Cognitive-behavioral stress management reduces distress and 24-hour urinary free cortisol output among symptomatic HIV-infected gay men

Efficacy of psychosocial interventions to reduce affective symptoms in sexual and gender minorities: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals are more likely than cisgender heterosexuals to experience mental, physical, and sexual health issues. A promising contemporary strategy to address the issue of affective symptoms in sexual and gender minorities (SGM) is psychosocial intervention.

OBJECTIVE

To systematically evaluate the effect of psychosocial interventions on the improvement of affective symptoms in SGM, and to provide a reference for the implementation of effective psychological interventions for SGM with affective symptoms.

METHODS

Between the date of database construction until December 10, 2022, a computerized search of the English-language literature published both nationally and worldwide was done. 8 literature databases and 3 additional gray databases were searched. We gathered randomized controlled trials that used psychological interventions for SGM. To evaluate risk bias in included papers in accordance with Cochrane cooperation criteria, we used Review Manager 5.4 software. In conjunction with post-test and follow-up data, mean differences were standardized using Stata 12.0 software. Subgroup analysis was used to investigate the cause of heterogeneity. The study was conducted strictly in accordance with PRISMA guidelines, and it was registered on the PROSPERO platform (CRD42023408610).

RESULTS

This review covered 18 research, and 14 studies were included in the meta-analysis. A total of 1194 study cases, including 706 cases from the control group and 488 cases from the experimental group, were included in these investigations. Compared to the control group, the psychosocial intervention group had significantly lower levels of depression (standardized mean difference (SMD) = -0.17;95% CI = [-0.30, -0.04]; p = 0.012) and anxiety (SMD = -0.22; 95% CI = [-0.41, -0.04]; p = 0.01), but no significant differences were found for distress (SMD = -0.19; 95% CI = [-0.45,0.07]; p = 0.021).

CONCLUSION

According to this study, psychosocial interventions helped lessen the symptoms of depression and anxiety in SGM but had no significant effect on their psychological distress. To assess the impact of psychological intervention on SGM, more randomized controlled trials with larger sample sizes and numerous follow-up times should be done.

The impact of a stress management intervention including cultural components on stress biomarker levels and mental health indicators among indigenous women

We examined the effectiveness of a 26-week culture-inclusive intervention on reducing salivary stress biomarker levels, and perceived stress, depressive, and post-traumatic stress disorder (PTSD) symptoms measured using scales in 53 Indigenous women in Ontario, Canada. Statistical analyses compared the average biomarker levels, and the area under the curve (AUC) of biomarkers. Differences in biomarkers and mental health scale scores pre- and post-intervention were compared using mixed models with a random intercept. Interaction terms were included between the intervention and age, education, disability, and HIV status, individually, to test for sub-group differences. Cortisol AUC post-intervention was decreased compared to pre-intervention (β -1.29 µg/dL; 95%CI -2.35, -0.23). There was a slight decrease in perceived stress levels (aOR: -2.80; 95%CI -5.09, -0.50). The associations were stronger among women of younger age, higher education, and no disabilities. These interventions can be effective, but future interventions should target Indigenous population sub-groups to address individual needs.

Sexual Orientation Change Efforts Do Not Increase Suicide: Correcting a False Research Narrative

Sexual orientation change efforts (SOCEs) signify activities designed to change or reduce homosexual orientation. Recent studies have claimed that such therapies increase suicide risk by showing positive associations between SOCE and lifetime suicidality, without excluding behavior that pre-dated SOCE. In this way, Blosnich et al.'s (2020) recent analysis of a national probability sample of 1518 sexual minority persons concluded that SOCE "may compound or create…suicidal ideation and suicide attempts" but after correcting for pre-existing suicidality, SOCE was not positively associated with any form of suicidality. For suicidal ideation, Blosnich et al. reported an adjusted odds ratio (AOR) of 1.92 (95% CI 1.01-3.64); the corrected AOR was .44 (.20-.94). For suicide planning, Blosnich et al.'s AOR was 1.75 (1.01-3.06); corrected was .60 (.32-1.14). For suicide attempts, Blosnich et al.'s AOR was 1.75 (.99-3.08); corrected was .74 (.36-1.43). Undergoing SOCE after expressing suicidal behavior reduced subsequent suicide attempts from 72 to 80%, compared to those not undergoing SOCE, when SOCE followed a prior expression of suicidal ideation (AOR .17, .05-.55), planning (AOR .13, .04-.45) or intention (AOR .10, .03-.30); however, SOCE following an initial suicide attempt did not significantly reduce further attempts. By violating the principle that a cause cannot occur after an effect, Blosnich et al. misstated the correct conclusion. Experiencing SOCE does not result in higher suicidality, as they claim, and may sharply reduce subsequent suicide attempts. Restrictions on SOCE will not reduce suicidal risk among sexual minorities and may deprive them of an important resource for reducing suicide attempts.

