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