HIV/AIDS AND DEPRESSION: A PSYCHOLOGICAL PERSPECTIVE

Christopher Albert, Ph.D. Counseling and Psychological Services

www.utpa.edu/counseling

University of Texas Pan American

HIV
Human Immunodeficiency Virus Retrovirus of the human T-cell and causative agent of the acquired immunodeficiency syndrome (AIDS) Latency between HIV diagnosis and appearance of AIDS symptoms can be from 10 to 15 years

AIDS
Stage at which HIV infection has led to the breakout of various illnesses, the most common being pneumocystis carinii pneumonia (60%), Kaposi s sarcoma (12%), and AIDS dementia complex (8-66%). This is associated with a certain level of reduction in the count of CD4 T helper cells (involved in activating and helping other immune cells).

DEPRESSION
State of lowered mood, often accompanied by disturbances of sleep, energy, appetite, concentration, interest, and sexual drive

TYPES OF DEPRESSION
Minor depression Depressive symptoms Clinical depression Major Depressive Disorder Adjustment Disorder with Depressed Mood

Why Treat Depression?

Can worsen without treatment Contributes to less adherence to medical treatment Can lead to maladaptive and even destructive coping behaviors (substance abuse, suicide, reckless behaviors) Affects interpersonal, vocational, and academic functioning

BEHAVIORAL MEDICINE
An interdisciplinary field of medicine concerned with the development and integration of psychosocial, behavioral, and biomedical knowledge relevant to health and illness. The term is often used interchangeably with health psychology, however, behavioral medicine development teams include psychiatrists, nurses, and other medical support staff. -Wikipedia, 2008

PSYCHONEUROIMMUNOLOGY
Study of the effects of psychological factors (e.g.: behavior, mood, stress) on immune system functioning

DEPRESSION AND HIV/AIDS

HIV-positive have nearly twice the rate of major depression as HIV-negative HIV with depressive disorders compared with HIV alone
Greater delays in medical treatment Worse adherence to medical treatment For women, higher mortality

DEPRESSION AND HIV/AIDS

Suicide rate among HIV-infected men may be 36 times that of age-matched uninfected men
(as cited in Antoni, 2000)

DEPRESSIVE FACTORS
Asymptomatic Period
Slow Sentence effect unable to hope or plan, vigilant and fearful about self and others Complex decision making (e.g.: who to inform?) Lifestyle changes Reconsidering life plans Preparations for death Worries about financial and health security Pressures of medical regimen

DEPRESSIVE FACTORS
Symptomatic Period
Reduced independence Fears about the future Death anxiety Concerns over body image Changes in self-concept Social isolation/conflictive relationships Prejudice from others Bereavement

ORGANIC DEPRESSION IN HIV/AIDS?

27% met criteria for a current mood disorder Depressive symptoms:
not related to cognitive measures or HIV disease status Strongly related to personality style, past psychiatric history, current stressful psychosocial situation

No evidence of organic depression

Judd, et al. (2005)

IATROGENIC FACTORS
Treatments for HIV disease, such as Efavirenz, may trigger onset of major depression
(as cited in Voss, et al., 2007)

PROTECTIVE FACTORS
Positive social support Optimism Adaptive coping
Acceptance, planning, and active coping vs denial and avoidance

THE FLIP SIDE

Fatalistic-pessimistic attitude is significant predictor of shorter survival time among men with AIDS Use of extreme denial or extreme acceptance associated with accelerated disease course, while distraction is associated with slower course People who remain socially isolated appear to show the fastest progression of disease

WHAT CHARACTERIZES SUPER SURVIVORS?

Healthy self-care behaviors Sense of connectedness Sense of meaning and purpose Maintaining perspective
(cited in Antoni, 2000)

PSYCHOTROPIC MEDICATION TREATMENT

Results of a meta-analysis across seven studies showed at least moderate positive effect
- Himelhoch & Medoff (2005)

- Generally can treat depression as in nonHIV/AIDS infected persons, though need to avoid certain side effects and interactions with other medications - SSRI s popular - Dehydroepiandronsterone
- Rabkin, McElhiney, & Rabjin, 2006

PSYCHOSOCIAL/BEHAVIORAL TREATMENTS
Support Psychoeducation Psychosocial Cognitive-Behavioral Existential