Assessing population-level stress through glucocorticoid hormone monitoring in wastewater

Stress is oftentimes overlooked in societies, despite its life-threatening impact. Here, we assessed the feasibility of measuring endogenous stress hormones to estimate population-level stress by wastewater-based epidemiology (WBE). Two primary glucocorticoids, cortisol and cortisone, were monitored in wastewater by liquid chromatography tandem mass spectrometry (LC-MS/MS), to assess changes in these physiological markers of stress in a student population (n = 26,000 ± 7100) on a university campus in the southwestern U.S. Daily composite samples were collected for seven consecutive days each month during the Fall (Autumn) 2017 and Spring 2018 academic semesters (n = 134). Reproducible weekly patterns were seen in stress hormone excretion, with the highest levels occurring on Mondays (124 ± 44 μg d^-1 per person) and Tuesdays (127 ± 54 μg d^-1 per person) and the lowest on Sundays (87 ± 32 μg d^-1 per person). Stress levels on weekdays (defined by class schedules Monday-Thursday) were significantly higher than on weekends (p < 0.05). During both Fall and Spring semesters, per person stress levels of these hormones were significantly higher (p < 0.05) during the first two months of each semester, 162 ± 28 μg d^-1 per person (August), 104 ± 29 μg d^-1 per person (September), 180 ± 14 μg d^-1 per person (January), and 114 ± 54 μg d^-1 per person (February) than in the remaining measured weeks in the semester, including finals week captured in both semesters. Overall Spring semester stress levels (113 ± 45 μg d^-1 per person) were significantly higher than the Fall (94 ± 42 μg d^-1 per person), p < 0.01. This study is the first to demonstrate the utility of endogenous biomarkers, specifically glucocorticoid hormones, to monitor population health status (in this instance community stress) in near real-time by wastewater assessments.

AWARENESS: A cognitive behavioral intervention to reduce intersectional minority stress among sexual minority men living with HIV who use substances

Introduction:

The minority stress model is the primary explanatory model for disparities in substance use and other mental health problems among sexual minority men (SMM) compared to heterosexual men. This pilot randomized controlled trial tested the feasibility of AWARENESS, a novel 9-session cognitive-behavioral psychotherapeutic intervention that targets intersectional minority stress and stigma, among sexual minority men living with HIV who use substances.

Methods:

Feasibility was determined by the number of participants screened to obtain the target sample size, the percentage of eligible participants randomized, percentage of study intervention and assessment visits attended, time to complete study procedures, and percentage of data completeness of intervention assessments. Forty-two sexual minority men living with HIV with any illicit substance use or who reported at least one occasion of consuming five or more drinks in one setting in the last three months were randomized to AWARENESS (n = 22) or an attention control condition (n = 20).

Results:

Feasibility of the trial was supported, with adequate completion of study procedures and visits (73% completed all intervention sessions, 71% completed all study assessment sessions). This trial also demonstrated the feasibility of using AWARENESS skills and strategies in relation to multiple intersecting identities, with participants discussing an average of 5.7 identities (e.g., sexual orientation) or individual characteristics (e.g., socioeconomic status) in relation to intervention content.

Conclusion:

Our results support the feasibility of an AWARENESS trial to reduce intersectional minority stress related to multiple identities and characteristics among sexual minority men living with HIV who use substances

Systematic review of sex differences in the relationship between hormones and depression in HIV

BACKGROUND

Major depressive disorder is the most common neuropsychiatric comorbidity of human immunodeficiency virus (HIV), and women are more frequently affected in the general population and among those with HIV. The rate of depression in HIV is three times higher than the general population. Differences in biomarkers in neuroendocrine and inflammatory pathways are one possible explanation for the increased prevalence of depression in individuals with HIV, especially biological women. Therefore, we aimed to perform a systematic review identifying differences in neuroendocrine factors leading to depression in men versus women with HIV.

