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Treatment Planning
Reece, McBride, Shacham, and Williams (2005) surveyed 102 providers of HIV-related mental health services working in the southeastern United States, the majority of whom were private practitioners. The survey was designed to solicit the perceptions of therapists regarding "the minimum number of sessions that they estimated to be necessary for a person to return to a normal range of functioning, without the use of psychotropic medications" (p. 77). Areas of interest included a range of mental health disorders (i.e., specific anxiety disorders, mood disorders, sexual and gender identity disorders, and other disorders) that providers had encountered while serving clients living with HIV and clients without HIV infection. Therapists were also asked their perceptions regarding therapy duration related to five HIV-specific mental health issues (receiving a new HIV diagnosis, HIV disclosure issues, reproductive decision-making, medical treatment compliance, and personal death and dying issues). "Across all mental health issues assessed, therapists indicated a greater need for therapy duration when an HIV diagnosis was also present, and this generally was consistent without regard to therapist education, demographics, or ... [theoretical] orientation" (p. 72).
The absence of a large number of significant differences in duration estimates according to theoretical orientation suggests that these estimates may be more reflective of therapists' clinical experience and actual differences between populations, making the findings relevant to the diverse population of therapists who provide mental health care to clients living with HIV. Particularly, there are implications for therapists favoring models of brief treatment and those working in agencies with specific care guidelines. When developing realistic and appropriate treatment plans for clients living with HIV, special attention should be given to the complex nature of mental health issues and their impact on treatment timelines. (p. 82)
Reece and colleagues conclude that, "while this study's findings do not represent an absolute, they may be helpful for establishing clinical guidelines for publicly-funded agencies where program effectiveness is often measured through process-oriented deliverables such as number of counseling sessions provided and the extent to which providers are able to retain clients in care" (p. 83).
Neuropsychological Impairment
Richardson, Nowicki, et al. (2005) evaluated NP functioning in a cohort of 220 women, of whom 70 were hepatitis C (HCV)-positive/HIV-positive, 27 were HCV-positive/HIV-negative, 75 were HCV-negative/HIV-positive, and 48 were HCV-negative/HIV-negative. Test performance demonstrated that
NP impairment was significantly higher for HCV-positive women in comparison with HCV-negative women ... [and w]omen co-infected with HCV and HIV demonstrated greater abnormal NP performance than those not infected with either ... . Women who were HCV-positive/HIV-positive and not taking antiretroviral therapy ... were more likely ... to demonstrate NP impairment than those who were HCV-negative/HIV-negative. In analyses controlling separately for education, intelligence quotient, depression, sedating drug use, head injury, ethnicity, and history of substance use, HCV continued to significantly predict NP impairment. ... After testing for an interaction between age and infection status, ... [the investigators] conducted age-stratified analysis and showed a significant effect of infection status for those aged under 40 years. (p. 1659)
In closing, Richardson, Nowicki, and colleagues comment on the cross-sectional design of this study, which limits their conclusions "to the observation of a strong statistical association between NP function and HCV, ... [and the suggestion] that the combined effect of HCV and HIV is greater than either alone in terms of NP impairment" (p. 1665). Regarding the practical significance of these findings, the investigators point out that
[t]he limitations found in speed of information processing requiring divided attention or set shifting have significant implications for impairment in performance of daily activities. The ability to concentrate, perform multiple tasks, and learn new information can lead to interference in driving, self care, employment, and adherence with therapy regimens for HIV and/or HCV. When co-infection occurs, ... [clinicians] should be especially sensitive to the possibility that the patient may be at increased risk of problems with treatment adherence. (pp. 1665-1666)
Adherence to Treatment
Wrubel et al. (2005) analyzed the responses of 71 maternal caregivers of children living with HIV to questions about the stresses involved in caring for these children. The purpose of this study was to examine "the mothers' perspective on medications and the interaction around giving or supervising medication in order to describe their impact on adherence practices" (p. 2431). The investigators found that "adherence practices were impacted in a positive way by mothers' commitment to adherence, and in a negative way by feelings of stigma and guilt, by the effects of bereavement on children and by children adopting their mothers' attitudes about medications. The interactive process of giving medication was shaped by children's behavior, mothers' developmental expectations for children, and, for mothers with HIV, their adherence for themselves" (p. 2423).
