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In a relatively short period of time, several major reviews and meta-analyses have been published that will interest the many practicing clinicians who offer cognitive-behavioral interventions (CBIs), stress management interventions, and cognitive-behavioral stress management (CBSM) interventions to people living with HIV.
Subpopulation-Specific CBIs
Crepaz et al. (2008) conducted a meta-analysis to determine "the efficacy of ... CBIs ... for improving the mental health and immune functioning of people living with HIV" (p. 4). CBIs
focus on the interaction of thoughts, feelings, and behaviors ... . Although there are various CBI techniques, the most common practices focus on altering irrational cognitions related to negative psychological states (e.g., depression, anger, anxiety), correctly appraising internal and external stressors, gaining stress management skills, and developing adaptive behavioral coping strategies. A recent systematic review of meta-analyses on CBIs ... showed that CBIs are highly effective for adult and adolescent unipolar depression, generalized anxiety disorder [or GAD], panic disorder, social phobia, posttraumatic stress disorder [or PTSD], and childhood depressive and anxiety disorders. Across many disorders, including depression and anxiety, the intervention effects are maintained for substantial periods (e.g., 12 months). In cases of depression, CBIs demonstrated greater long-term effects, with relapse rates half those of pharmacotherapy ... . (pp. 4-5; see also
Minority Report
)
The investigators included data from 15 controlled trials, published between 1991 and 2005, in their analysis. Eleven of these 15 trials taught stress management skills, and 10 were offered in a group format. Crepaz and colleagues found that "[s]ignificant intervention effects were observed for improving symptoms of depression ..., anxiety ..., anger ..., and stress ... . There is limited evidence suggesting intervention effects on CD4 cell counts ... . The aggregated effect size estimates for depression and anxiety were statistically significant in trials that provided stress management skills training and had more than 10 intervention sessions" (p. 4). Additional analyses
showed that the significant intervention effects on depression and anxiety were observed at the immediate postintervention assessment; however, there was no evidence for longer term effectiveness. It is plausible that without boosters, there would be a gradual discontinuation in the practice of skills to correctly assess irrational thoughts and improve coping and stress management skills. ... [T]he findings ... suggest that the challenge of coping with emotional issues over the course of HIV infection may require on-going behavioral reinforcement to prevent relapse. (p. 10)
Crepaz and colleagues correctly acknowledge a variety of limitations to this meta-analytic review, a number of which
reflect the limitations of the primary studies. Some trials included an immediate postintervention assessment but no follow-up assessment with which to compare the results. This omission makes it difficult to determine whether the intervention effects are sustainable over time or whether they are merely a statistical artifact. It would be valuable if future trials assessed outcomes of interest at multiple-assessment periods and for longer periods after the intervention. Moreover, the failure to report on potentially important variables (e.g., medication adherence, taking antidepressant medication) in the primary studies limited ... [the] ability [of Crepaz and colleagues] to examine more closely clinical moderators of the intervention effects on mental health and immune function. Clear and transparent reporting of key elements such as these in intervention studies would improve the quality of future meta-analyses ... . All the trials relied on convenience samples and over half of the trials had a sample size less than 100. It would be beneficial for the field if prospective, controlled trials were conducted to evaluate the impact of CBIs on larger, more generalizable cohorts and clearly report the power analysis for the anticipated effect.
... Certainly, more research in this area is needed. It would be valuable if future research closely examined the relationship among interventions, psychological states, medication adherence, and immune functions – particularly long term – and identified other relevant moderators of the intervention effects. Such research inquiry will likely lead to significant and sustained improvement in mental health among persons living with HIV. (p. 12)
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"Coping with a chronic, life-threatening disease ... is not without consequence
as disease progression often involves a series of psychological and physical stressors
that may impair daily functioning and quality of life. These stressors may involve
a variety of physical symptoms, pain, concerns over disclosure of and
stigma associated with HIV, and distress regarding one's own mortality ... ."