METHODS

A comprehensive search of 8 databases was performed, followed by title and abstract screening and later full-text screening by two independent researchers. A risk of bias assessment was completed.

RESULTS

Twenty-six full-text articles were included in the review. Significant correlations between depression and neuroendocrine marker levels were found for cortisol (both sexes), testosterone (only in men), oxytocin (only tested in women), and estradiol (only in women). No significant correlation between depression and hormone level was found for prolactin, dehydroepiandrosterone (DHEAS), or sex hormone binding globulin (SHBG). Nearly all studies included only men or women and did not directly compare neuroendocrine markers between the two sexes. One study found that the correlation between cortisol levels and depression scores was stronger in women than men.

CONCLUSION

Neuroendocrine systems are highly active in the brain and important in the development and persistence of mental illness. Given that HIV can, directly and indirectly, impact hormone signaling, it is likely contributing to the high rate of depression in individuals with HIV. However, few studies explore neuroactive hormones in depression and HIV, nor how this connection may differ between the sexes. More high-quality research is needed in this area to explore the link further and inform possible avenues of treatment.

Propensity score matching evaluation of psychological stress and hair cortisol among people living with HIV in China

To compare the psychological stress level and hair cortisol level of people living with HIV (PLWH) with those without HIV in China, a total of 220 participants were initially enrolled in the study, including 200 PLWH and 20 people living without HIV. Psychological stress level, including quality of life, anxiety, perceived stress and psychological resilience, was self-reported in both groups with related scales. The cortisol in hair was extracted and assessed by LC-APCI-MS/MS method. Propensity score matching analysis was performed to balance the baseline covariates of the two groups, whereas the difference in psychological stress level and hair cortisol level between the two groups was compared. Furthermore, the associations between psychological stress level and cortisol level were examined. Two comparison groups were matched by 1:3 propensity score matching, which yielding 20 people living without HIV and 60 PLWH. Ultimately, in regarding to the psychological stress, the levels of the anxiety (34 vs. 26, p < 0.001), perceived stress (38.5 vs. 33, p = 0.001) and psychological resilience (31 vs. 26, p = 0.004) were higher among PLWH than those living without HIV, but the people without HIV showed higher quality of life (109 vs.116, p < 0. 001). The hair cortisol level (34.66 vs. 21.61, p = 0.002) in PLWH was higher than those living without HIV. However, there were no significant associations between psychological stress level and cortisol level (p > 0.05). The PLWH showed higher level of psychological stress and cortisol than those without HIV. No relationship was seen between psychological stress level and cortisol level in PLWH.

Associations Among Trajectories of Sleep Disturbance, Depressive Symptomology and 24-Hour Urinary Cortisol in HIV+ Women Following a Stress Management Intervention

Objective: The burden of sleep disturbance and depressive symptomology is high for persons living with HIV and particularly so for women. While cognitive behavioral stress management (CBSM) is shown to reduce symptoms of depression and 24-hr urinary free cortisol output (CORT) in HIV+ men, less is known about the effects of CBSM on mood and concomitant sleep disturbance in HIV+ women. The study aim is to model longitudinal change in sleep disturbance, depressive symptomology, and CORT for HIV+ women exposed to a 12-week CBSM intervention or control condition. Methods: Self-reported sleep quality and depressive symptomology, along with CORT, was collected from surveys at baseline and approximately every three months thereafter for nine months from 130 HIV+ women (M_age = 38.44, SD = 7.73). The data was used to specify a parallel process latent growth model with CORT as a time-varying covariate. Results: The model showed acceptable fit. There was a linear decline in sleep disturbance (β = -0.32, p < .05) and logarithmic decline in depressive symptomology (β = -0.33, p < .05) for those receiving the intervention. Decline in sleep disturbance predicted lower CORT at nine months. Furthermore, having less depressive symptoms at baseline was associated with lower initial levels of sleep disturbance and greater improvement in sleep quality over time. There was no discernible association between sleep and mood disturbance in the control group. Across groups, there was a consistent association between older age and greater sleep disturbance (r = 0.34, p < .01). Conclusion: Sleep disturbance appears to be a behavioral target for CBSM in HIV+ women although older age, preintervention levels of depressive mood, and time-varying levels of CORT output may limit improvement in sleep quality over time.

