mental health AIDS

Summer 2008 Newsletter / Volume 9, Issue 4

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Neuropsychological Impairment

In a pilot study that assessed the psychomotor performance of 46 men and women living with HIV, Vance, Smith, Neidig, and Weaver (2008) found an association between anger and psychomotor impairment on Trails A and the Grooved Pegboard for non-dominant hand, neuropsychological tests commonly used to assess cognitive performance among persons living with HIV. The investigators reason that "interventions that focus on anger management could have a therapeutic effect on psychomotor performance" (p. 93).

Adherence to Treatment

Active substance use has the potential to affect antiretroviral adherence negatively. To understand better the associations among correlates of schedule adherence (i.e., the percentage of antiretrovirals taken on time), Atkinson, Nilsson Schönnesson, Williams, and Timpson (2008) "developed an exploratory path model of schedule adherence" (p. 260) with data from a sample of 130 African American crack cocaine users who were living with HIV and prescribed HAART. Atkinson and colleagues found that "the effects of psychological distress on schedule adherence were mediated by patients' relationship with their doctor and optimism towards antiretroviral treatment. Adherence was also associated with patients' self-efficacy regarding their medical regimen which, in turn, was associated with their social support" (p. 260). In the view of these investigators,

[c]linicians will need technical knowledge and skill with behaviour change to promote adherence in HIV-positive drug users ... . Other potential interventions may include peer counselling and social support[.] ... Results ... suggest that schedule adherence may be increased by improving adherence self-efficacy and treatment optimism and by alleviating psychological distress. But they also suggest that factors directly linked to adherence may in turn be influenced by other factors. ... [This] study suggests that the quality of the patient-doctor relationship plays an indirect, but important role in schedule adherence. Thus, educational interventions ... [for] doctors to promote patient-centred medicine should be encouraged and evaluated. (pp. 266-267)

Nurses, too, can benefit from such training, as demonstrated by DiIorio et al. (2008). She and her colleagues randomly assigned 247 low-income, primarily African American recipients of HIV care in Atlanta to one of two conditions: five sessions of motivational interviewing (MI) delivered by registered nurses in one-to-one counseling sessions over a 3-month period ("Get Busy Living")4 or a care-as-usual control condition. All study participants were either initiating ART or changing their antiretroviral treatment regimen. The MI intervention "sought to build confidence, reduce ambivalence and increase motivation for ART medication-taking.5 Medication adherence was measured by the Medication Event Monitoring System (MEMS®) from the time of screening until the final follow-up conducted approximately 12 months following the baseline assessment" (p. 273). DiIorio and colleagues found that

[p]articipants in the intervention condition showed a trend towards having a higher mean percent of prescribed doses taken and a greater percent of doses taken on schedule when compared to the control group during the months following the intervention period. This effect was noted beginning at about the eighth month of the study period and was maintained until the final study month. Although the finding was weaker for overall percent of prescribed doses taken, the results for the percent of doses taken on schedule suggests that the MI intervention may be a useful approach for addressing specific aspects of medication adherence, such as ... [adherence] to a specified dosing schedule. (p. 273)

Depression can also negatively affect antiretroviral adherence. On this point, Horberg et al. (2008) reviewed data from a cohort of patients seen for HIV medical care in two large health maintenance organizations who were initiating a new HAART regimen. In total,

3359 patients were evaluated [and monitored over a 12-month period]; 42% had a depression diagnosis, and 15% used SSRIs [(selective serotonin reuptake inhibitors; antidepressants)] during HAART. Depression without SSRI use was associated with significantly decreased odds of achieving > 90% adherence to HAART ... . Depression was associated with significantly lower odds of an HIV RNA level < 500 copies/mL ... . Depressed patients compliant with SSRI medication (> 80% adherence to SSRI) had HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART. Comparing depressed with nondepressed HIV-infected patients, CD4 T-cell responses were statistically similar; among depressed patients, those compliant with SSRI had statistically greater increases in CD4 cell responses. (p. 384)

Horberg and colleagues emphasize that, "[b]ecause depression is negatively associated with HAART adherence and with clinical outcome measures for these patients, ... screening for depression is essential. ... Patients who are found to be depressed should be offered therapy, because compliant SSRI medication use was associated with improved HAART adherence and HIV laboratory parameters" (p. 389).

