According to Stebbing et al. (2008), "preclinical and cohort studies suggest that certain antidepressants are associated with a predisposition to cancer whereas others decrease the risk" (p. 2305). Additionally, "despite extensive data demonstrating that HIV infection and associated immunosuppression predisposes individuals to a wide range of cancers . . . (including non-AIDS-related malignancies . . .), no studies have specifically investigated the association between antidepressant use, length of antidepressant exposure, and the development of both AIDS-related and non-AIDS-related cancers in the highly active antiretroviral therapy (HAART) and pre-HAART eras" (p. 2306).
Stebbing and colleagues therefore set out "to assess whether different classes of antidepressants were associated with changes in cancer incidence in a population of HIV-1 infected individuals, based on duration of exposure" (p. 2305). The investigators found that, within a "cohort of 10,997 patients . . . attending a large HIV center during the pre-HAART and HAART eras, a total of 2,004 (18%) were prescribed antidepressants. . . . A total of 1,607 (15%) individuals were diagnosed with cancer. There were no significant associations between any class of antidepressant and any type of cancer . . . , in either the pre-HAART or HAART era" (p. 2305). Stebbing and colleagues conclude that "antidepressants, irrespective of their class, do not affect cancer risk in HIV-infected individuals" (p. 2305).
Neuropsychological Impairment
In a racially diverse sample of 93 children living with HIV, Hochhauser, Gaur, Marone, and Lewis (2008) "examined the impact of environmental risk factors on the cognitive decline normally observed with pediatric HIV disease progression" (p. 695). The investigators found that "immunosuppression was clearly associated with poorer cognitive outcome in the high-risk children" (p. 695); in other words, there was greater risk for HIV-associated cognitive decline among children living in highly stressful environments. Notably, "this relationship was not seen in those with lower levels of environmental risk" (p. 695). These findings have several implications, according to Hochhauser and colleagues:
First, while medication adherence has been shown to be worse in stressed or disorganized families . . . , it may also be most crucial for those children, as it is they whose neuropsychological functioning is at greatest risk from HIV neurotoxicity. Second, reducing environmental stressors may prove to be neuroprotective. This may be particularly important for patients for whom reducing immunosuppression . . . may be difficult or impossible. In these cases, perhaps their impact on cognitive functioning could be moderated by taking measures to reduce stress. Such interventions might include concrete actions to improve the child's home or family environment . . . or perhaps stress-reduction interventions like psychotherapy or massage therapy. (p. 696)
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Adherence to Treatment
Leserman, Ironson, O'Cleirigh, Fordiani, and Balbin (2008) "examine[d] demographic, health behavior and psychosocial correlates (e.g., stressful life events, depressive symptoms) of nonadherence" (p. 403) among 105 men and women residing in South Florida and taking antiretrovirals. Within this sample,
44.8% had missed a medication dose in the past 2 weeks, and 22.1% had missed their medication during the previous weekend. Those with three or more stressful life events in the previous 6 months were 2.5 to more than 3 times as likely to be nonadherent (in the past 2 weeks and previous weekend, respectively) compared to those without such events. Fully 86.7% of those with six or more stresses were nonadherent during the prior 2 weeks compared to 22.2% of those with no stressors. Although alcohol consumption, drug use, and symptoms of depression were related to nonadherence in the bivariate analyses, the effects of these predictors were reduced to nonsignificance by the stressful event measure. (p. 403)
Leserman and colleagues suggest that "having many stressful events may be a more robust correlate of nonadherence than depression. Persons who report more stressful events may have more chaotic lifestyles that may account for their missed medications. . . . These findings suggest that while interventions for depression may be useful, cognitive behavioral interventions that address stress and coping may have a greater impact on adherence to HIV medication" (p. 409).
Malta, Strathdee, Magnanini, and Bastos (2008) conducted a "systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU[s]) and identif[ied] . . . factors associated with non-adherence to HIV treatment" (p. 1242). The investigators selected 41 peer-reviewed studies published between 1996 and 2007; these studies included
a total of 15,194 patients, the majority of whom were HIV-positive DU[s] (n = 11,628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e., Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g.[,] directly observed therapy) and/or drug addiction treatment (especially substitution therapy). (p. 1242)
Malta and colleagues conclude that, although HAART adherence was lower among DUs "than other populations – especially among users of stimulants, incarcerated DU[s,] and patients with psychiatric comorbidities – adherence to HAART among HIV-positive DU[s] can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support" (p. 1242). Moreover, "most papers [included in this review] suggest that the adherence to HAART among HIV-positive [DU]s can be similar to those found among other [people living with HIV/AIDS], once proper timing to initiate treatment is followed, comorbidities are properly managed and treated, psychosocial support is provided, and drug treatment, particularly substitution therapy, is instituted" (p. 1253).