HIV-1 Infection, Injecting Drug Use, and Neuroendocrine Response to Psychological Stress

BACKGROUND

Previous studies have suggested that HIV-1 infection is associated with neuroendocrine abnormalities including alterations in autonomic nervous system (ANS) activity. The norepinephrine (NE) response to cold pressor stress, an α-adrenergic challenge, is blunted in HIV-1 infection. Given the relation of ANS activity to the function of the hypothalamic-pituitary-adrenal (HPA) axis and its role in cognitive functioning, changes in response to stress may be a factor in HIV-related cognitive dysfunction.

OBJECTIVE

In this study, we evaluated the NE and cortisol response of persons in three groups.

DESIGN/PARTICIPANTS

We studied stress response in three groups: (1) those with HIV-1 infection and a history of injecting drug use (IDU), those with HIV-1 infection but no IDU, and a control group of uninfected individuals without a history of IDU. Stress was induced by administering a neuropsychological test known to induce an immediate increase in NE, the Stroop Color-Word Test. Blood samples were obtained immediately before and after participants completed the Stroop and then at two intervals over the next 20 minutes. Data were analyzed using mixed-effects repeated measures models.

MAIN MEASURES

Serum norepinephrine, epinephrine, and cortisol.

RESULTS

Analyses showed that those with both HIV-1 infection and history of IDU had a significantly greater NE response to stress that did not return to baseline over 20 minutes compared to those without infection or IDU history. Epinephrine and cortisol responses followed similar patterns, but between-group differences were not statistically significant.

CONCLUSIONS

The combination of history of IDU and HIV infection may produce an exaggerated neuroendocrine response that does not quickly return to baseline levels. Given the potential impact of these on cognitive and physical function in affected these individuals, implementing stress management techniques with them may be important.

AWARENESS: Development of a cognitive-behavioral intervention to address intersectional minority stress for sexual minority men living with HIV who use substances

Sexual minority (i.e., nonheterosexual) individuals are at greater risk than heterosexual individuals for substance use and poor mental health attributed to exposure to minority stress (Meyer, 2003). Minority stress is stress that places an additional burden on sexual minority people over and above the stress experienced by heterosexual people. Sexual minority men may also be subject to minority stress related to intersecting identities or individual characteristics (e.g., HIV status, race). This study obtained initial feedback about the AWARENESS intervention from sexual minority men living with HIV who use substances and determined the feasibility of the intervention to address minority stress related to intersecting identities. AWARENESS is a 9-session cognitive-behavioral intervention targeting minority stress as a driver of greater substance use and poorer mental and physical health. Ten sexual minority men living with HIV who were episodic substance users (>1 episode of illicit drug use or binge drinking in the previous 3 months) began the intervention. Feedback on the intervention was obtained through open-ended interviews analyzed using thematic analysis and Likert scale questionnaires about experiences with the intervention. Therapists tracked identities discussed in relation to minority stress to evaluate feasibility of AWARENESS to address intersectional minority stress. Participants identified they gained cognitive-behavioral skills to cope with intersectional minority stress and described destigmatization and integration of identities. Participants discussed an average of 3.2 identity characteristics in addition to sexual minority status in relation to intervention content. This study lays the groundwork for additional testing of this intervention. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Mind-body practices for people living with HIV: a systematic scoping review

BACKGROUND

Mind-body practices are frequently used by people living with HIV to reduce symptoms and improve wellbeing. These include Tai Chi, Qigong, yoga, meditation, and all types of relaxation. Although there is substantial research on the efficacy of mind-body practices in people living with HIV, there is no summary of the available evidence on these practices. The aim of this scoping review is to map available evidence of mind-body practices in people living with HIV.