By approaching pediatric adherence "as an interactive process in which the life context of mothers' experiences, attitudes and feelings strongly impact their adherence practices for their children with HIV ..., [the investigators] were able to show that even aspects of adherence that seem discrete, like side effects, have a component of interactive significance[,] with mothers feeling emotional pain over having to force their children to do something aversive. For some mothers, this emotional pain led them to occasional non-adherence" (p. 2430).
Wrubel and colleagues suggest that their findings "point to promising avenues for intervention, such as addressing unresolved guilt over infecting one's child or changing expectations for child's responsibility for the regimen" (p. 2431). "The practice that appeared to support adherence was that of sharing the responsibility for the medications before adolescence. ... Possibly, as younger children grow into adolescence, the adherence practice of sharing responsibility for medication might evolve into the children['s] gradually assuming more and more of the responsibility themselves" (p. 2431).
Paradoxically, from a clinical perspective, the impact of successful pediatric adherence on the caregiving mother's well-being bears examination.
Seen from the point of view of the caregiving mothers' daily life experiences, consistent adherence often came at an emotional cost to those mothers. Even if mothers are fully committed, have resolved guilt feelings, and are not concerned with stigma, they may still have to deal with negative feelings twice a day over having to cause their children pain. They may have to suppress repeatedly their feelings of frustration, or, they may feel worn down by their children's repetitive resistance to taking the medications. In addition, these mothers' lives play out against a backdrop of the painful knowledge that their children have a potentially fatal illness. Persistent or recurring negative emotions could ultimately take a toll on the mothers' mental or physical well-being. The negative effect on mothers' well-being can, in turn, impact their children's depressive mood ..., families' quality of life ..., and, ... [quite possibly], mothers' adherence practices. (p. 2431)
How well do adolescents adhere to antiretroviral regimens? Murphy et al. (2005) assessed antiretroviral adherence at 3-month intervals in a cohort of 231 adolescents from 13 cities throughout the United States who were living with HIV. Study participants were largely female (72.7%) and African American (74.9%); their average age was 18.4 years. The investigators found that,
[a]t the initial visit, approximately 69% of the adolescents reported being adherent to antiretroviral therapy. Adolescents in the later HIV disease stage were less likely to be adherent compared with those in the earlier disease stage. Less alcohol use and being in school were associated with adherence by adolescents on weekends and over the preceding month. Longitudinal adherence was investigated among 65 subjects initially adherent with available information for at least 4 consecutive visits. The median time to nonadherence was 12 months, and failure to maintain adherence was significantly associated with younger age and depression. Among adolescents who attained an undetectable viral load, only about 50% maintained an undetectable viral load for the year. (p. 764)
Drawing on these disturbing findings, Murphy and colleagues characterize the types of interventions that may promote antiretroviral adherence among adolescents.
[I]ntervention should include assisting adolescents in problem-solving issues concerning substance use and lowered adherence. This may include teaching them to plan their medication-taking schedule for times when they will not be drinking and/or using drugs, or referral to substance use treatment for those adolescents with problematic levels of use. In addition, intervention should include teaching adolescents to maintain a consistent schedule during the week to assist in facilitating adherence. Moreover, adolescent patients with advanced HIV disease are likely to need more intervention support than do patients in an earlier disease stage. Finally, many adolescent patients may need intervention that focuses on dealing with depression over time. Patient-level intervention, health care provider-level interventions, and health care system modification may all be necessary if the challenge of antiretroviral medication adherence by adolescents with HIV is to be successfully surmounted. (p. 769)
Speaking specifically to the treatment of depression, Murphy and colleagues note that,
[i]n the past, adolescents have had a relatively poor response to antidepressants that are typically efficacious with adults. ... However, the Treatment [for] Adolescents [With] Depression Study 3 ... has recently compared fluoxetine, cognitive behavioral therapy, a combination of both, and a placebo medication – the first comparison in adolescents – and found support for antidepressant therapy with adolescents, especially when combined with cognitive behavioral therapy. Thus, there are now better avenues of treatment for adolescent depression. Adolescents being considered for ... HAART should be screened for depression. Those who are depressed may need both treatment for depression as well as interventions to assist them in adhering to their new treatment regimen for successful long-term adherence. (pp. 768-769)
Adolescents, children, and their caregivers are not the only subpopulations in need of assistance with adherence. Kalichman, Cherry, and Cain (2005) designed a two-session-plus-one-booster- session approach to supply a nurse-delivered HIV treatment adherence intervention for antiretroviral users with lower health literacy. The intervention, which was pilot tested with 30 men and women living with HIV,
succeeded in delivering [pictographic] educational information about HIV disease processes and medication mechanisms, and increased knowledge was retained over a 3-month period. In addition, the intervention was delivered in a motivational interviewing style that may have contributed to increases in intentions to adhere to medication schedules. The intervention sessions also delivered focused and interactive behavioral skills-building activities that likely resulted in the observed increases in medication adherence self-efficacy. In addition, ... the ... intervention reduced the number of nonadherence events that occurred over the follow-up period. These findings ... converge to suggest that a brief two-session plus one booster session nurse-delivered counseling intervention may have a substantial benefit for medication adherence among people living with HIV who have lower health literacy skills. (pp. 13-14)
Encouraged by the results of this small pilot study, Kalichman and colleagues believe that further research on this intervention is warranted.
