Examining Stress OutcomesAmong Depressed Mothers

Treated with IPT

Jill M. Cyranowski, Ph.D.Assistant Professor of Psychiatry and Psychology

Western Psychiatric Institute and ClinicUniversity of Pittsburgh Medical Center

PMBC-related research goals Aims of pilot study Feasibility outcomes: recruitment, retention and compliance Pilot study results Acute physiological and emotional

reactivity to child-focused interpersonalstressor

Examining correlates of the cortisolresponse to waking among depressed andnever-depressed moms

Overview

DepressionAnd Interpersonal Life Stress

Major depression associated with perturbations in neuroendocrine and autonomic stress response Importance of understanding depression-

related HPA/SAM dysreguation within asocial/interpersonal context

Evidence of interactions between depression and recent life stress or early childhood trauma

If you improve interpersonal function… alleviating interpersonal problems increasing social support

… decrease depressive symptoms

Role of stress Interpersonal problems engender stress Social support buffers one from the negative

effects of life stress

IPT as a Research Platform

MOOD

Interpersonal Events

Stress Outcomes Study (SOS):Study Goals

Use of non-invasive physiologic procedures that could be implemented in outpatient depression clinic Salivary cortisol Cardiovascular reactivity Continuous EKG for Heart Period Variability (HPV) Obtain dynamic assessment of stress system that examined stress reactivity within a social context Examine the feasibility of study procedures Would mothers be willing and able to participate? Incorporation into clinic procedures

Stress Outcomes Study (SOS):Study Goals

Incorporate thorough psychosocial assessment Perceived stress, early life trauma Social support, social function Could we incorporate a proxy evaluation of

levels of expressed emotion (EE) displayed bymothers when talking about their children

Study Participants

Depressed mothers recruited from parent treatment trial (MH64518, Holly Swartz, PI) Age 18-60, mother of child aged 6-18 being

treated in a WPIC child psychiatric clinic Met SCID MDD criteria, HRSD > 15 Randomly assigned to receive either

IPT-MOMS or TAU (treatment as usual) Control mothers matched on age and ethnicity Timing of baseline (“early treatment”) assessment Goal: within 4 weeks of entry into parent study IPT mothers had received an average of 4

sessions prior to baseline assessment

Feasibility: Recruitment

36Approached

27Enrolled

Reasons for not enrolling: ▪ 2 - Not interested ▪ 1 - Interested, but did not FU ▪ 1 - Travel too difficult ▪ 3 - Felt “overwhelmed” ▪ 1 - Work conflict

5Withdrawn

22Matched

12TAU

10IPTReasons for withdrawal:

▪ 1 did not enter parent study ▪ 2 early d/c from parent study ▪ Time 1 assessment out of window ▪ 1 would not complete questionnaires

Feasibility: Retention & Compliance

Controls Depressed

Time 1

Assessment

22 22

Time 2

Assessment

20 20

91%

Retention rate

91%

Retention rate

Data available to

examine AM rise

in salivary cortisol

17

(77.3%)

17

(77.3%)

In-Clinic Stress Reactivity Task: Examining Acute Physiological

and Emotional Reactivity to a Child-Focused

Interpersonal Stressor

Give speech about “an interpersonal situation with your [son/daughter] that made you feel angry or stressed.” ■ Describe the situation ■ How did you deal with the situation? ■ How did you feel about the situation and the people involved? ■ How well do you think you handled the situation? How

satisfied are you with the way it all turned out?