---- Scott-Sheldon, Kalichman, Carey, & Fielder, 2008, p. 129
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De-stressing Distress
Recognizing the utility of stress management skills training for persons living with HIV, Scott-Sheldon, Kalichman, Carey, and Fielder (2008) conducted a meta-analysis to examine "the impact of stress-management interventions at improving psychological, immunological, hormonal, and other behavioral health outcomes among HIV+ adults" (p. 129). "For this review, stress management was defined as any method such as cognitive restructuring, social support training, or mindfulness meditation used to assist with coping and/or managing stress among people living with HIV" (p. 130).
The meta-analysis integrated the results of 35 randomized controlled trials in which 46 separate stress management interventions were evaluated. All studies appeared between 1989 and 2006. The vast majority (89%) were published in journals, although unpublished papers (e.g., dissertations or conference reports) were also included. "These studies sampled 3,077 adults with HIV with a retention rate of 80% at follow-up (based on the largest available n at any follow-up)" (p. 131).
The investigators offered more specific details on the interventions included in the meta-analysis:
Interventions were conducted in small groups (64%) or one-on-one (36%); small group interventions consisted of a median of 10 sessions of 90 minutes and tended to have a median of two facilitators and eight participants, whereas one-on-one interventions consisted of a median of 16 sessions of 49 minutes each. Interventions frequently included coping skills (59%), intrapersonal skills training (e.g., planning of stress management; information-only or actively practiced; 50%), and active practice of mental and/or physical relaxation exercises (48%); they often included HIV/AIDS education (including rationale for stress management; 37%), social support (37%), and exercise education, planning, or practice (26%). Interventions infrequently included medication adherence (13%) or nutritional education, planning, or practice (7%), relaxation exercise information (discussed or demonstrated but not practiced; 11%), or spirituality (4%). Supplemental materials (e.g., brochures, guided relaxation audiocassettes) were provided in 33% of the interventions. Intervention content was frequently tailored to the group (37%) or individual (22%) with 37% of facilitators matched to the participant(s) on some characteristic (gender, race, HIV status, sexual orientation, or age). Of the 35 interventions reporting details about the intervention leaders, 71% used professionals-in-training (e.g., clinical graduate students) and/or professionals (terminal professional degree, e.g., PhD).
The most typical comparison condition, used by 74% of investigators, was an assessment-only control (i.e., no explicit stress-management treatment or wait-listed). Of the 12 interventions using … more active comparison conditions (e.g., education-only, brief form of intervention), these interventions were characterized by a median of eight sessions of 75 minutes each with a median of one facilitator and 4.25 participants. Supplemental materials (e.g., brochures, relaxation exercises) were provided in 17% of the active comparisons conditions. (p. 133)
Scott-Sheldon and colleagues found that "stress-management interventions for adults living with HIV infection were ... effective in reducing emotional distress including anxiety, depression, and psychological distress. These interventions also reduced fatigue and improved quality of life. The effect sizes ... observed were in the small to medium range, consistent with effects found for stress-management interventions (i.e., mindfulness-based) in cancer, heart disease, and other chronic illnesses ..." (p. 134). Of interest is the additional finding that "reductions in anxiety were adversely related to inclusion of medication adherence information and/or planning in the intervention content. It is important to note that few studies included medication adherence components but, when they did, the anxiety-reducing effects of stress management were lessened. ... [The investigators] hypothesize that improving adherence to demanding medication regimens, such as those required in treating HIV infection, requires increased vigilance and may inadvertently elevate anxiety" (pp. 134-135).