METHODS

The Arksey and O'Malley (Int J Soc Res Methodol 8:19-32, 2005) methodological framework was used. A search of 16 peer-review and grey literature databases, websites, and relevant journals (1983-2015) was conducted. To identify relevant studies, two reviewers independently applied the inclusion criteria to all abstracts or full articles. Inclusion criteria were: participants were people living with HIV; the intervention was any mind-body practice; and the study design was any research study evaluating one or several of these practices. Data extraction and risk of bias assessment were performed by one reviewer and checked by a second, as needed, using the criteria that Cochrane Collaboration recommends for systematic reviews of interventions (Higgins and Green, Cochrane handbook for systematic reviews of intervention. 2011). A tabular and narrative synthesis was carried out for each mind-body practice.

RESULTS

One hundred thirty-six documents drawing on 84 studies met the inclusion criteria. The most widely studied mind-body practice was a combination of least three relaxation techniques (n = 20), followed in declining order by meditation (n = 17), progressive muscle relaxation (n = 10), yoga (n = 9) and hypnosis (n = 8). Slightly over half (47/84) of studies used a RCT design. The interventions were mainly (46/84) conducted in groups and most (51/84) included daily individual home practice. All but two studies were unblinded to participants.

CONCLUSION

The amount of available research on mind-body practices varies by practice. Almost half of the studies in this review were at high risk of bias. However, mindfulness, a combination of least three relaxation techniques and cognitive behavioral strategies, and yoga show encouraging results in decreasing physical and psychological symptoms and improving quality of life and health in people living with HIV. More rigorous studies are necessary to confirm the results of Tai Chi, Qigong, and some relaxation techniques.

Cortisol levels before and after cognitive behavioural therapy in patients with eating disorders reporting childhood abuse: A follow-up study

The etiopathogenesis of eating disorders (EDs) is complex and still not well understood. Biological, psychological and environmental factors (e.g. childhood abuse) have all been considered to be involved in the onset and the persistence of EDs. The hypothalamic-pituitary-adrenal (HPA) axis is a relevant biological factor capable of influencing the onset and the course of EDs and not many information are available about the impact of a Cognitive Behavioral Therapy (CBT) on cortisol changes in EDs. The HPA-axis functioning has been evaluated before and after CBT in a group of patients with Anorexia Nervosa (n = 34) and Bulimia Nervosa (n = 35) according to the presence/absence of a history of sexual/physical abuse. At baseline, only patients reporting childhood abuse showed lower morning cortisol levels as compared with other patients of the same diagnostic group and Healthy Controls. After CBT, a variation of cortisol levels has been found only in patients without abuse, suggesting a role of childhood adversities in the persistence of HPA-axis alterations in Eating Disorders.

Effects of liver depression and psychological stress on human uterine leiomyoma cells by an AR-cAMP-PKA signal transduction pathway

OBJECTIVE

Based on the emotional theory of Traditional Chinese Medicine, and combined with the modern medicine theory of psychological stress, a research model of human uterine leiomyoma cells (ULM) was cultured in vitro to determine the effectiveness of adrenergic receptor (AR) agonists in human ULM cell growth. In addition, we studied the functional influence of "liver depression and psychological stress theory" on fibroid formation by intervening in the AR-cAMP-PKA signaling pathway. The intention was to establish a new method to prevent and cure fibroids through "liver depression and psychological stress theory" and provide an experimental basis for the Traditional Chinese Medicine emotional theory.

MATERIALS AND METHODS

Primary human ULM cells were enriched by collagenase digestion. Immunohistochemistry and hematoxylin and eosin (HE) staining were used for cytological identification. Using this model, we studied intervention using specific AR agonists on ULM cells to observe the influence of "liver depression and psychological stress theory" on estrogen receptor (ER), progesterone receptor (PR), vascular endothelial growth factor (VEGF) and fibroblast growth factors (FGF).

RESULTS

Norepinephrine (NE) and epinephrine (E) are adrenergic receptor agonists. They promoted ULM cell proliferation and increased the levels of ER, PR, VEGF and FGF. In contrast, isoproterenol (ISO) inhibited ULM cell proliferation and decreased the levels of ER, PR, VEGF and FGF. The protein expression of cAMP and PKA in ULM cells was reduced and the levels of ER, PR, VEGF and FGF were increased when co-treatment with the α-AR blocker (phentolamine). The β-AR blocker (metoprolol) displayed an opposite effect.

