Download HIV-AIDS & Depression

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