mental health AIDS

Spring 2005 Newsletter

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Psychopharmacology

In a 4-week, open-label pilot study, Rabkin, McElhiney, Rabkin, and Ferrando (2004) evaluated the efficacy of modafinil (Provigil®; a wake-promoting agent) for fatigue in people living with HIV. They found that 80% of 30 enrollees experienced a reduction in symptoms of fatigue and, in many respondents, symptoms of nonmajor depression. Improvements in verbal memory and executive function were also noted. While small sample size and the absence of a placebo comparison group limit the conclusions that may be drawn from this initial study, the authors "recommend that clinicians treating HIV+ patients inquire directly about fatigue severe enough to interfere with daily activities ... and if it is identified, offer treatment" (p. 1694).

Neuropsychological Impairment

Cristiani, Pukay-Martin, and Bornstein (2004) investigated the interaction between HIV disease stage and use of marijuana . They stratified 282 individuals by disease stage (i.e., HIV-negative, HIV-positive and asymptomatic, HIV-positive and symptomatic) and frequency of marijuana use (i.e., no/minimal use [ < 12 times per year] and frequent use [ > 52 times per year, with nearly daily use by many of those sampled]). They found that

frequent marijuana use may be associated with cognitive dysfunction in the context of more advanced HIV infection. Although the main effect for marijuana use only approached significance, there was a significant interaction, suggesting that frequent marijuana use was associated with greater cognitive impairment among subjects with symptomatic HIV infection. This effect appeared to be primarily related to performance on memory tasks. These results cannot be attributed to the influence of confounding variables such as depression, anxiety, or alcohol use, all of which were included as covariates in the data analysis. (p. 333)

Cristiani and colleagues conclude that, while marijuana appears to exert a "minimal" residual cognitive impact on those who are uninfected or in the early stages of HIV infection, "there is a synergistic effect of HIV and marijuana use in patients with advanced HIV disease. This is consistent with other data suggesting that the subtle effects of some conditions may become more manifest in the setting of immunocompromise" (p. 330).

With regard to intervention, the authors reason that chronic users should be encouraged to reduce their level of marijuana consumption. "However, this may be in conflict with the management of other symptoms associated with HIV infection. Since some HIV infected patients use marijuana for control of nausea and appetite, reduction in marijuana use may lead to increase in these symptoms. Individuals with continued chronic marijuana use should be alerted to the possibility of greater memory dysfunction, and could be encouraged to use memory books or other assistive devices to circumvent their memory problems" (p. 334).

Stress Management

Ironson et al. (2005) randomly assigned 56 women living with HIV to one of two conditions: a 10-week group therapy program (90 minutes of cognitive behavioral stress management, 30 minutes of relaxation training) or a low-intensity comparison condition (45 minutes of informational/educational videotapes, 75 minutes of entertainment videotapes). Through measures taken on two occasions 3 months apart, Ironson and colleagues found that

AIDS self-efficacy was related to both decreased viral load and increased CD4 over time. Thus people who believe they have the skills to prevent re-infection and the skills to slow down the development of symptoms actually appear to have better biological outcomes. How could this occur? Self-efficacy ... or beliefs about one's capabilities and potential to meet situational demands is known to influence effort, perseverance, perception of control, personal choices, thought patterns, depression and perceptions of stress ..., all of which are salient to the individual coping with AIDS. (p. 232)

These investigators also found that "increases in cognitive behavioral skills were ... related to decreases in viral load ... [and that] increases in cognitive behavioral self-efficacy were ... related to decreases in depression and anxiety" (p. 232). They conclude that "improving participants' self-efficacy may impact on disease progression and wellbeing" (p. 233).