■ Told that speech would be video taped and that their performance would be rated at a later time

Speech Stress

In-Clinic Reactivity Task

10 minHabituation 10 min

Resting Baseline

Recovery 1(20 min)

5 minFree

Speech

4 minSpeechStress

Recovery 2(20 min)

Series of 2-3 BP assessments

POMS assessment

2 minSpeech

Prep

Controls(N=22)

IPT(N=10)

TAU(N=12)

Age mean(SD)

44.30(7.41)

42.22(7.82)

45.58(8.53)

Education mean(SD)

15.50(2.44)

14.40(2.95)

15.50(2.43)

BMI mean(SD)

27.59(5.85)

28.35(6.09)

31.34(6.16)

% Married or living with partner

% 86% 60% 58%

Study Participants: Demographics

Controls(N=22)

IPT(N=10)

TAU(N=12)

BDI Beck Depression

mean(SD)

2.05(1.81)

16.20*(5.47)

21.18*(8.09)

MASQGD Depression

mean(SD)

15.27(2.71)

23.60**(3.89)

31.36**(7.72)

PSSPerceived Stress

mean(SD)

17.77(5.35)

33.20(5.71)

36.73(5.71)

PSWQ Worry Questionaire

mean(SD)

39.41(10.59)

51.38*(8.52)

63.00*(13.62)

Study Participants: Clinical Variables

IPT vs TAU group comparison: ** p < .01, * p = .06

Mood Reactivity:POMS Depression Scale

POMS Depression

0

1

2

3

4

5

6

7

8

9

10

Baseline Post Speech Recovery 1

Assessment

Controls (N=22)

Dep TAU (N=12)

Mood Reactivity:POMS Depression Scale

POMS Depression

0

1

2

3

4

5

6

7

8

9

10

Baseline Post Speech Recovery 1

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Mood Reactivity:POMS Depression Reactivity Scores

Visit 2: Raw Change in POMS DepressionBaseline to Speech Stress

1.09

5.92

3.4

0

1

2

3

4

5

6

7

Base to Speech Stress

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Physiological Reactivity: Diastolic Blood Pressure

Visit 2: Diaslolic BP

60

65

70

75

80

85

90

95

Baseline FreeSpeech

Sp StressPrep

SpeechStress

Recovery1

Recovery2

Assessment

Controls (N=22)

Dep TAU (N=12)

Physiological Reactivity: Diastolic Blood Pressure

Visit 2: Diaslolic BP

60

65

70

75

80

85

90

95

Baseline FreeSpeech

Sp StressPrep

SpeechStress

Recovery1

Recovery2

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Physiological Reactivity: Diastolic Blood Pressure Reactivity Scores

Visit 2: Raw Change in DBPBaseline to Speech Stress

9.46

13.73

9.08

8

9

10

11

12

13

14

15

Base to Speech Stress

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Physiological Reactivity: Heart Rate

Visit 2: Heart Rate

70

72

74

76

78

80

82

84

86

88

90

Baseline FreeSpeech

Sp StressPrep

SpeechStress

Recovery1

Recovery2

Assessment

Controls (N=22)

Dep TAU (N=12)

Physiological Reactivity: Heart Rate

Visit 2: Heart Rate

70

72

74

76

78

80

82

84

86

88

90

Baseline FreeSpeech

Sp StressPrep

SpeechStress

Recovery1

Recovery2

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Physiological Reactivity: Heart Rate Reactivity Scores

Group effect, controlling for: marital status, smoking status, menopausal status, psychotropic med use, and cardiovascular med use, F (2,41) = 4.74, p = .01

Visit 2: Raw Change in HRBaseline to Speech Stress

2.57

8.26

4

0

1

2

3

4

5

6

7

8

9

10

Base to Speech Stress

Assessment

Controls (N=22)

Dep TAU (N=12)

Dep IPT (N=10)

Examining Correlates of the CortisolResponse to Waking Among Depressed

And Never-Depressed Moms

Ambulatory Cortisol Assessment Protocol

Focus on feasibility of implementation Asked to obtain samples for 2 day period 5 samples per day 1 - First wake

2 - 30-mins post-wake3 - 11:00 AM4 - 3:00 PM5 - 8:00 PM

Patients given pre-programmed timers, watches, and diary/instruction cards (“spit kit”)

Used MEMSCAPS for electronic verification

Determining Cortisol Data Integrity

Examined reliability of sample timing using MEMSCAP data and diary cards 2 waking samples – within 10 minutes 11 PM, 3:00 PM, 8:00 PM – within 60 minutes Eliminated any subjects/samples where