CONCLUSIONS

AR agonists modulated ER, PR, VEGF and FGF levels in ULM cells in an AR-cAMP-PKA-dependent signaling pathways to influence fibroid occurrence and development.

Psychological Distress Mediates the Effect of Alexithymia on 2-Year Change in HIV Viral Load

PURPOSE

Individuals with trait alexithymia (AL) display poor cognitive assimilation of thoughts, feelings, and emotions. This may result in the persistence of stress, anxiety, and depressive disorders. The cumulative effect of this psychological distress is also linked clinical markers of human immunodeficiency virus (HIV) disease progression. This study examines the indirect effect of AL on HIV viral load as a function of baseline levels and change in psychological distress.

METHODS

N = 123 HIV positive adults aged 37.9 ± 9.2 years provided blood samples for HIV-1 viral RNA and CD4 T lymphocytes along with self-reported stress, anxiety, and depression every 6 months for 2 years. A second-order conditional latent growth model was used to represent baseline and 2-year change in cumulative levels of psychological distress and to test the indirect effect of baseline levels of trait AL on change in HIV-1 viral load through this latent measure.

RESULTS

AL was associated with baseline and latent change in psychological distress. Furthermore, baseline psychological distress predicted 2-year change in HIV-1 viral RNA after controlling for viral load at baseline. Altogether, trait AL had a significant indirect effect on change in viral load (β = 0.16, p = 0.03) as a function of baseline levels of distress.

CONCLUSION

Identification and communication of thoughts, feelings, and emotions are important for long-term psychological adaptation in HIV. Greater psychological distress, in turn, allows for persistence of peripheral viral replication.

The influence of marital status on the stage at diagnosis, treatment, and survival of adult patients with gastric cancer: a population-based study

Background & Aims

Marital status was reported as a prognostic factor in many cancers. However, its role in gastric cancer (GC) hasn't been thoroughly explored. In this study, we aimed to investigate the effect of marital status on survival, stage, treatment, and survival in subgroups.

Methods

We used the Surveillance, Epidemiology and End Results (SEER) database and identified 16910 GC patients. These patients were categorized into married (58.44%) and unmarred (41.56%) groups. Pearson chi-square, Wilcoxon-Mann-Whitney, Log-rank, multivariate Cox regression, univariate and multivariate binomial or multinomial logistic regression analysis were used in our analysis. Subgroup analyses of married versus unmarried patients were summarized in a forest plot.

Results

Married patients had better 5-year overall survival (OS) (32.09% VS 24.61%, P<0.001) and 5-year cancer-caused special survival (CSS) (37.74% VS 32.79%, P<0.001) than unmarried ones. Then we studied several underlying mechanisms. Firstly, married patients weren't in earlier stage at diagnosis (P=0.159). Secondly, married patients were more likely to receive surgery (P < 0.001) or radiotherapy (P < 0.001) compared with the unmarried. Thirdly, in subgroup analyses, married patients still had survival advantage in subgroups with stage II-IV and no radiotherapy.

Conclusions

These results showed that marital status was an independently prognostic factor for both OS and CSS in GC patients. Undertreatment and lack of social support in unmarried patients were potential explanations. With the knowledge of heterogeneous effects of marriage in subgroups, we can target unmarried patients with better social support, especially who are diagnosed at late stage and undergo no treatment.

Developmental psychoneuroendocrine and psychoneuroimmune pathways from childhood adversity to disease

Childhood adversity has been repeatedly and robustly linked to physical and mental illness across the lifespan. Yet, the biological pathways through which this occurs remain unclear. Functioning of the inflammatory arm of the immune system and the hypothalamic-pituitary-adrenal (HPA)-axis are both hypothesized pathways through which childhood adversity leads to disease. This review provides a novel developmental framework for examining the role of adversity type and timing in inflammatory and HPA-axis functioning. In particular, we identify elements of childhood adversity that are salient to the developing organism: physical threat, disrupted caregiving, and unpredictable environmental conditions. We propose that existing, well-characterized animal models may be useful in differentiating the effects of these adversity elements and review both the animal and human literature that supports these ideas. To support these hypotheses, we also provide a detailed description of the development and structure of both the HPA-axis and the inflammatory arm of the immune system, as well as recent methodological advances in their measurement. Recommendations for future basic, developmental, translational, and clinical research are discussed.