Adherence to Treatment

Deloria-Knoll et al. (2004) surveyed 255 predominantly white, male, and highly-educated antiretroviral recipients participating in a multi-site study and found that one-third reported skipping at least one medication dose in the 3-day period preceding completion of the questionnaire. Importantly,

[a]sking patients to report difficulty taking antiretroviral medications or whether they took a drug holiday identified an additional 16% of patients experiencing adherence problems and explained significantly more of the failure to achieve undetectable viral load than merely asking about skipped doses. It may be useful to further evaluate patient-expressed difficulty in taking medications as a surrogate or supplemental marker of skipping. This may promote better clinician understanding of scenarios in which medication nonadherence is likely. Likewise, such a marker may be especially useful in situations, such as face-to-face interviews, where patient concerns over "disappointing" their [provider] or being negatively stigmatized as nonadherent may interfere with the honesty of reporting. In such situations, some patients may feel more comfortable admitting "difficulty taking their medicine" than nonadherence outright. Thus, soliciting patient responses regarding attitudes, concerns, and adverse effects consequent to HIV therapy, in addition to making direct queries regarding adherence, may help to better identify those who are suboptimally adherent and can only be of benefit in promoting enhanced patient-[provider] communication overall. (pp. 726-727)

Mannheimer et al. (2005) assessed changes in quality of life (QoL) over a 12-month period in a racially and ethnically diverse sample of 1,050 clinical trial participants receiving antiretrovirals.

This longitudinal study demonstrated that the QoL improved over time for HIV-infected individuals receiving [antiretrovirals]. ... . Significant improvements in QoL were noted as early as 1 month after initiating ... HAART ... for the physical ... and 4 months for the mental ... component of QoL. The improved QoL was sustained over the 12-month study period. The improvements in QoL were most striking among those with the highest adherence levels. In a cross-sectional analysis at 4, 8, and 12 months after initiation of new [antiretroviral] regimens, significant differences were seen at 4 months for [the mental summary score] and at 12 months for both [mental] and [physical] summary scores and in seven of the eight QoL domains. In each case, those reporting 100% adherence had the greatest gains, those with 80-99% adherence levels had smaller benefits, and those with < 80% adherence had lower QoL scores than at baseline. Longitudinal data showed that participants reporting 100% adherence at either 3 or 4 of the total of 4 study follow-up visits over the 12 months achieved the best QoL outcomes, highlighting the importance of consistent adherence. (p. 18)

Mannheimer and colleagues conclude that, "[w]hile previous data have suggested a requirement of at least 95% adherence for the best virological outcomes ..., clinical benefits such as improved QoL may occur at lower adherence levels" (p. 19).

Coping, Social Support, & Quality of Life

Orlando, Tucker, Sherbourne, and Burnam (2005) assessed the association between psychiatric symptoms of depressive and anxiety disorders and physical components of health-related quality of life (HRQOL) over time. They studied 2,431 individuals within a nationally representative sample of 2,864 adults receiving HIV medical care in 1996. Controlling for a number of variables (including HIV disease stage and symptoms), Orlando and colleagues found that "[p]atients who initially had a greater number of symptoms of depressive disorder showed increased pain and declines in general health perceptions over an 8-month follow-up, and patients who initially had higher perceptions of general health, lack of pain, and physical functioning exhibited significant decreases in the number of symptoms of either depressive or anxiety disorders or both" (p. 24). They go on to observe that

[t]he reciprocal nature of the association between psychiatric symptoms and certain physical components of HRQOL emphasizes the importance of addressing poor HRQOL among HIV-infected individuals, as well as detecting and treating psychiatric problems in this population. Given that improvement in HRQOL can lead to improved mental health, identifying and treating HIV-positive people experiencing high levels of pain, for example, may prevent development and escalation of mental health symptomatology. On the other hand, adequately addressing psychiatric problems in this population should result in improved functioning and well-being. (p. 25).

Vosvick et al. (2004) surveyed 146 adults living with HIV and found that "[g]reater pain and stress were associated with greater sleep disturbance . Greater assistance from friends was associated with greater sleep disturbance, whereas greater understanding from friends regarding participants' HIV-related stress was associated with less sleep disturbance" (p. 459). Vosvick and colleagues therefore suggest that "assessing the available sources of social support as well as what type of support each source can provide may allow ... providers to effectively intervene and improve sleep quality for persons living with HIV or AIDS" (pp. 461-462).

