Research offers clues on treating depression, stress
Many interventions show success
Ongoing research suggests there are many successful strategies to help people with HIV cope with depression and stress.
Clinicians and psychologists who have worked with HIV-positive patients emphasize how important it is for clinicians to screen all such patients for depression. HIV treatment should include questions about whether patients are having difficulty sleeping, a change in appetite, feelings of sadness, a loss of interest in daily activities, a depletion of normal energy level, trouble concentrating, and any thoughts of harming themselves.
Patients who appear to have mild depression could be referred to an HIV support group or a mental health professional. Those who have more severe signs of depression may be candidates for antidepressant medications.
Strategies now being used
Here is a look at some of the strategies featured in ongoing and recent research to prevent and alleviate depression and stress:
1. Accentuate the psychological factors that contribute to long-term survival with HIV. A Florida researcher has been involved in studies that offer clues to why some HIV patients remain healthier and live longer than others and how to help patients manage stress.
"We have another year to go on the study, but our preliminary results show some psychological factors related to staying healthy with HIV," says Gail Ironson, PhD, MD, professor of psychology and psychiatry at the University of Miami in Coral Gables, FL.
The psychological factors that appear to be important are these:
• The patient has a good, collaborative relationship with his or her doctor. "Often we find that the people who are doing well had changed doctors if they had a doctor they didn’t like," Ironson says. "They needed a doctor they could talk to and maybe ask, I’m using this alternative treatment. What do you think about this?’ or say, I don’t like the side effects of this medication. Can we work to find some other combination?’"
• The patient uses psychological protectors, such as optimism and staying involved. "A lot of long-term survivors have gotten involved in helping other people with HIV," Ironson says.
• The patient has good social support. "Some people will be wonderful, and others will reject you, so you have to move on to creating a support system for yourself and realize that not everyone is going to be supportive," Ironson says.
• The patient has a clear, comfortable idea of his or her spirituality. "Often patients wouldn’t find the support they needed in traditional religion," Ironson explains. "So long-term survivors, instead of rejecting religion altogether, would redefine their spirituality so they could still have comfort from some of the beliefs without feeling they were rejected by their religion."
• The patient can express emotions. This may involve a gay HIV-infected man finding another gay man to confide in and discuss what he’s going through. This also is a way for the HIV-infected person to come to terms with the illness and find some meaning in it.
Alternatively, Ironson says, the two variables that predicted faster disease progression were stressful life events and having an angry personality. People with an angry personality fared all right until they were confronted with a major stressful event, such as the death of a loved one, job loss, or loss of a relationship.
2. Focus on improving coping skills and effectiveness training. "Living with HIV disease, like living with other chronic conditions, can be really psychologically draining," says Margaret Chesney, PhD, professor of medicine at the University of California San Francisco (UCSF). "In addition to the day-to-day effort that’s required to maintain and take medications and to try to maintain optimal health, you have a very stigmatized disease."
Chesney is the co-director of the Center for AIDS Prevention Studies at UCSF, and she has received federal grants to study how clinicians can help people living with HIV cope with their infection. The studies have assessed a model for coping-effectiveness training for HIV-infected people.
The program trains people, either in groups or individually, to identify what is causing them stress, whether it’s the disease itself, job troubles, family troubles, or other problems. Then they identify what can be changed to reduce the stress.
The intervention is based on a model that compares maladaptive coping strategies with adaptive ones. Maladaptive strategies include using emotion-focused coping in situations that can be changed and problem-solving solutions in situations that cannot.1
"There are a lot of things about life we can’t change right now," Chesney says. "But what we can do is teach people how to manage their moods when they’re confronted with something they can’t do anything about."
Adaptive strategies include using emotion-focused coping — such as cognitive restructuring, relaxation, and humor — when confronted with a stressful situation that cannot be changed and using problem-focused coping — such as problem-solving, social/communication skills, and negotiation — when confronted with a situation that can be changed.1
"We tell people, Take a break from having HIV. This weekend, go have fun. Remember your medicines, but let’s not think about or talk about HIV until Monday,’" Chesney offers as one adaptive coping strategy.
The coping effectiveness training study found that this type of program results in less psychological distress, improved coping, and better mood among HIV-infected men.1 "Our intervention did reduce depression, and it reduced burnout, which is a combination of anger and exhaustion," Chesney says.
Ongoing research is evaluating how to help HIV patients maintain positive coping strategies over time. Investigators also are adding focus-on-the-positive enhancements to the training, Chesney says. "Our patients said, You never talk about any of the positive things in our lives,’" she explains. "’HIV has taught me to live life to the fullest, and you don’t ask anything about that.’"
That led researchers to the conclusion that people can experience stress and stressful events while finding something positive to focus on. For instance, contracting HIV is a stressful negative event, but if a person can find meaning in his or her life because of the illness, then it becomes something positive, as well.
3. Include a psychosocial component in HIV medical treatment. "Clinicians have to be very astute and mindful of the high likelihood of depression and anxiety disorders," says Jerry Durham, PhD, RN, FAAN, dean and professor in the Barns College of Nursing at the University of Missouri in St. Louis. "If it comes to the point of becoming clinical depression, then the clinician needs to evaluate the individual for medical interventions, talk therapy, or some kind of therapy that the individual can participate in."
A variety of therapies will work, including group therapy, couples therapy, relaxation therapies, and self-managed therapies in which people are trained to handle their own psychological needs.
The chief difference between people who experience depression and have HIV and people who experience depression and have some other chronic illness is the availability of a support network.
Most people who suffer from a chronic condition are able to find community, religious, or family support fairly routinely. Even if the person suffers from a rare chronic condition and there are no support groups in the person’s immediate area, it’s possible that person could talk to a stranger on an airplane about the disease without fear of social repercussions.
Still fighting prejudice
This is less likely to be true of HIV. While HIV-infected patients often can find support groups consisting of other people with the disease, they often are stigmatized by their church, community, and even family. Although more people have become compassionate about HIV in the past decade, it’s still common for HIV-infected individuals to be rejected when their HIV status is made public. Discrimination and religious condemnation also continue across the United States.
"One has to be very careful with whom one shares information," Durham says. "There’s a higher burden among people with HIV, and, in some cases, they blame themselves for their condition, which is part of their guilt and depression, as well."
That’s why it’s important for clinicians to encourage HIV patients to share their troubles with an intimate friend or group of people who will not judge and can understand what they are going through, he adds.
"For many people, it’s important to find support from family, friends, or support groups," Chesney says. "People with HIV need to look at themselves and say, I’m carrying a heavy load, and I need someone to help me carry this."
Reference
1. Chesney M, Folkman S, Chambers D. Coping effectiveness training for men living with HIV: Preliminary findings. Int J STD & AIDS 1996; 7(Suppl 2):75-82.
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