Similarly, Vranceanu et al. (2008)

used brief self-report screening measures of depression and post-traumatic stress disorder (PTSD) in ... HIV/AIDS care settings to examine (1) frequency of positive screens for these diagnoses; (2) the degree to which those with a positive screen were prescribed antidepressant treatment; and (3) the association of continuous PTSD and depression symptom scores, and categorical (screening positive or negative) PTSD and depression screening status, to each other and to ART adherence as assessed by the [MEMS®], regardless of antidepressant treatment. (p. 313)

The investigators analyzed available data from 156 adults living with HIV that were taken at five time points, yielding a total of 444 data points. Vranceanu and colleagues found that

[p]articipants screened positive for PTSD at 21% of visits, ... depression at 22% of visits[, and for both at 14% of visits] ... . At visits when participants screened positive for both depression and PTSD, 53.6% of the time they were on an antidepressant. Those who screened positive for PTSD were more likely to also screen positive for depression. In multiple regression analyses that included both continuous and dichotomous PTSD and depression and controlled for shared variance due to clustering of multiple observations, only depression contributed significant unique variance, suggesting the primary role of depression and the secondary role of PTSD in poor adherence in individuals with HIV. (p. 313)

Vranceanu and colleagues suggest that the results of this study

highlight the importance of assessing and treating depression in HIV-infected individuals. Although not directly related to adherence measures, PTSD increased the likelihood of depression, and thus negatively affected adherence through an indirect pathway, or through common distress. Brief instruments such as those used in this study6 could be incorporated in[to] the care of [individuals living with] HIV ... . This would allow referral to evidence-based treatment methods for PTSD and depression, via antidepressant or cognitive-behavioral therapy, which may increase ART adherence and potentially enhance HIV treatment outcomes. (p. 320)

Finally, Koenig et al. (2008) used a randomized controlled design to examine "whether persons who participated in ... [a clinic-based multicomponent social support] intervention7 achieved and maintained better adherence, and subsequently had better virologic outcomes, in the first 6 months of therapy compared with those who received standard-of-care adherence counseling" (p. 161). Two components of the intervention merit specific mention:

To tailor strategies to each individual patient's needs[,] ... a structured interview [was used] to help patients identify adherence barriers, generate possible solutions, select strategies to overcome the barriers, and, in subsequent meetings, evaluate how the strategies were working. This interview, ... the Semi-Structured Interview for Developing Medication Adherence Plans (SIDMAP), was used at each patient contact to identify, and then evaluate and revise, adherence barriers and strategies as they evolved over time.

... A second component of the intervention involved identifying and involving a support partner ... [to] assist the patient with adherence. ... Support partners attended meetings with the patient and [the] nurse-interventionist, contributing to the identification of barriers and generation of helpful strategies, and were also welcomed at informational multipatient group meetings. Outside of clinic visits, they provided tangible and ongoing adherence-related assistance to the patient. (p. 160)

Importantly,

[o]f 226 participants who were randomized and began the trial, 87 (38%) were lost to the study by 6 months. The proportion of adherent participants declined steadily over time … [in both the intervention and control groups]. Sustained adherence was associated with increased odds of achieving an undetectable [viral load] ... . In intention-to-treat analyses, a larger proportion of the intervention group than the control group was adherent ... and achieved an undetectable [viral load] ... . However, the majority of participants who remained … [in the] study experienced some reduction in [viral load] ..., regardless of experimental condition. (p. 159)

In other words, "[d]espite the efficacy of the intervention on adherence, and the significant association between sustained adherence and viral suppression, the intervention was not consistently associated with improved health outcomes. Specifically, whereas a larger proportion of those randomized to the intervention had undetectable viral loads, the effect of intervention was not statistically significant when considering just those who remained on-study" (p. 167). These findings prompt Koenig and colleagues to observe that "[e]arly discontinuation of care and treatment may be a greater threat to the health of HIV patients than imperfect medication-taking" (p. 159).

Coping, Social Support, & Quality of Life

Polzer Casarez and Miles (2008) explored spiritual coping through interviews with 38 African American mothers living with HIV in the southern United States and found that the "women dealt with the stresses of HIV through a relationship with God" (p. 118). These mothers, who had a child who was also living with HIV,

viewed God as all-powerful, a major force in all aspects of their lives, and particularly critical in living with HIV and dealing with [the] possibility of death. The relationship between the mothers and God operated through a partnership; essential to this partnership was the woman's participation in spiritual practices [(e.g., prayer, reading the Bible)] that helped her communicate with God and strengthened her faith and trust in God. The study further explicates the dimensions of their spirituality, namely the perspective that God is in control and that the women had to participate in that relationship for God to respond. Furthermore, as a result of their spirituality, the women experienced less worry, fear, and distress associated both with their diagnosis and with their child's health.