In Canada , Burgoyne (2005) evaluated the relationship between perceived social support and viral load over a 4-year period among 34 adults receiving outpatient medical care for HIV. "Social support in this study emphasized perceptions of accessibility to others with whom to express mutual loving and caring, share activities and openly discuss issues of concern" (p. 122). Measures were taken at baseline, in Year 2, and again in Year 4. Burgoyne reports that

[a]dults living with HIV infection and who consistently took HAART over a relatively long-term period of time appeared to experience better clinical benefit in terms of virological suppression if they perceived having positive interpersonal, informational and emotional support available to them. Attempts to illuminate the direction of causation between social support perceptions and viral load outcome met with some success. Study results suggested a trend in which social support did portend viral load outcomes. However, not all of the criteria for supporting causality were satisfactorily met. (p. 122)

Burgoyne nonetheless suggests that "[t]hese findings underscore the importance of service delivery provision in which patients' social support and goals directed to maximizing that support receive focused attention" (p. 121).

Of course, not all relationships are supportive. To estimate the proportion of adults engaged in HIV care whose close relationships can be characterized as abusive, Galvan et al. (2004) employed a self-administered, computer-assisted instrument with a stratified random subsample of 1,421 persons included in a nationally representative sample of 2,864 adults receiving HIV medical care in 1996. Of the 51% of subsample respondents reporting that they had a spouse or primary relationship partner during a 6-month period, 26.8% reported abuse in that close relationship . Forty-eight percent of the reported abuse was mutual and, interestingly, abuse was received and perpetrated with equal frequency. Abuse in a close relationship was associated with younger age, drug dependence, binge drinking, the presence of a psychiatric disorder, and HIV seroconcordance between partners. When controlling for these factors, however, these investigators found that "[m]ales and females, those with male partners and those with female partners, were all about equally likely to be in an abusive relationship" (p. 449). Also, abuse was more common among African Americans and Latinos in this sample. Even when controlling for the factors noted above, these investigators found that "African Americans were more likely than Whites to be involved in an abusive relationship" (p. 441).

Galvan and colleagues expand on these findings as follows:

Abuse in the close relationships of HIV-positive people is a problem of substantial magnitude with implications for the physical and psychological health of this already vulnerable group. [As with] many other public health problems, African Americans and Latinos appear to be more vulnerable to relationship abuse. HIV medical and social service providers should routinely inquire about issues of abuse, particularly in these subpopulations, and regardless of the gender or sexual orientation of the individuals. Appropriate referrals to abuse prevention programs, as well as to substance abuse and mental health programs, should be provided as needed. Curbing substance abuse among people with HIV may be a particularly potent [method] of reducing relationship abuse. Although problems with both relationship abuse and substance use have been previously recognized in the at-risk population, the present study indicates that the scope of these problems among people already infected with HIV is substantial. (p. 450)

Continuing on this theme, Newcomb and Carmona (2004) conducted baseline and follow-up interviews with a community sample of 113 Latinas (79 HIV-positive, 34 HIV-negative) "to estimate the influence of acculturation, HIV status, and adult trauma , including ... [IPV] and sexual assault, on subsequent changes in psychological adjustment (depression) and substance use 1 year later" (p. 417). They found that education protected study participants from HIV, depression, and IPV, but increased the likelihood of substance use. Additionally, IPV and sexual assault were found to be the "primary predictors" of changes in depression and substance use, and these effects were exacerbated when the woman was HIV-positive. "HIV status [has] an immediate impact on psychological adjustment in the form of depression and higher incidents of adult trauma" (p. 424), according to the authors. They stress that "intervention programs that work specifically with HIV-positive Latinas need to ... assess for adult trauma and victimization, as well as provide intervention to minimize depression ..." (p. 424). Furthermore, "Latinas who experience violence may look to substances to cope with such trauma, highlighting the need ... to address both psychological adjustment and substance use prevention for battered and traumatized women" (p. 425). Finally, Newcomb and Carmona contend that "support groups for HIV-positive women that address trauma histories and target the enhancement of coping skills may help to ameliorate depression and self-medication through drugs" (p. 426).

