PhD, Yeates Conwell, MD, Hugh Crean, PhD, Tara Gellasch, MD, and Marsha Wittink, MD, for their suggestions on an earlier draft of this paper.

References (56)

  • HC Schulberg et al.

    The effectiveness of psychotherapy in treating depressive disorders in primary care practice: clinical and cost perspectives

    Gen Hosp Psychiatry

    (2002)
  • JE Ware et al.

    The MOS 36-item short-form health survey (SF-36): I. conceptual framework and item selection

    Med Care

    (1992)
  • K. Liang et al.

    Longitudinal data analysis using generalized linear models

    Biometrika

    (1986)
  • J Miranda et al.

    The need for mental health services research focusing on poor young women

    J Ment Health Policy Econ

    (1999)
  • A Fernandez

    Burden of chronic physical conditions and mental disorders in primary care

    Br J Psychiatry

    (2010)
  • PE Greenberg

    The economic burden of depression in the United States: how did it change between 1990 and 2000?

    J Clin Psychiatry

    (2003)
  • American Academy, o.O.S

    Musculoskeletal conditions in the United States

    Am Acad Orthop Surg Bull

    (1999)
  • MJ Bair

    Impact of pain on depression treatment response in primary care

    Psychosom Med

    (2004)
  • S Mavandadi

    Effect of depression treatment on depressive symptoms in older adulthood: the moderating role of pain

    J Am Geriatr Soc

    (2007)
  • JF Karp

    Pain predicts longer time to remission during treatment of recurrent depression

    J Clin Psychiatry

    (2005)
  • AF Leuchter

    Painful physical symptoms and treatment outcome in major depressive disorder: a STAR*D (Sequenced Treatment Alternatives to Relieve Depression) report

    Psychol Med

    (2010)
  • AM DeVeaugh-Geiss

    The adverse effects of comorbid pain on depression outcomes in primary care patients: results from the ARTIST trial

    Pain Med

    (2010)
  • D.M. Almeida et al.

    Do daily stress processes account for socioeconomic health disparities?

    J Gerontol B Psychol Sci Soc Sci

    (2005)
  • J. Banks et al.

    Disease and disadvantage in the United States and in England

    JAMA

    (2006)
  • J. Mirada et al.

    Unmet mental health needs of women in public-sector gynecologic clinics

    AM J Obstet Gynecol

    (1998)
  • LA Cooper

    The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients

    Med Care

    (2003)
  • M. Dwight-Johnson et al.

    Treatment preferences among depressed primary care patients

    J Gen Intern Med

    (2000)
  • S Stuart et al.

    Interpersonal psychotherapy: a clinician's guide

    (2003)
  • Cited by (12)

    View all citing articles on Scopus
    View full text