Echoing findings reported by Crepaz and colleagues, these investigators report that "[s]tress-management interventions do not appear to improve CD4+ counts, viral load, or hormonal outcomes compared with controls" (p. 129). Scott-Sheldon and colleagues speculate that
[t]he absence of immunological or hormonal benefits may reflect the studies' limited assessment period (measured typically within 1-week postintervention), participants' advanced stage of HIV (HIV+ status known for an average of 5 years), the inclusion/exclusion of participants using ART [(antiretroviral therapy)], the lack of information regarding ART adherence, and/or sample characteristics (predominately male and White participants). Future investigation should examine more diverse samples, explore patient characteristics that might moderate intervention efficacy, and use lengthier assessment periods to understand better the impact of stress-management interventions for HIV+ adults. (pp. 136-137)
An important issue raised by this review is the
applicability of stress-management interventions for all persons affected by HIV. The majority of participants in the [randomized controlled trials] ... studied were men (82%) and White (56%); only 3% of study participants had a history of severe mental illness. These characteristics contrast with the epidemiology of HIV and AIDS, when people of color, women, those with alcohol and other drug dependencies, the homeless, and the mentally ill are disproportionately vulnerable. ... Along with research to test enhanced and lower cost interventions, studies are needed to test stress-management strategies that can be used in clinical and community services for non-Whites and women, including those with histories of mental health and substance abuse problems. Along these same lines, there is no basis for generalizing the stress-management interventions tested thus far to developing countries that are home to the vast majority of people living with HIV/AIDS worldwide. ... Research is needed to examine the efficacy and cost benefits of stress-reduction interventions that can serve people living with HIV/AIDS at greatest need. (p. 136)
Combination Punch
Brown and Vanable (2008) assembled a focused review and critique of CBSM interventions for persons living with HIV. This paper "(1) summarizes key features of stress management interventions for HIV-infected people that employ cognitive-behavioral intervention strategies, (2) synthesizes stress, coping, psychological, and health status outcomes from these interventions, and (3) provides a methodological critique of the literature and guidance for the future application of stress management interventions in HIV research and care settings" (p. 27). The investigators "reviewed 21 stress management interventions designed for HIV-infected individuals that included both cognitive and behavioral skills training" (p. 26). More specifically,
[a]cross all the interventions, the cognitive and behavioral approaches were designed to facilitate adaptive coping and reduce the negative effects of stress. Emotional regulation strategies and reducing overall psychological distress were often specified as goals of the interventions. As a behavioral strategy, the majority of studies (76%) included a relaxation training component, with progressive muscle relaxation the technique most often included ... . Another key behavioral component of most interventions (62%) was to identify participants’ existing social support, discuss the importance of support networks, and encourage adoption of strategies to enhance the use of social support to cope with stress ... . Furthermore, across interventions, the use of other active coping strategies (e.g., problem solving) was stressed as more adaptive than avoidant coping strategies (e.g., substance use).
In all of the reviewed interventions, stress management skills training also included modules on the use of cognitive strategies to modify HIV-infected people's approach to appraising stressors and modules that encouraged the use of active problem-solving strategies. For instance, cognitive distortions and automatic thoughts about HIV-related stressors were often identified and targeted via cognitive restructuring. In studies evaluating variations of coping effectiveness training ..., the focus was on the stress appraisal process and matching the stressor’s level of perceived changeability with the use of either problem- or emotion-focused coping strategies. Similarly, in problem-solving approaches, participants were taught to clearly identify characteristics of specific stressors, brainstorm potential solutions, select a coping strategy, and evaluate the effectiveness of the chosen solution for the problem situation. (p. 28)
The stress management interventions incorporated into this review were largely administered over multiple sessions and in a group format. It should be noted that
[s]ome studies excluded patients with the presence or history of specific HIV symptoms or an AIDS diagnosis (67% ...), as well as cognitively impaired patients or those with psychotic symptoms (71% ...). Although all interventions sought to improve stress management, a surprisingly high percentage of studies (57% ...) excluded individuals based on current or past psychiatric [history], substance abuse history, or personality disordered history. The degree to which individuals were experiencing psychological distress, especially their level of depression, often served as either an exclusion or inclusion criteri[on] … . For example, some studies only recruited individuals with moderate levels of depression ..., while other interventions would not allow individuals diagnosed with major depressive disorder to participate ... . (p. 31)
Brown and Vanable found that "[m]ost studies noted positive changes in perceived stress, depression, anxiety, global psychological functioning, social support, and quality of life. However, results were mixed for coping and health status outcomes ..." (p. 26).