Over a 24-month period, Pereira et al. (2004) studied 28 black, non-Hispanic (i.e., African American, Haitian, Bahamian, and Jamaican) women living with HIV and human papillomavirus (HPV) infection . HPV infection is a risk factor for cervical dysplasia, a gynecologic condition common among HIV-positive women and the precancerous phase of cervical cancer. The authors found that women with an inhibited interpersonal coping style 3 kept fewer clinic appointments for special immunology primary care and obstetrics/gynecology care during the first 12-month period under study, an association that strengthened during the second 12-month study period. This association continued even when the authors controlled for the possible influence of recent depressed mood on attendance at clinic visits.

[T]hese findings suggest that psychosocial assessment, including interpersonal coping style assessment, should be implemented at the point of a woman's entry into the health care system for the medical management of HIV. For many women, entry occurs during pregnancy, suggesting that psychosocial assessment should be performed at a woman's first prepartum visit. Based on the results of these assessments, brief coping skills interventions could be delivered to women with vulnerable coping styles throughout the prepartum period ... . Given the amount of stress many women experience after childbirth, HIV+ HPV+ women may benefit from more intensive psychosocial interventions postpartum. (p. 201)

Lastly, to identify factors associated with attempts at workforce reentry, Martin, Arns, Chernoff, and Steckart (2004) compared 235 people living with HIV/AIDS who were enrolled in a workforce-reentry assistance project to 51 people living with HIV/AIDS who were not. They observed "a consistent pattern of improved health among those who enrolled in the program compared to those who did not. No other pattern of group differences was observed, but both groups evidenced indices of poorer mental health and higher rates of substance abuse than suggested by national norms" (p. 28). Martin and colleagues are quick to point out that

people with HIV/AIDS who choose not to attempt workforce entry may have legitimate concerns over their health and health stability. ... [T]hese concerns may be related to ... objective health indices and thus may reflect a rational and deliberate decision-making process in determining whether to attempt workforce reentry. ... People with HIV/AIDS are well advised to carefully consider the potential health-related effects that their workforce-reentry efforts may have, and [clinicians] working with people with HIV/AIDS-related disabilities should be sensitive to the impact these health indices may have on workforce-reentry attempts. Many HIV-related physical symptoms (e.g., disabling neuropathy: pain in limbs and extremities) may be invisible to interviewers ... . ... [Also, b]ecause substance abuse has been found to be an obstacle to successful workforce reentry among people with disabilities, substance abuse treatment may need to be closely coordinated or integrated into workforce-reentry programs targeted at people with HIV/AIDS. (p. 35)

- Compiled by Abraham Feingold, Psy.D.

1 "The contemplation stage is apparent when the individual shows awareness that a true problem exists. At this stage, the individual begins to think about change but has not yet made a commitment to overcome his/her problem behavior. The contemplation stage is characterized by ambivalence toward change. ... In the preparation stage of change, motivation to change is high, and the individual begins to prepare for the changes that are forthcoming. The individual in this stage often needs assistance in identifying effective strategies that will facilitate desired behavior change" (p. 392).

2 Additional information on meth use, HIV risk, and intervention may be found in Tool Boxes in the Spring and Summer 2004 issues of mental health AIDS.

3 "Individuals who are interpersonally inhibited have the desire to reach out to others in times of need but actively restrain themselves from doing so, often because of the fear of negative interpersonal consequences. By this definition, it is likely that interpersonal inhibition is associated with health behaviors that occur within a social context, such as health care utilization" (p. 197).

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