Although God was perceived to be in control of all aspects of their lives, for these women, a particularly salient characteristic of God's control was the power to heal or to help them during a crisis. God helped them by providing supportive intermediaries or giving them the inner strength to manage the stressors they faced. (p. 127)

The investigators make a point of noting that "[m]others' participation in their relationship with God mostly focused on their own internal spiritual practices. However, some also discussed church attendance as an important spiritual practice and source of support. On the other hand, a number of mothers voiced reluctance to attend church due to fear of disclosure of their HIV status and the stigma, or because of negative attitudes of church members about people with HIV" (p. 128).

Polzer Casarez and Miles urge clinicians who are "working with mothers with HIV to acknowledge their spirituality and assess how spirituality helps them cope with and manage their illness" (p. 118).8 Among women for whom spiritual beliefs and/or practices contribute to self-care and coping with HIV, "in-depth exploration could focus on specifics of her spiritual practices, her views about how spirituality helps, and how the ... [clinician] might support her spiritually. Sensitive probing might also reveal dilemmas the woman faces regarding church attendance and related concerns about stigma and disclosure[.] ... Helping women express concerns about the stigma related to HIV and problem-solving ways to manage these concerns is important" (pp. 129-130).

Murphy and Marelich (2008) investigated resiliency – "the capacity for successful adaptation despite challenging circumstances" (p. 284) – among 111 well children between the ages of 6 and 11 years whose mothers were living with HIV disease. Mothers and their children were assessed at four time points: baseline, 6 months, 12 months, and 18 months. Murphy and Marelich found that

[i]n this sample ... more severe maternal illness was associated with decreased resiliency. Resilient children of HIV-positive mothers in this sample reported better coping self-efficacy than did non-resilient children. ... The children classified as resilient also evidenced better self-esteem and higher self-report of effectiveness than the non-resilient children. Data from the mothers of these children served as a second informant validation of those findings, with mothers reporting lower negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem. This may be linked to better coping skills, in that these children may be able to cope with depression more effectively than the non-resilient children. (p. 289)

Murphy and Marelich are quick to note, however, that

the majority of the children (68%) were classified as non-resilient. Those children are dealing with poorer coping self-efficacy and more depressive symptoms. They could benefit from a number of efforts to improve their resiliency outcomes. First, such children are likely to not report that they have a strong adult attachment in their life, and research indicates they could strongly benefit from such a contact. ... Second, non-resilient children of HIV-infected mothers could benefit from problem solving and coping skills training. Children can be taught to label feelings, develop self-control, learn problem-solving skills and apply anger management techniques ... . Children in such programs, in addition to showing skills acquisition, may show improvements in clinical symptomatology. Finally, these children also may benefit from direct psychotherapeutic intervention for depression. Relieving psychological distress may assist these children in being able to function and cope more adaptively, as well as facilitate attachment to adult figures that can provide support. (p. 289)

Although countless studies have examined the influence of stress, coping, and depression on HIV disease progression, far less attention has been paid to the contribution of personality characteristics to the advancement of HIV disease. To address this gap in research, Ironson, O'Cleirigh, Weiss, Schneiderman, and Costa (2008) monitored a diverse sample of 104 men and women living with HIV disease over a 4-year period. Their purpose was to examine how the Five-Factor Model or the "Big Five" personality domains (Neuroticism [N], Extraversion [E], Openness [O], Agreeableness [A], Conscientiousness [C]) and their respective facets9 and profiles are related to changes in CD4 cell count and viral load.

Ironson and colleagues found that the domains of O, E, and C were significantly associated with slower disease progression over the 4-year period, "controlling for age, education, gender, race, initial disease status, and antiretroviral medications" (p. 251). Delving more deeply,

[f]acets of the[se] ... domains that were significantly related to slower disease progression were assertiveness, positive emotions, and gregariousness ... [within the E domain]; ideas ... [and a]esthetics ... [within the O domain]; [and] achievement striving and order [within the C domain] ... . In addition, profile analyses suggested personality styles which seem to underscore the importance of remaining engaged[;] ... Creative Interactors (E+O+), Upbeat Optimists (N-E+), Welcomers (E+A+), Go Getters(C+E+), and Directed (N-C+) ... had slower disease progression, whereas the "homebody" profile ... [E-O-] was significantly associated with faster disease progression. (p. 245)

Importantly, this study "did not account for psychiatric disorders in the sample nor were psychotropic medications included in the analysis. It is possible that acute psychiatric disturbances or their treatment may have biased the personality assessment. Similarly, the absence of neuropsychological assessment or physician assessed hepatitis C allows for the possibility that unidentified cognitive impairments or co-occurring liver disease may have unduly influenced some of the relationships reported here" (p. 251).

