mental health AIDS

Spring 2006 Newsletter / Volume 7, Issue 3

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Psychopharmacology

Himelhoch and Medoff (2005) "performed a systematic review and meta-analysis of double-blinded, randomized controlled trials to examine efficacy of antidepressant treatment among HIV-positive depressed individuals and evaluate whether the results are generalizable to women and minorities" (p. 813). The investigators identified seven studies with a total of 494 participants published between 1994 and 2004 and report that this "meta-analysis ... found that antidepressant medication is efficacious … [and] that heterogeneity across studies was strongly related to placebo response” (pp. 817-818). Because "[w]omen were nearly absent from and minorities were underrepresented in the studies investigated" (p. 813), Himelhoch and Medoff conclude that “antidepressant medication is efficacious in treating depression among depressed outpatient HIV-positive men. However, the underrepresentation of women and minorities limits the generalizability of these findings and suggests that future studies should be directed to remedy this disparity” (p. 819).

Rabkin, McElhiney, Rabkin, McGrath, and Ferrando (2006) conducted an 8-week, double-blind, placebo-controlled trial of dehydroepiandrosterone (DHEA) for the treatment of nonmajor depression (i.e., persistent subsyndromal major depressive disorder 2 or dysthymia) in 145 men and women living with HIV/AIDS. Among the 133 who completed the trial, in which DHEA dosing was flexible (100-400 mg/day) and side effects were few, the response to DHEA was superior to the response to placebo. This was also the case in the intent-to-treat analysis, involving all of the original 145 study participants. Rabkin and colleagues observe that "[n]onmajor but persistent depression is common in patients with HIV/AIDS, and DHEA appears to be a useful treatment that is superior to placebo in reducing depressive symptoms. The low attrition rate in this group of physically ill patients, together with requests for extended open-label treatment, reflect[s] high acceptance of this readily available intervention" (p. 59) 3. They conclude that, "[f]or patients who are unwilling to take antidepressants, who express a strong preference for an 'alternative' treatment, and who have nonmajor depression, DHEA may be a reasonable choice. ... [The investigators] suggest documenting informed consent for an 'unapproved' treatment and monitoring response and potential adverse events at regular intervals" (pp. 65-66).

Adherence to Treatment

In a small study involving 24 teens and young adults between the ages of 16 and 24 who were living with HIV, Naar-King et al. (2006) found that, "consistent with the adult literature, self-efficacy and psychological distress were associated with medication adherence, and together accounted for almost half the variance in adherence. Social support was not associated with adherence, but social support specific to taking medications was correlated with self-efficacy" (p. 47). Although these findings require replication with a larger and more diverse sample of youth living with HIV, the "results suggest that interventions that boost self-efficacy (e.g., motivational interventions) and reduce emotional distress (e.g., cognitive behavioral therapy) may be beneficial for improving adherence" (p. 47).

Stress Management

Antoni et al. (2006) randomly assigned 130 MSM living with HIV and receiving HAART to one of two conditions: either a 10-week, cognitive behavioral stress management (CBSM) group intervention offered in conjunction with individualized antiretroviral medication adherence training (MAT) from a clinical pharmacist (CBSM + MAT; n = 76) or a MAT-Only condition (n = 54). Data were collected at four time points (baseline, 3 months following randomization, 9 months following randomization, and 15 months following randomization). The investigators "found no differences in HIV viral load among the 130 men randomized. However, in the 101 men with detectable viral load at baseline, those randomized to CBSM + MAT (n = 61) displayed reductions of 0.56 log 10 units in HIV viral load over a 15-month period after controlling for medication adherence. Men in the MAT-Only condition (n = 40) showed no change. Decreases in depressed mood during the intervention period explained the effect of CBSM + MAT on HIV viral load reduction over the 15 months" (p. 143). Despite the relatively low proportion (60%) of study participants returning for follow-up at 9 or 15 months after randomization, Antoni and colleagues suggest that "[a] time-limited CBSM + MAT intervention that modulates depressed mood may enhance the effects of HAART on suppression of HIV viral load in HIV+ men with detectable plasma levels" (p. 143).