Marital status and survival of patients with oral cavity squamous cell carcinoma: a population-based study

BACKGROUND

The relationship between marital status and oral cavity squamous cell carcinoma (OCSCC) survival has not been explored. The objective of our study was to evaluate the impact of marital status on OCSCC survival and investigate the potential mechanisms.

RESULTS

Married patients had better 5-year cancer-specific survival (CSS) (66.7% vs 54.9%) and 5-year overall survival (OS) (56.0% vs 41.1%). In multivariate Cox regression models, unmarried patients also showed higher mortality risk for both CSS (Hazard Ratio [HR]: 1.260, 95% confidence interval (CI): 1.187-1.339, P < 0.001) and OS (HR: 1.328, 95% CI: 1.266-1.392, P < 0.001). Multivariate logistic regression showed married patients were more likely to be diagnosed at earlier stage (P < 0.001) and receive surgery (P < 0.001). Married patients still demonstrated better prognosis in the 1:1 matched group analysis (CSS: 62.9% vs 60.8%, OS: 52.3% vs 46.5%).

MATERIALS AND METHODS

11022 eligible OCSCC patients were identified from Surveillance, Epidemiology, and End Results (SEER) database, including 5902 married and 5120 unmarried individuals. Kaplan-Meier analysis, Log-rank test and Cox proportional hazards regression model were used to analyze survival and mortality risk. Influence of marital status on stage, age at diagnosis and selection of treatment was determined by binomial and multinomial logistic regression. Propensity score matching method was adopted to perform a 1:1 matched cohort.

CONCLUSIONS

Marriage has an independently protective effect on OCSCC survival. Earlier diagnosis and more sufficient treatment are possible explanations. Besides, even after 1:1 matching, survival advantage of married group still exists, indicating that spousal support from other aspects may also play an important role.

Change in urinary cortisol excretion mediates the effect of angry/hostile mood on 9 month diastolic blood pressure in HIV+ adults

Cardiovascular disease is a growing concern in HIV disease management and nearly 1 out of 3 persons living with the virus is hypertensive. Biobehavioral factors such as anger, hostility, and HPA axis reactivity are emperically linked to blood pressure regulation. Whether HPA axis or mood disturbance increases risk for hypertension remains unclear in HIV disease. The aim of this study was to determine whether 9-month change in angry/hostile mood predicts alterations in systolic (SBP) or diastolic blood pressure (DBP), and whether this change is mediated by 24-h urinary cortisol (CORT) output. Sixty-one HIV positive adults, aged 41.1 ± 8.6 years, assigned to the control condition of a stress management intervention provided blood samples, 24-h urine specimens, blood pressure in-office, and self-reported mood at baseline and a 9-month follow-up. CORT was tested as a mediator in two separate models controlling for baseline BP, CD4 count, HIV-1 viral load, protease inhibitor use, body mass index, smoking status, and family history of cardiometabolic disease. Increase in angry/hostile mood was associated with greater SBP (β = 0.33, CI 0.09, 0.56, p = 0.01) and DBP (β = 0.39, CI 0.16, 0.62, p < 0.001) at follow-up. CORT partially mediated the effect of angry/hostile mood on DBP (β = 0.28, CI 0.03, 0.54, p = 0.03). Change in CORT was not related to SBP (β = 0.12, CI -0.20, 0.44, p = 0.46). The final mediation model accounted for 41.2% of the variance in 9-month DBP. Angry or hostile mood may contribute to increased risk for hypertension in persons treated for HIV via disturbance of the HPA-axis.

Chronic distress and the vulnerable host: a new target for HIV treatment and prevention?