Speaking to the importance of these findings, Ironson and colleagues point out that these

domains, facets, and profiles may have particular relevance for psychosocial and behavioral medicine interventions to improve disease management in people living with HIV in several important ways. First, the observed associations between personality and HIV disease progression may help to identify those at risk for a less favorable disease course. Second, the observed associations in the present study between personality and established risk factors for an accelerated disease course (i.e., depression, substance use, medication adherence) may also help to specify the targets for psychosocial interventions.

Perhaps most importantly, personality assessment may help to triage patients into the most appropriate treatment. For example, those low in C may benefit from increased environmental supports around medication and medical appointment adherence ... ; those low in [E] may particularly benefit from social support utilization interventions; and those high in [O] may be particularly receptive to alternative or complimentary treatments. It is important to remember, however, that the purpose of personality assessment and the aim of any treatment intervention is not to change the individual’s personality, but rather, with appropriate training, to enable the individual to change … [his or her] attitudes and behavior given … [his or her] basic tendencies or personality. Targeting specific treatment that best conforms to the individual’s personality may help to ensure a more effective intervention and better health outcomes. (pp. 251-252)

---- Compiled by Abraham Feingold, Psy.D.

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 4 "The majority (approximately 80%) of the sessions were held in person and lasted on average between 20 and 90 minutes[,] with a median of 45, 32 and 30 minutes for sessions 1, 2 and 3-5, respectively. Session 1 was completed in-person for all participants. Telephone sessions (for sessions 2-5) were conducted as needed for participants who were unable to meet the counsellor in the clinic. For sessions 2-5, 17%, 21%, 15% and 16% were completed via telephone. ... Participants were paid $10 for completing the first MI session and $5 for each of the remaining four sessions. In addition to the five MI sessions, participants in the intervention group received a copy of the Get Busy Living video, a journal and a calendar" (p. 275).

 5 See the Tool Box on "Emerging Methods for Motivating Effective Medication Practice" in the Summer 2006 issue of mental health AIDS for more information on the application of MI to antiretroviral medication-taking.

 6 "The SPAN ... is an abbreviated form of the widely used Davidson Trauma Scale ... and is a reliable and valid screening tool for PTSD ... . It has four items measuring startle, physiological arousal, anger, and numbness" (p. 316). "The PC-SAD is a reliable and valid tool for assessing depression in the primary care setting. ... The PC-SAD is a 37-item DSM-IV-compatible depression screening. ... It does not overlap with somatic symptoms of HIV infection" (p. 316).

 7 "The intervention involved five sessions with ... [a] nurse-interventionist delivered just prior to and during the first 2 months following dispensing of medication. Two of these sessions occurred before the dispensing of medication (7-14 days apart), and three sessions occurred following medication dispensing (at Weeks 2, 4, and 8). In addition, there was also a session at 6 months. ... Support partners were welcome at all sessions, but were required to attend at least one of the first two sessions and two of the first four. Participants were also contacted by phone five times between intervention sessions: at Weeks 1, 6, and 10 and at Months 4 and 5 after beginning medications. In addition, participants were required to attend at least two of six group educational sessions at any time during the intervention. ... The first two sessions typically lasted 2 to 3 hours, depending on how much the patient already understood about HIV disease and antiretroviral medications; Sessions 3 through 6 typically lasted about 1.5 hours, ranging from 45 min to 2 hours" (pp. 161-162).

 8 See the Tool Box on "All That Is Sacred: A Primer on Spiritual Assessment" in the Spring 2007 issue of mental health AIDS for information on a two-stage spiritual assessment process.

 9 The personality domains measured by the Revised NEO Personality Inventory (NEO-PI-R), and their respective facet scales, are as follows: Neuroticism (Anxiety, Angry Hostility, Depression, Self-Consciousness, Impulsiveness, Vulnerability); Extraversion (Warmth, Gregariousness, Assertiveness, Activity, Excitement Seeking, Positive Emotions); Openness (Fantasy, Aesthetics, Feelings, Actions, Ideas, Values); Agreeableness (Trust, Straightforwardness, Altruism, Compliance, Modesty, Tender-Mindedness); Conscientiousness (Competence, Order, Dutifulness, Achievement Striving, Self-Discipline, Deliberation). "Interpretation on the domain level yields a rapid understanding of the individual, while interpretation of specific facet scales gives a more detailed assessment" (Costa & McCrae, 1995, p. 21).

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