TELEPHONE-BASED PSYCHOEDUCATION
Up to 12 scheduled calls over 6 months Depression scores improved (Beck Depression Inventory) but the psychoeducation intervention did not fair better than assessment-only control
Stein & Bishop, 2007

SUPPORTIVE THERAPY FOR ADHERENCE TO ANTIRETROVIRAL TREATMENT (STAART)

Techniques to increase medication adherence and learn effective strategies to cope with stress and depression Enhanced HIV treatment readiness Reduced depressive symptoms in those who were depressed
Balfour, Kowal, & Silverman, 2006

Group Based Stress Reduction

Weekly over two to three months Decreased perceived stress, affective distress, or depressive symptoms in HIV-positive men
(cited in Antoni, 2000)

BEREAVEMENT SUPPORT GROUP

10 weeks Decreased distress level and grief among 56 asymptomatic or early symptomatic HIVpositive gay men
(cited in Antoni, 2000)

COPING EFFECTIVENESS TRAINING (CET)

Increased in self-efficacy and decreases in perceived stress and burnout when compared with men assigned to either an HIVinformation group or waiting list control
(cited in Antoni, 2000)

COGNITIVE-BEHAVIORAL AND SUPPORT GROUPS

Both superior to a control standard of care group in reducing distress. Both groups showed about equal effectiveness
(cited in Antoni, 2000)

COGNITIVE-BEHAVIORAL AND EXISTENTIAL GROUPS

Again, both effective in improving mood, but none superior to the other.
(cited in Antoni, 2000)

IMPORTANT THERAPY INGREDIENTS

Reducing stress Improving coping Building social support Providing healthy environment for expressing feelings

COGNITIVE BEHAVIORAL STRESS MANAGEMENT (CBSM)(Antoni, 2000)

10 structured modules, group based
Health education Increasing awareness of thoughts, emotions, and physical responses Teaching cognitive techniques Coping-skills training Interpersonal skills training Relaxation techniques Enhancing support resources

CBSM RESEARCH
Randomly assigned 65 gay men who did not know HIV serostatus to standard control, exercise control, or CBSM. Treatment ran through notification period (10 weeks) Measures of progress through Notification period, Asymptomatic stage, and Pre-AIDS stage

CBSM RESULTS
CBSM participants versus control group:
Less emotional distress during notification Positive immune response as opposed to negative over a five and ten week period. Stronger immune response found in later stages of the disease

CBSM RESULTS
More home practice of skills learned associated with larger decreases in distress AND larger increases in NK and CD4 cells

CBSM RESULTS
Follow-ups
Two years: Distress at time of diagnosis, HIVspecific denial coping, and low active participation in CBSM or exercise groups all predicted faster disease progression One year: Decreases in denial and greater frequency of relaxation home practice during the 10-week intervention period were predictive of higher CD4 cell counts

CBSM RESULTS
At Asymptomatic stage
CBSM associated with reports of increases in adaptive coping (acceptance, planning) and decreases in maladaptive coping (denial, mental disengagement)

CBSM RESULTS
At Pre-AIDS stage
Lower depression scores Continued evidence of stronger immune functioning Home practice continues to be associated with better mood

FULL-BLOWN AIDS
Lacking research in this area for psychological interventions Most effective treatment may be employing an existential approach and/or psychosocial intervention combined with pharmacological treatment Recycling through stages of Kubler-Ross model (denial, anger, bargaining, depression, and acceptance) continual emotional crises

HISPANICS AND HIV/AIDS

According to the Center for Disease Control and Prevention (2004) In 2001, HIV/AIDS third leading cause of death among Hispanic men aged 35 to 44, and the fourth leading cause of death for Hispanic women in that age range

HISPANICS AND HIV/AIDS

Among racial/ethnic groups, second highest AIDS rate was for Hispanics (African Americans the highest)

HISPANICS AND HIV/AIDS

Sexual contact with other men is primary cause of HIV infection for Hispanic men Sexual contact with men is primary cause of HIV infection for Hispanic women

HISPANICS AND HIV/AIDS

Culturally-related barriers to adequate care:
Certain traditional values, such as machismo, may make it difficult to confront the epidemic in Hispanic communities Reluctance to acknowledge risky behaviors Some women may be reluctant to discuss issues with partner (e.g.: condom use) for fear of physical safety or loss of financial security

RELAXATION TECHNIQUES
Diaphragmatic (slow, deep) breathing Autogenic training Progressive muscle relaxation Relaxation imagery Mindfulness meditation