Coping, Social Support, & Quality of Life
Henderson, Safa, Easterbrook, and Hotopf (2005) assessed an ethnically diverse sample of 148 individuals receiving HIV medical care in south London. They found that 65% experienced fatigue, which was associated with "[s]ignificant psychological distress ..., functional impairment ... and a higher CD4 count" (p. 347). Importantly, the presence of fatigue was "most strongly associated with psychological factors and not with more advanced HIV disease or the use of [HAART]" (p. 347).
The strong association between psychological distress and markers of quality of life has implications for the clinical management of fatigue in HIV-infected patients. Firstly, it suggests that the symptom of fatigue should elicit not only a search for physical mechanisms, but also detailed questioning about depression and anxiety. Secondly, the high rates of psychological distress described here suggest that a proportion of patients ... may benefit from specific interventions such as antidepressant medication, which may also improve fatigue. Thirdly, there is growing evidence that nonpharmacological treatments such as cognitive behaviour therapy and graded exercise therapy are effective in the treatment of medically unexplained fatigue occurring in chronic fatigue syndrome ... . Such treatments aim to help improve functioning by giving patients strategies for managing fatigue. Given the high prevalence, and apparently serious consequences for functional capacity, of fatigue in individuals with HIV infection, there is a need for further evaluation of these interventions in the HIV-infected patient population. (p. 350)
In France, Funck-Brentano et al. (2005) monitored 30 perinatally HIV-infected adolescents (between the ages of 12.0 and 17.4 years) receiving care in a Paris clinic over a period of 2 years: 10 who agreed to participate in supportive group therapy (group 1), 10 who declined participation (group 2), and 10 who lived too far from Paris and were not invited to participate (group 3). The psychodynamically oriented group therapy met in 90-minute sessions once every 6 weeks for 26 months.
At baseline, the three groups had similar characteristics overall. ... After 2 years, worries about illness had decreased in group 1, whereas the scores had increased or remained the same for the other adolescents ... . The adolescents in group 1 had less negative perception of treatment at 2 years than those in groups 2 and 3 ... . After intervention, the percentage of adolescents with an undetectable viral load had increased in group 1 from 30 to 80% (P = 0.063) but was unchanged in groups 2 and 3. Considering the three groups altogether, the decrease in ... viral load correlated with improvement ... [in perceptions of HIV treatment]. (p. 1501)
As Funck-Brentano and colleagues see it, "[t]his pilot study suggests that the peer support group [therapy] had a beneficial effect on the adolescents' acceptance and perceptions of their HIV infection. The findings even suggest that this improvement in well-being could have a positive influence on biological variables" (p. 1506).
On this point, Ashton et al. (2005) looked at satisfaction with social support and the use of maladaptive coping strategies (specifically, mental disengagement, behavioral disengagement, and the venting of emotions) as predictors of HIV-related health symptoms in a sample of 65 primarily low-income men and women living with HIV/AIDS who were diverse with regard to gender, ethnicity, and sexual orientation. Coping strategies, social support satisfaction, and HIV-related health symptoms were assessed at baseline; HIV-related health symptoms were reassessed at 3, 6, and 12 months following the baseline measurement. Ashton and colleagues found that
even after controlling for baseline CD4 T cell count and number of HIV-related physical health symptoms, participants' use of venting as a strategy for coping with HIV stress predicted greater increase in HIV-related physical health symptoms during the next year. ... [They] also found that when satisfaction with social support was considered, this overshadowed venting as a significant predictor of change over the next year in the number of HIV-related physical health symptoms, with more satisfaction predicting greater decline in number of physical health symptoms. (p. 596)
The investigators are quick to point out that "[a]dditional factors not examined in this study such as antiretroviral treatment adherence, regular follow-up and preventive care clinic visits, recreational drug use, and sexual risk behavior may be affected by poor coping and in turn cause a faster increase in physical health symptoms" (p. 596). Despite these limitations, Ashton and colleagues conclude that the results "are consistent with the possibility that the use of maladaptive coping strategies and satisfaction with social support affect HIV disease progression. These results build on those of a growing number of studies that suggest that interventions to improve social support and coping strategies can promote better health" (p. 596).