Serostatus Disclosure

Serovich, Oliver, Smith, and Mason (2005) interviewed 57 adult MSM living with HIV in a large city in the American Midwest for the purpose of ascertaining serostatus disclosure methods used with casual sex partners. The investigators placed these disclosure strategies into five categories: point-blank disclosure, stage setting (i.e., using hints and symbols to prime the disclosure), indirect disclosure (i.e., offering clues that one is HIV-positive without overtly stating so), buffering (i.e., disclosing through a third party), and seeking similars (i.e., surrounding oneself with potential sex partners who are more likely to be accepting). Serovich and colleagues urge clinicians

to share these strategies with the HIV-positive men with whom they work [and to] assist men [to] move from indirect disclosing to more point-blank strategies as comfort permits. ... Theoretically, men who are aware of the robust variety of disclosure strategies available will be able to find strategies that are comfortable for them and match their environmental and relational circumstances. Thus, a combination of knowledge, creativity, and the ability to minimize risks and costs may be the key to successful HIV disclosure. (p. 831)

Coping, Social Support, & Quality of Life

Crothers et al. (2005) assessed the impact of cigarette smoking on health and quality of life in a cohort of 867 U.S. veterans living with HIV and receiving care in the HAART era. Crothers and colleagues found that "HIV-positive patients who currently smoke have increased mortality and decreased quality of life, as well as increased respiratory symptoms, COPD [chronic obstructive pulmonary disease], and bacterial pneumonia. These findings suggest that smoking cessation should be emphasized for HIV-infected patients" (p. 1142).

On this point, Vidrine, Arduino, Lazev, and Gritz (2006) randomized a low-income, inner-city, multiethnic sample of 95 cigarette smokers receiving HIV primary care services to one of two conditions. The first condition was the recommended standard of care (i.e., brief advice from a physician to quit smoking, targeted self-help reading material, and a 10-week supply of nicotine replacement therapy [the nicotine patch]). The second condition was the recommended standard of care plus an innovative eight-session smoking cessation intervention delivered by cellular telephone. At the 3-month follow-up assessment, among the 77 (81%) study participants who were evaluated at that time, "[a]nalyses indicated biochemically verified point prevalence smoking abstinence rates of 10.3% for the usual care group and 36.8% for the cellular telephone group" (p. 253). In other words, "participants who received the cellular telephone intervention were 3.6 times ... more likely to quit smoking compared with participants who received usual care ... . (p. 253). Drawing on these findings, Vidrine and colleagues conclude that "individuals living with HIV/AIDS are receptive to, and can be helped by, smoking cessation treatment. In addition, smoking cessation treatment tailored to the special needs of individuals living with HIV/AIDS, such as counseling delivered by cellular telephone, can significantly increase smoking abstinence rates over that achieved by usual care" (p. 253).

French investigators (Préau et al., 2005) assessed beliefs regarding control over health outcomes (i.e., health locus of control), as well as health-related quality of life (HRQL) among 302 individuals living with HIV at the time they initiated HAART and again 44 months later. Préau and colleagues found that "[p]atients with the belief that their health depends on chance have a lower mental HRQL in the long term. To understand this result, ... several studies have already shown a significant impact of chance locus on depressive symptomatology in the context of chronic illness ... . It appears necessary to modify this belief at [the] initiation of treatment to optimise long-term mental HRQL and to try to avoid or limit the negative effect of lower mental HRQL and depressive symptomatology on clinical progression" (p. 411).

Early intervention is a theme picked up by May, Lester, Ilardi, and Rotheram-Borus (2006), who examined predictors of first childbearing among 181 adolescent daughters who had a parent living with HIV. Some of these adolescents had been randomized (along with their parents) to a family-based coping skills intervention and monitored for up to 7 years. The investigators found that, "[o]verall, daughters of [parents living with HIV] ... had a high rate of early childbearing compared to national and local rates. First childbearing tended to be delayed by (a) being in a coping intervention, (b) being less emotionally distressed, (c) receiving academic counseling, and (d) having a positive perception of their family's finances" (p. 72).

Both the family-based coping skills intervention and academic counseling were protective factors for early childbearing. In a model controlling for interactions among these predictors, daughters in the intervention condition benefited the most: they were far less likely to parent children during adolescence. The combination of the coping intervention condition and academic counseling appeared to have a synergistic effect and dramatically reduced the relative risk of early parenthood (96% reduction). However, the intervention was not protective for a very small subgroup of youth with high levels of emotional distress who perceived their families as poor. (pp. 81-82)

May and colleagues conclude that "[c]linicians working with HIV-affected families should provide psychoeducational and referral information to parents regarding the risks of early childbearing, as well as the benefits of both mental health and academic referrals for affected adolescents" (p. 83).