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"[S]tress management training is increasingly viewed as integral to the
broader goal of assuring that patients maintain adequate self-care for their illness ... .
In so far as stress management interventions can reduce distress and, potentially, improve
disease management and health outcomes, an evaluation of the current state of the science
with regard to these interventions is of considerable importance."
---- Brown & Vanable, 2008, p. 27
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Promises to Keep
Although CBSM interventions show considerable promise when employed with persons living with HIV, Brown and Vanable contend that "this literature is limited by measurement problems, research design features, a narrow focus on HIV-infected men who have sex with men [(MSM)], and feasibility concerns for intervention dissemination" (p. 26). "In addition, the exclusive focus on group-based intervention approaches and the need to target unique concerns of HIV-infected patients raise significant concerns about the feasibility of disseminating interventions to resource-limited settings" (p. 35). Brown and Vanable expand upon these points and their remediation as follows:
Measurement of Intervention Outcomes and Processes
-
Lack of Consensus Regarding Best Practices for Assessment of Coping Hinders Interpretability of Interventions' Effectiveness – ... In the absence of consensus regarding best practices for coping assessment, a greater emphasis on assessment of coping self-efficacy may be warranted. Coping self-efficacy can be assessed without reference to a particular stressor and is arguably of more direct relevance to the way in which coping skills are taught in stress management interventions. That is, interventions typically seek to modify participants' ability and confidence to successfully manage stress across situations using adaptive coping strategies. Thus, the level of coping self-efficacy may generalize well to a variety of stressful situations ... . (p. 35)
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Need to Identify Active Ingredients of Stress Management Interventions – The reviewed interventions typically implemented multi-session programs with numerous components included in the treatment package. Further assessment of the efficacy of individual treatment components compared to other strategies should be employed. Similarly, the bulk of interventions were tested in a group format. Therapy process variables and nonspecific group factors may be important active ingredients to consider when evaluating the efficacy of stress management interventions. ... It may be that ... the provision of additional social support in group interventions ... play[s] an important role in treatment outcomes. (p. 35)
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Use of Depression Scales that Overlap with HIV Symptoms May Result in Inaccurate Assessment of Depressive Symptoms – In the diagnostic criteria for mood disorders, somatic symptoms are prominent diagnostic features[.] ... A potential solution for depression assessments for HIV-infected patient samples is to focus on the cognitive and affective domains of depression, rather than physical symptoms that may be a function of HIV or medication side effects ... . (p. 36)
Research Designs to Evaluate Intervention Efficacy
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Future Studies Should Include Comparison Conditions with Equivalent Treatment Intensity and Length – The majority of studies compared a stress management intervention condition to a no intervention control group. ... [F]uture studies should utilize research designs that allow the effect of treatment intensity to be controlled for by using comparison treatments of equal length and intensity. Indeed, in research designs that included support group comparison conditions, differences between the stress management and comparison conditions were often more minimal ... . (p. 36)
- Studies Should Include Longer Follow-up Assessments to Assess Long-Term Intervention Efficacy – ... Most of the reviewed studies reported only on data from preintervention and an immediate postintervention assessment (52%). Longitudinal assessments may be especially important for the measurement of immune status markers that may vary naturally with time ... . Conducting longer follow-ups could also facilitate a greater focus on within-person variability for intervention outcomes. ... (p. 36)
Sample Characteristics