Wake time > 11:00 am Subject taking corticosteriod (Advair) Subject indicated problem in comment section Sample outside of temporal assessment window

Used Day 1 samples if: Day 1 was weekday, and First two morning samples were good Otherwise, used Day 2 samples

Blunted Cortisol Response to AwakeningAmong Depressed Women

From Stetler & Miller (2005), Journal of Abnormal Psychology

Ambulatory Salivary Cortisol Outcomes:Initial Assessment

V1: Ambulatory Cortisol

0

5

10

15

20

25

First Wake 30 M Post-Wake

11:00 AM 3:00 PM 8:00 PM

Assessment

Co

rt V

alu

es

Controls (N=17)

Dep TAU (N=10)

Dep IPT (N=7)

Self-Reported Early TraumaIn Depressed and Never-Depressed Women

Controls(N=22)

Depressed(N=22)

Total(N=44)

ETI – Total Severity Md 52 * 165 * 88

ETI – Emotional Abuse Md 14 * 128 * 48

ETI – General Trauma Md 6 26 19

ETI – Physical Abuse Md 3 12 8

ETI – Sexual Abuse Md 0 .5 0

27% of Controls scored above group Md73% of Depressed scored above group Md

LES Life Events Reported in Past YearIn Depressed and Never-Depressed Women

Controls(N=18)

Depressed(N=18)

Total number of eventsendorsed

M(SD)

3.17(1.76)

9.50**(5.43)

Cumulative positivity ratings of impact

M(SD)

3.00(3.85)

2.44(1.95)

Cumulative negativity ratings of impact

M(SD)

-3.00(3.53)

-17.33**(13.33)

** p < .01

Stability of AM Rise Indicator over16 Week Study Period

Controls r

p

N

.683**

.007

14

Depressed r

p

N

.398

.159

14

Associations With AM Cortisol Rise:Early Life Trauma

Controls Depressed

Time 1 Time 2 Time 1 Time 2

ETI Total Severity RhopN

-.362.15417

-.200.47515

-.350.16817

-.658**.00815

ETI Emotional Abuse RhopN

-.100.70317

.007.9815

-.270.29517

-.537*.03915

ETI General Trauma RhopN

-.025.92317

-.198.47815

-.302.23817

-.763**.00115

Associations With AM Cortisol Rise:Impact of Past Year Life Events (LES)

Controls Depressed

Time 1 Time 2 Time 1 Time 2

Cumulative Positive Impact

RhopN

.591*.01217

.693**.00415

.161

.53617

-.110.69715

Cumulative Negative Impact

RhopN

-.114.66417

-.355.19415

-.211.41617

-.624*.01315

Depressed Group:Early Trauma (ETI) x Recent Life Events (LES)

-2

0

2

4

6

8

10

12

14

16

Low Negative Life Events High Negative Life Events

AM

co

rtis

ol r

ise

Low Early Trauma

High Early Trauma

Main effect for LES, F(1,14) = 5.80, p < .05

Pilot work supports the feasibility of incorporating

assessment of physiologic stress reactivity and diurnal regulation within outpatient treatment trials Importance of examining stress outcomes within an social/interpersonal context Current social function and social stress Early life traumaIPT trials represent an ideal platform for

examiningrelationship among stress, depression andinterpersonal function over time IPT conceptual model provides ideal fit IPT provides non-pharmacologic probe to

examine relationships over time

Conclusions

Acknowledgements

Holly Swartz Tara HofkensEllen Frank Heather SpielvogleJanet Amico Kristen FreyAnna Marsland

Lynda RoseKathy Light Patty HouckPete Gianaros John Scott DMDPP staff Deb Stapf

Grant Support:National Institute of Mental Health grants

MH64144 (Cyranowski) and MH64518 (Swartz)

Pittsburgh Mind-Body CenterWPIC Mental Health Intervention Research

Center