Lastly, as regular readers of mental health AIDS are no doubt aware, "[m]ost ... longitudinal studies demonstrating relationships between psychosocial variables and ... HIV ... disease progression utilized samples of gay men accrued before the era of ... HAART ..., without including viral load ... as an indicator of disease progression or assessing the impact of medication adherence" (p. 1013). To contemporize this field of inquiry, Ironson et al. (2005) conducted a 2-year investigation involving a multiethnic sample of 177 men and women in the "midrange" of HIV disease progression (i.e., CD4 cell counts between 150 and 500 cells/mm 3; no AIDS-defining symptoms) who were receiving HAART. Controlling for sociodemographic variables (i.e., age, gender, ethnicity, education) and a host of medical variables (i.e., baseline CD4 count and viral load, antiretroviral medications prescribed and adherence to same), Ironson and colleagues found that

even in the era of powerful HAART medications, psychosocial variables still account for significant variation in CD4 cell number and do so for [viral load] as well. The results provide valuable confirmation of earlier studies ... that established these relationships for depression, negative life events, and coping before the availability of HAART. In addition to depression, ... [these] results establish that hopelessness and denial/avoidant coping have significant relationships with both CD4 and [viral load] changes over time and extend findings to both men and women with access to HAART throughout the entire period of the study. This ... study ... establishes a prospective relationship between hopelessness, denial/avoidant coping, life event stress, and accelerated rate of increase in [viral load]. (A prospective relationship between depression and [viral load] has previously been noted for women ... .) In fact, plasma [viral load]s may be more sensitive to psychological influences than CD4, as indicated by higher increase and decline ratios. (pp. 1018-1019)

With this evidence that "feelings of hopelessness, depressed mood, and avoidant coping predict an accelerated decline in CD4 cells and an increase in HIV [viral load]" (p. 1020), Ironson and colleagues echo the conclusions of Cruess et al. (2005) noted in the Winter 2006 issue of mental health AIDS by pointing out that

[p]harmacologic ... and behavioral treatments ... have been shown to decrease depression in HIV patients. To the extent that these treatments may also attenuate both depressed affect and disease progression, large scale clinical intervention trials are needed to determine whether reducing distress and hopelessness, and improving adaptive coping skills in HIV infected individuals can decrease disease progression. Recent findings from a study of stress management in gay men with HIV ... suggest ... that this may be the case, as least for [viral load]. (p. 1020)

Treating depressive symptoms may also have the added benefit of increasing the likelihood that women living with HIV will utilize a HAART regimen at all to forestall HIV disease progression. At 6-month intervals over a 6-year period (1996-2001), Cook et al. (2006) monitored a multisite cohort of 1,371 women living with HIV who screened positive for depressive symptoms. The analysis conducted by these investigators

identified an association between prior treatment for depressive symptoms and the probability of later HAART use ... . Compared to [those] receiving no depression treatment, women with high levels of depressive symptoms were significantly more likely to be taking HAART regimens if they had been taking antidepressants while also receiving mental health therapy, or receiving mental health therapy alone. Interestingly, women who were taking antidepressants without mental health therapy did not differ significantly from those receiving no depression treatment in their likelihood of HAART. 4 This relationship between type of treatment for depressive symptoms and HAART use remained significant, even controlling for the women's self-reported crack, cocaine, or heroin use, their ethnicity, their income, and their clinical indicators of CD4 and viral load. (p. 96)

Additionally, Cook and colleagues found that African American women, as well as women who reported that they were using crack, cocaine, or heroin, were also less likely to adopt HAART regimens. Drawing attention to the unaddressed mental health needs of women living with HIV in general, and of women who are African American and women who use substances in particular,

[t]hese findings suggest that efforts to enhance depressed women's access to depression therapy may increase their use of the latest HIV therapies. Given the demands of complex HAART regimens, their potential for troublesome side effects, and the need for perfect adherence, it is unlikely that women struggling to cope with high levels of depressive symptoms will successfully initiate and continue their use of HAART. (p. 97)

– Compiled by Abraham Feingold, Psy.D.

__________

1 A detailed discussion of structured treatment interruptions (STIs) may be found in a Tool Box in the Winter 2003 issue of mental health AIDS entitled "The Promises and Pitfalls of STIs: A Primer for Mental Health Professionals."

2 Patients with this diagnosis "met three or four of the nine criteria for major depressive disorder, including depressed mood and/or loss of interest" (p. 61).

3 The U.S. Food and Drug Administration classifies DHEA, a weakly active adrenal androgen, as a nutritional supplement; as such, it is available over the counter.

4 "It is interesting to note that greater HAART utilization among women who received both antidepressants plus mental health therapy conforms to the currently accepted best-practice standard of care for treating depression. Evidence-based practice research indicates that combining psychopharmacotherapy and psychotherapy can be more effective than either modality alone ..." (p. 97).

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