- Focus on Samples of High-functioning HIV-infected, Caucasian MSM Limits the Generalizability of Findings to Other HIV-infected Subgroups – ... [F]uture research should implement and test stress management interventions targeting a broader range of HIV-infected patient populations, especially ... [injecting] drug users, women, and ethnic minorities. ... In addition, a major limitation of the literature concerns the fact that most studies excluded patients who were experiencing psychological distress. ... Thus, findings from the reviewed studies are not generalizable to HIV-infected patients reporting mental health difficulties (the very patients who may benefit most from these interventions). ... [F]uture stress management programs should be adapted for individuals experiencing psychological distress. The role of premorbid mental health functioning could then be examined as a potential mechanism influencing the intervention's efficacy. Indeed, one of the reviewed studies noted that individuals with the highest preintervention assessment levels of distress reported the most significant decreases in psychological distress after a stress management intervention ... . (pp. 36-37; see also
Swiss Tease)
Data Analytic Concerns
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Multiple Statistical Comparisons Increase the Likelihood of Type I [(False Positive)] Errors – ... Future studies should focus on analyses guided by a priori hypotheses, report on all key outcomes measured, control for multiple statistical tests, use more conservative alpha levels for exploratory analyses, or report effect sizes and confidence intervals for findings. (p. 37)
- Literature Focuses on Statistical Significance with Little Attention Given to Clinical Significance – ... In the case of stress management treatments, clinical significance should focus primarily on the practical change in one's ability to adaptively manage stress. In turn, clinical significance for these interventions would then evaluate the impact of this change on an individual's functioning in other domains such as psychological health and immune functioning. Thus, future research should clearly identify treatment goals and provide measurements of the degree to which HIV-infected patients evidence clinically significant improvement after completing a stress management intervention. (p. 37)
Intervention Dissemination and Tailoring to HIV-infected Individuals
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Need for Cost-effective, Easily Disseminated Stress Management Interventions – ... Although group-delivered training provides the added benefit of fostering social support, some HIV-infected patients may be reticent to attend groups because of confidentiality concerns or dislike of group meetings. Thus, the usefulness of group stress management interventions may be limited to a relatively small subset of patients who could otherwise benefit from such programs. ... An important gap in the literature is to examine the efficacy of briefer, more cost-effective stress management approaches that can meet the needs of a broad range of patients. ... [P]articularly promising ... approach[es include] ... the use of [telephone-based and computer-delivered interventions] ... . (p. 37)
- Future Interventions Should Target the Unique Stressors Faced by Individuals Living with HIV – The reviewed interventions typically provided participants with broad stress management training[;] ... few interventions have included modules designed to address the unique challenges of being HIV infected. For example, HIV-infected patients often report significant levels of stigma and discrimination that could be targeted in ... interventions for this population ... . In addition, stress associated with maintaining satisfying, intimate relationships with partners could also be highlighted ... . These unique challenges, along with others, should be given greater attention within the context of HIV-infected stress management interventions. ... (pp. 37-38)
– Compiled by Abraham Feingold, Psy.D.
References
Brown, J.L., & Vanable, P.A. (2008). Cognitive-behavioral stress management interventions for persons living with HIV: A review and critique of the literature. Annals of Behavioral Medicine, 35(1), 26-40.
Crepaz, N., Passin, W.F., Herbst, J.H., Rama, S.M., Malow, R.M., Purcell, D.W., Wolitski, R.J., & the HIV/AIDS Prevention Research Synthesis (PRS) Team. (2008). Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning. Health Psychology, 27(1), 4-14.
Scott-Sheldon, L.A., Kalichman, S.C., Carey, M.P., & Fielder, R.L. (2008). Stress management interventions for HIV+ adults: A meta-analysis of randomized controlled trials, 1989 to 2006. Health Psychology, 27(2), 129-139.