Tarakeshwar et al. (2005) conducted semistructured interviews with a convenience sample of 28 women living with HIV who had experienced childhood sexual abuse (CSA) for the purpose of "examin[ing] the challenges and coping strategies related to CSA among women and the impact of their HIV diagnosis on these coping strategies. ... [The investigators] also asked the women whether they perceived a connection between their CSA and their HIV infection" (p. 666).
The interviews revealed that CSA raised challenges in four areas: disclosure of the abuse, sexual problems, relationship difficulties, and psychological distress. The women used two strategies to cope with their CSA: illicit substances to numb their emotional distress and sexual activity, and alienation to gain control in relationships. When diagnosed with HIV, the women initially coped with their illness by using these two strategies. The women reported that, over time, they were able to accept their HIV illness, seek social support, find alternative sources of significance, and use spirituality to sustain their growth. However, they continued to suffer psychological distress related to their sexual trauma. Further, most of the women did not perceive any connection between the two traumas. (pp. 655-656)
When women were able to identify a connection between the traumas, however, they
were able to integrate the psychological impact of their sexual trauma with their lifestyle that placed them at risk for HIV infection. For women who are to cope with the traumas of sexual abuse and HIV infection, such an understanding can help them identify aspects for their life that need attention (e.g., increasing self-worth, having relationships with men) and process the ways ... [these traumas have] impacted or continue ... to impact their everyday life. Further, this has implications for HIV secondary prevention interventions, which assume that women have the power to enforce preventive measures such as condom use. ... [These] findings suggest that for those who have suffered from sexually traumatic experiences, this assumption is questionable. (p. 667)
Tarakeshwar and colleagues discuss the implications of their findings at length:
First, they highlight the significance of the setting and the manner in which women are informed of their HIV status. As such, women diagnosed with HIV who also report a sexual abuse history can be provided with appropriate resources to help them recognize healthier patterns of coping much earlier in the course of their illness. Second, assessments of sexual abuse among women who have HIV are important and should be part of routine diagnostic interviews when women test for HIV serostatus. ... Third, given that women are more likely to seek health care for their HIV disease ... than sexual abuse, HIV health providers could be ideal points of triage for identifying women who have experienced sexual abuse and making appropriate referrals. Finally, given that HIV is now a manageable chronic disease, addressing the ways women who have HIV cope with distress related to sexual trauma becomes important, especially for sustaining successful management of their HIV illness and from a public health perspective, preventing further transmission of HIV infection. ... [This] study's findings indicate that even if medications are available for women who have HIV, those who have experienced sexual abuse may continue to suffer from psychological distress related to their sexual trauma. Consequently, their ability to adhere to HIV secondary prevention treatment may be affected ... .
... [These] results also inform potential topics for psychological interventions with women who have HIV and a history of CSA. The finding that the HIV diagnosis intensified their feelings of powerlessness, betrayal, and victimization, and that CSA continued to be a source of distress despite adaptive coping with HIV infection underscores the importance of attending to sexual abuse among HIV-infected women. Such attention includes validating the women's experiences of sexual abuse, raising awareness of the emotions and coping patterns triggered by their abuse and other traumatic experiences in their life, and examining ways that these emotions and coping patterns may be linked to their HIV risk behaviors and their current functioning. ... [This is not to suggest] that there is a causal relationship between CSA and HIV infection – only that the sexually abusive experiences increase vulnerability to HIV infection. Further, as the physical health of these women is intertwined with their psychological well-being, attention should be given to the ways the women are managing their HIV infection and related stressors (e.g., side effects, financial problems) and connecting them with the appropriate resources. The remarks made by women who identified a link between their sexual trauma and HIV infection make … it necessary for interventions to examine the power held by women in their relationships ... , especially to enforce HIV prevention such as condom use. The study's findings also raise our attention to the resilience displayed by these women in the face of trauma. Interventions must explore resources, such as their spirituality and their social support, that provide the motivation, strength, and support to find alternative sources of significance and help women to sustain them. Perhaps integrated medical and mental health treatment for individuals who are living with HIV provides us an opportunity to intervene and facilitate positive growth. (pp. 668-669)
To evaluate "an interpersonal model of depression symptom trajectories tailored to the experiences of women with HIV" (p. 678), Milan et al. (2005) "examined how bereavement, maternal role difficulty, HIV-related social isolation, and partner conflict predicted change in depressive symptoms over 5 years in 761 women with HIV, controlling for sociodemographic and clinical health factors" (p. 678). Milan and colleagues found that more than half of the women sampled reported heightened depressive symptoms when compared with the general population, and that there was little change at the group level in these symptoms over this 5-year study period. Among the women who reported a significant change in depressive symptoms over that time, partner conflict was the strongest predictor of this change of the four interpersonal factors studied.