Stress Management
In a departure from the traditional cognitive-behavioral approach to HIV-related stress management (research about which is coincidently and conveniently summarized in the Tool Box in the Summer 2008 issue of mental health AIDS), McCain et al. (2008) conducted a "randomized clinical trial . . . to test effects of three 10-week stress management approaches – cognitive-behavioral relaxation training (RLXN), 4 focused tai chi training (TCHI), 5 and spiritual growth groups (SPRT) 6 – in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection" (p. 431). According to the investigators, the "purpose of the research was to determine whether the three 10-week stress management interventions would improve and sustain improvements 6 months later in the domains of psychosocial functioning, quality of life, and physical health among persons with varying stages of HIV infection. These three outcome domains, along with neuroendocrine and immune mediating variables, were measured by multiple indicators derived from the psychoneuroimmunology (PNI) paradigm" (p. 431). "Interventions were conducted with groups of 6-10 participants who met in suitably equipped conference rooms in an office setting for 90-min sessions weekly for 10 weeks. Participants who attended less than 8 of the 10 intervention sessions were deemed as having incomplete treatments and classified as withdrawn from the study" (p. 433).
McCain and colleagues found that, "in comparison to the CTRL group, both the RLXN and TCHI groups less frequently used emotion-focused coping strategies, and all three intervention groups had higher lymphocyte proliferative function. Generally, decreased emotion-focused coping can be considered an enhancement in coping strategies; however, there was no concurrent increase in problem-focused or appraisal-focused coping, making interpretation of this change more tenuous" (p. 437). Similarly, "the consistent finding of increased lymphocyte proliferation indicates the interventions were associated with enhancement in immune system functional status. . . . However, because there was no significant change in salivary cortisol, the mechanism of increased lymphocyte function is not clear. Ongoing assessment of cytokine activity or patterns of production may ultimately yield insight into other mechanisms involved in immune function changes" (pp. 437-438).
Despite these challenges in interpreting the study findings, McCain and colleagues contend that, in general,
study findings support use of the PNI-based model for stress management in individuals living with HIV infection. Despite modest effects of the interventions on psychosocial functioning in this sample, the robust finding of improved immune function with these stress management approaches has important clinical implications, particularly for persons with immune-mediated illnesses. . . . Findings of this study indicate that immune function and possibly coping and quality of life may be enhanced with cognitive-behavioral stress management, tai chi, and spirituality-based interventions. While further research is needed to examine specific effects of various stress management interventions and to expand the repertoire of alternative approaches that might be effective in enhancing adaptational outcomes, this study contributes to a growing body of well-designed research that generally lends support to the integration of stress management strategies into the standard care of individuals living with HIV infection. (p. 439)
Coping, Social Support, & Quality of Life
Murphy, Greenwell, Resell, Brecht, and Schuster (2008) "investigated current autonomy among early and middle adolescents affected by maternal HIV (N = 108), as well as examined longitudinally the children's responsibility taking when they were younger (age 6-11; N = 81) in response to their mother's illness and their current autonomy as early/middle adolescents" (p. 253). Within this sample of primarily low-income Latino and African American families residing in Los Angeles County, "children with greater attachment to their mothers had higher autonomy [when performing household-centered activities], and there was a trend for children who drink or use drugs alone to have lower autonomy. In analyses of management autonomy[, which encompasses activities performed outside the home], attachment to peers was associated with higher autonomy" (p. 253). In their longitudinal analysis of this cohort, Murphy and colleagues found that "those children who had taken on more responsibility for instrumental caretaking roles directly because of their mother's illness showed better autonomy development as early and middle age adolescents" (p. 253). Importantly, the investigators also found that autonomy was associated "with 'positive' characteristics such a mother-child bond and coping self-efficacy" (p. 271). Murphy and colleagues conclude that
"parentification" of young children with a mother with HIV/AIDS – that is, the young children taking on household responsibilities due to the mother's illness – may not negatively affect later autonomy development in these children. While it may indeed have other detrimental effects, such as more absence from school and school performance . . . , in at least this limited sample of children affected by HIV, higher responsibility taking as a result of maternal HIV/AIDS among young children was associated with later early/middle adolescent higher autonomy functioning. . . . Thus, even if they experienced some distress from parentification at an earlier age, it did not interfere with their long-term early and middle adolescent autonomous functioning. (p. 272)