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Minority Report
Although many cognitive-behavioral treatments have received empirical support, "the samples in ... effectiveness studies are composed primarily of White European American individuals" (Horrell, 2008, p. 160). Moreover,
simply including minority individuals in research studies ... [does] not provide enough information regarding the effectiveness of psychotherapeutic interventions with minority populations ... . Several confounding factors have been hypothesized to influence the effectiveness of psychotherapeutic interventions with ethnic minorities, including socioeconomic status, immigration history, minority (or social) status, level of education, access to health care, and degree of assimilation with the White majority culture ... . None of these constructs operate independently of one another, making the task of identifying variables that affect treatment outcomes extremely complicated ... . (Horrell, 2008, pp. 160-161)
Looking as far back as 1950, Horrell (2008) identified 12 studies, published between 1994 and 2005, that examined the effectiveness of cognitive-behavioral therapy (CBT) "with adults of African American, Asian American, or Hispanic/Latino descent with a variety of diagnoses[, including] ... depression, ... PTSD ..., panic disorder with agoraphobia, and substance abuse ..." (p. 161). A portion of Horrell's summary statement follows:
On the basis of the 12 studies reviewed ..., CBT appears to be an effective treatment for use with clients from ethnic minority backgrounds. Seven studies demonstrated significant treatment gains with CBT compared with a placebo or wait-list control. CBT was effective in reducing the symptoms of a variety of disorders, including depression, PTSD, GAD, and panic disorder. ... The only study that did not report promising results for the use of CBT with ethnic minority participants was conducted with depressed individuals who were HIV[-]positive (Markowitz et al., 2000).1 The authors found an increase in self-reported depressive symptoms in a small subgroup of African Americans who received CBT. Further investigation is needed to determine the effectiveness of CBT in the treatment of depression in chronically ill African American men. (p.166)
References
Horrell, S.C.V. (2008). Effectiveness of cognitive-behavioral therapy with adult ethnic minority clients: A review. Professional Psychology: Research & Practice, 39(2), 160-168.
Markowitz, J.C., Spielman, L.A., Sullivan, M., & Fishman, B. (2000). An exploratory study of ethnicity and psychotherapy outcome among HIV-positive patients with depressive symptoms. Journal of Psychotherapy Practice & Research, 9(4), 226-231.
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1 Horrell writes that "Markowitz, Spielman, Sullivan, and Fishman (2000) examined the interaction between ethnicity and psychotherapy intervention for HIV-positive individuals with major depression. ... There was a significant difference in scores on the outcome measures from baseline to posttreatment; however, the authors found a significant ethnicity by treatment interaction for both outcome measures and post hoc analyses, indicating differences only for African American participants. Specifically, African Americans assigned to the CBT treatment had significantly higher depression scores at posttreatment than individuals from other ethnic backgrounds or those African Americans assigned to any of the other treatment groups. It should be noted that small numbers of participants were assigned to each treatment condition; between three and eight participants were in each of the four treatment conditions. In addition, the authors conducted post hoc tests and reported no Bonferroni or similar correction, allowing the risk of Type I error, which the authors did suggest was a possibility ... . According to the authors, these results suggest that modifications to CBT may be needed before it is used to treat African Americans with depression. However, as there was no description of the CBT intervention used, it was difficult to compare these results with the results from other studies" (p. 164).
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Swiss Tease
Berger et al. (2008) randomly assigned 104 adults attending HIV primary care clinics in four Swiss cities and taking combination ART (cART) to standard medical care or to standard medical care plus CBSM group training. The study objective was "to investigate the effect of such training on virological, immunological and psychological parameters over a 12-month study period" (p. 768). The CBSM training
consisted of 12 weekly group sessions lasting 2 h and provided during a 12[-]week period for each group. ... Sessions were moderated by one cognitive-behavioral psychotherapist (university degree and formal ... cognitive-behavioral training) and one postgraduate psychotherapy trainee (university degree and second year in cognitive behavioral training). Group sizes ranged between four and 10 participants. The rationale of the intervention utilized a manual-based multicomponent approach, including HIV-relevant topics and psychotherapeutic techniques ... .