Reflecting on this finding, Milan and colleagues observe that
[p]artner conflict may have a particularly strong impact on mental health in women with HIV because the disease influences women's physical, economic, and social needs ... and therefore may increase their vulnerability or dependence within relationships. In addition, HIV can alter the nature of partnerships. As examples, HIV may change the sexual relationship between a woman and her partner, influencing this mode of intimacy. For HIV-concordant couples, the disease may be associated with blame or may be a shared experience resulting in additional social support. Finally, positive HIV status may lead some women to remain in a conflictual relationship because they believe the disease limits options for alternative partners. (p. 686)
Although the investigators are careful to note that "the magnitude of effects was not large and the practical significance of results cannot be determined without more treatment outcome research focusing on women with HIV," (p. 686), they suggest that these findings
highlight the potential utility of therapies with an interpersonal focus ... and the importance of focusing on current relational issues, particularly the quality of intimate relationships. This might be accomplished by incorporating topics such as conflict resolution, communication skills, or anger management into therapy modalities often used to treat depression, in a manner that is culturally appropriate. Women in longer term relationships may also benefit from dyadic approaches. In addition, because partner conflict was associated with worse outcomes regardless of initial depression levels, offering such programs in settings other than mental health facilities (e.g., medical clinics, social service agencies) for women with HIV who are not currently depressed may have preventive benefits. (p. 686)
Altering depression symptom trajectories experienced by women living with HIV may have additional benefits. Evans et al. (2002) studied 63 HIV-positive and 30 HIV-negative women and found an association between depression in the women who were living with HIV and alterations in two components of innate cellular immunity: natural killer (NK) cells and CD8 T lymphocytes. Findings “suggest that depression may decrease [NK] cell activity and may lead to an increase in activated CD8 T lymphocytes and viral load” (p. 1757). For reasons such as these, depression has been associated with more rapid HIV disease progression.
More recently, this research team (Cruess et al., 2005) extended this work through a 2-year study of 57 women living with HIV for whom these investigators had "complete NK cell activity and depression data measured at two time points" (p. 2125). "Among the 57 HIV-seropositive women, improvements in the diagnostic status of depression and decreases in ... [depressive symptomatology] were significantly associated with increases in NK cell activity over time ... . Eleven women (19.3%) had a major depression diagnosis that resolved over time, and this group also had a significant increase in [NK] cell activity ... during this period" (p. 2125).
Referencing their earlier work, Cruess and colleagues conclude that these findings
provide the first evidence that resolution of major depression is associated with significant increases in NK cell activity over time in HIV-seropositive women. These results extend previous findings demonstrating depression-associated decrements in NK cell numbers and function and suggest that these alterations are reversible with the resolution of the depressive episode. Increasing evidence suggests that depression may have a negative impact on the progression of HIV disease, and chronic depression has been associated with mortality in HIV-seropositive women. Given the role that innate immunity plays in the host's defense against HIV infection, further studies assessing antidepressant treatment effects could shed light on the relationship and underlying mechanisms of depression, immunity, and the progression of HIV disease. (p. 2129)
– Compiled by Abraham Feingold, Psy.D.
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1 Examples of skill-building interventions for persons with SMI are outlined in a Tool Box in the Fall 2005 issue of mental health AIDS entitled "Reducing HIV Risk Among Adults With Severe Mental Illness."
2 "Coping self-efficacy is a measure of beliefs about one's ability to cope with stress by managing emotional responses and effective problem solving, including making plans to address problems and following them through" (p. 231).
3 Treatment for Adolescents With Depression Study (TADS) Team. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 292(7), 807-820.
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Winter 2006 Newsletter / Volume 7, Issue 2
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