Murphy and colleagues acknowledge that these findings require additional exploration with larger samples. Nevertheless, the investigators stress that if
HIV-positive mothers, due to their fatigue or illness, must rely on their young children at times to perform behaviors that most children their age do not typically perform, then it is critical that there be a strong focus on the mother developing or maintaining: (1) A high level of attachment and bond between herself and the child; and (2) strong support of the child to assist in the child developing strong coping self-efficacy. . . . [I]f a child does indeed have to sometimes function in a "parentified" role, then the data from this study indicate that children with a close attachment to their mother and who have good coping self-efficacy will have higher autonomy as they develop; these are both issues that can be worked on and improved in family therapy. (p. 272)
With a sample of 104 MSM averaging 50 years of age and living with HIV, Dutch investigators (Kraaij, van der Veek, et al., 2008) assessed relationships among "coping strategies, goal adjustment, and symptoms of depression and anxiety" (p. 395). The investigators found that "cognitive coping strategies had a stronger influence on well-being than . . . behavioral coping strategies: positive refocusing, positive reappraisal, putting into perspective, catastrophizing, and other-blame were all significantly related to symptoms of depression and anxiety. In addition, withdrawing effort and commitment from unattainable goals, and reengaging in alternative meaningful goals, in [the] case that preexisting goals can no longer be reached, seemed to be a fruitful way to cope with being HIV[-]positive" (p. 395). With regard to intervention, as Kraaij and colleagues see it, "the focus of treatment could be the content of thoughts and bringing about effective cognitive change, combined with working on goal adjustment. Various studies showed the positive effects of cognitive-behavioral oriented interventions . . . and coping effectiveness training . . . in improving psychological states in HIV-infected men. Future studies should be undertaken looking at the effectiveness of intervention programs focusing on cognitions and life goals" (p. 400).
In another study by this research group with the same sample of MSM (Kraaij, Garnefski, et al., 2008), the investigators found that greater
use of positive refocusing, refocus[ing] on planning, positive reappraisal, putting into perspective, and less use of other-blame, was related to higher levels of personal growth. . . . [P]ositive reappraisal appears to be the most powerful predictor of personal growth.
Another important predictor . . . was goal self-efficacy. Respondents who reported a higher belief in their ability to adjust their goals when important goals are obstructed by being HIV-positive, reported higher levels of personal growth. (p. 303)
As in the study described above (Kraajj, van der Veek, et al., 2008), Kraajj, Garnefski, and colleagues conclude that cognitive-behavioral oriented interventions and coping effectiveness training "could be offered to improve personal growth. The specific focus of treatment could be then the content of thoughts, combined with working on goal adjustment. Ingredients of treatment should be a combination of (positive) cognitive coping strategies and goal self-efficacy" (p. 303).
---- Compiled by Abraham Feingold, Psy.D.
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4 The structured RLXN training intervention "consisted of physical and mental relaxation skills training, with a focus on individualized combinations of relaxation techniques, as well as active coping strategies for stress management. Participants were expected to routinely practice relaxation techniques during and following the intervention, and daily practice frequency was recorded each week. Each participant was given a set of eight 30-min audiotapes specifically produced for use in this study" (p. 433).
5 A focused short form of TCHI "involving eight movements was developed for this study. The intervention sequence began with a focus on breathing and balance, both key elements in all tai chi exercises. The sequence of movements taught was focused on developing each individual's skills in balancing, focused breathing, gentle physical posturing and movement, and the active use of consciousness for relaxation. Training videotapes were provided to participants for weekly and ongoing practice of the techniques" (p. 434).
6 "The SPRT . . . intervention was designed to facilitate personal exploration of spirituality and to enhance exploration of the spiritual self and awareness of the meaning and expression of spirituality. Each session was designed to explore an aspect of spirituality and included the intellectual process of knowing or apprehending spirituality; the experiential component of interconnecting one's spirit with self, others, nature, God, or a higher power; and an appreciation of the multisensory experience of spirituality. The process of weekly journal entries facilitated increased awareness and the integration of spirituality into daily life" (p. 434).