With the exception of the first (introduction) and last (discussion) session, each session was dedicated to a particular topic (e.g. stress, depression, work, etc.). (p. 769)
The treatment modules in the CBSM included:
Psycho-education – Each topic is described and discussed in terms of its relevance to HIV; participants also receive written material including summaries on recent scientific findings and 'to do' lists
Group dynamic exercises – Empathy, respect, trust and cohesion within the group are encouraged and practiced with short and defined ice-breaker, e.g., sharing personal information, and trust-building, e.g., establishment of group rules, exercises
Homework – Each topic is accompanied by homework, which encompasses either the assessment of problematic/helpful aspects or the transfer and practice of techniques learned to everyday life
Cognitive strategies – The objective is to identify and acknowledge cognitions as major determinants of feelings and behavior and, if necessary, to modify them; alternative self-instructions are then practiced in role-plays and real life
Progressive muscle relaxation (PMR) – The objective is to train participants to recognize muscular tension and to self-induce relaxation; in the first five sessions, PMR techniques are taught by the psychotherapist, whereas in the remaining sessions, participants act as PMR trainers for the group; participants also receive written and spoken (CD) PMR instructions (p. 769)
Notably, "[a]ll dependent variables were assessed at baseline and at 1, 6 and 12 months after termination of CBSM training in the intervention group" (p. 769).
Berger and colleagues "found no effects of CBSM training on morbidity, viral load and CD4 cell counts, and adherence to cART compared with standard medical care. However, ... [the investigators] did observe benefits of CBSM training on quality of life and psychological distress. Notably, significant improvements in distress were only observable in individuals with high distress at baseline" (pp. 772-773). Berger and colleagues conclude that
CBSM group training is an efficacious and effective intervention for enhancing quality of life and psychological well-being in HIV-infected persons taking stable [ART] with restored immunity and little somatic morbidity. Its beneficial effects are particularly observed among persons who present with depression and anxiety scores at baseline ... which indicate high psychological distress. Therefore, screening for psychological distress ... and referral to individually acceptable psychotherapeutic interventions should be integral to HIV management ... . (p. 774)
In comparing this study to those reviewed in the main Tool Box, several advances in study design highlighted by Berger and colleagues bear mentioning. These include "the inclusion of a [diverse] group of HIV-infected persons from ... routine practice clinical setting[s,] ... the longitudinal assessment of the clinically relevant markers of HIV infection, the use of an intervention according to a manual, and the recruitment at multiple study centers" (p. 773). Berger and colleagues also recognize that "the mode of group training might have affected the acceptability of the intervention, which would explain the fact that only a small proportion (6.1%) of eligible individuals actually agreed to participate. Other routes of administration with known efficacy, such as individual psychotherapy, might prove to be more accessible to HIV-infected persons who are unwilling to participate in group therapy sessions ..." (pp. 773-774).
Although "[t]he absence of an effect of CBSM on clinical markers may be explained by the relatively small contribution of psychosocial factors to HIV progression among persons on cART with complete viral suppression and restored immune function" (p. 774), Berger and colleagues suggest that "[s]ince a negative impact of psychological distress on HIV disease progression has been demonstrated in prospective studies with a follow-up of up to 9 years ..., effects of CBSM training on the clinical status might be observed in the long-term observation of HIV-infected individuals with high levels of psychological distress" (p. 774).
Reference
Berger, S., Schad, T., von Wyl, V., Ehlert, U., Zellweger, C., Furrer, H., Regli, D., Vernazza, P., Ledergerber, B., Battegay, M., Weber, R., & Gaab, J. (2008). Effects of cognitive behavioral stress management on HIV-1 RNA, CD4 cell counts and psychosocial parameters of HIV-infected persons. AIDS, 22(6), 767-775.
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Summer 2008 Newsletter / Volume 9, Issue 4 
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