Pathologic stress (distress) disturbs immune, cardiovascular, metabolic, and behavioral homeostasis. Individuals living with HIV and those at risk are vulnerable to stress disorders. Corticotropin-releasing hormone (CRH) is critical in neuroendocrine immune regulation. CRH, a neuropeptide, is distributed in the central and peripheral nervous systems and acts principally on CRH receptor type 1 (CRHR1). CRH in the brain modulates neuropsychiatric disorders. CRH and stress modulation of immunity is two-pronged; there is a direct action on hypothalamic-pituitary-adrenal secretion of glucocorticoids and through immune organ sympathetic innervation. CRH is a central and systemic proinflammatory cytokine. Glucocorticoids and their receptors have gene regulatory actions on viral replication and cause central and systemic immune suppression. CRH and stress activation contributes to central nervous system (CNS) viral entry important in HIV-associated neurocognitive disorders and HIV-associated dementia. CNS CRH overproduction short-circuits reward, executive, and emotional control, leading to addiction, cognitive impairment, and psychiatric comorbidity. CRHR1 is an important therapeutic target for medication development. CRHR1 antagonist clinical trials have focused on psychiatric disorders with little attention paid to neuroendocrine immune disorders. Studies of those with HIV and those at risk show that concurrent stress-related disorders contribute to higher morbidity and mortality; stress-related conditions, addiction, immune dysfunction, and comorbid psychiatric illness all increase HIV transmission. Neuropsychiatric disease, chronic inflammation, and substance abuse are endemic, and chronic distress is a pathologic factor. It is being understood that stress and CRH are fundamental to neuroendocrine immunity; therapeutic interventions with existing and novel agents hold promise for restoring homeostasis, reducing morbidity and mortality for those with HIV and possibly reducing future disease transmission.

Effects of Quality of Life and Coping on Depression among Adults Living with HIV/AIDS

This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS ( N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.

Untangling the Gordian knot of HIV, stress, and cognitive impairment

As individuals live longer with HIV, this "graying of the HIV epidemic" has introduced a new set of challenges including a growing number of age and inflammation-related diseases such as cardiovascular disease, type II diabetes, cancer, and dementia. The biological underpinnings of these complex and co-morbid diseases are not fully understood and become very difficult to disentangle in the context of HIV and aging. In the current review we examine the contributions and interactions of HIV, stress, and cognitive impairment and query the extent to which inflammation is the linchpin in these dynamic interactions. Given the inter-relatedness of stress, inflammatory mechanisms, HIV, and cognitive impairment, future work will either need to address multiple dimensions simultaneously or embrace the philosophy that breaking the aberrant cycle at any one point will subsequently remedy the other related systems and processes. Such a single-point intervention may be effective in early disease states, but after perpetuation of an aberrant cycle, adaptations in an attempt to internally resolve the issue will likely lead to the need for multifaceted interventions. Acknowledging that HIV, inflammation, and stress may interact with one another and collectively impact cognitive ability is an important step in fully understanding an individual's complete clinical picture and moving towards personalized medicine.

Sexual Risk Behaviors in the Adolescent Offspring of Parents with Bipolar Disorder: Prospective Associations with Parents' Personality and Externalizing Behavior in Childhood

We recently reported that adolescent and young adult offspring of parents with bipolar disorder (OBD), relative to control offspring, were more likely to engage in sexual risk behaviors (SRBs). The present prospective study aimed to determine the contribution of parents' personality and offspring behaviour problems in middle childhood to offspring SRBs 10 years later. We hypothesized that offspring externalizing problems in childhood would mediate the relationship between parents' personality traits of neuroticism and agreeableness and adolescent SRBs. Furthermore, we expected these associations to be more robust among the OBD than controls. At baseline, 102 offspring (52 OBD and 50 controls) aged between 4 and 14 years were assessed along with their parents, who completed a self-report personality measure and child behavior rating. Behaviour ratings were also obtained from the children's teachers. Ten years later the offspring completed an interview assessing SRBs. Mediation analyses using bootstrapping revealed that, after controlling for age and presence of an affective disorder, externalizing behaviors served as a pathway through which high parental neuroticism, low parental agreeableness, and low parental extraversion were related to SRBs in offspring. Moderated mediation analyses revealed that the relationship between parental neuroticism and childhood externalizing problems was stronger for OBD than controls. These findings add to our previous results showing parents' personality contributes to intergenerational risk transfer through behavioral problems in middle childhood. These results carry implications for optimal timing of preventative interventions in the OBD.

Stress management reduces intraindividual cortisol variability, while not impacting other measures of cortisol rhythm, in a group of women at risk for breast cancer

OBJECTIVE

The stress hormone cortisol exhibits a diurnal rhythm throughout the day, as well as within person variability. Recent statistical approaches allow for the estimation of intraindividual cortisol variability ("ICV") and a greater ICV has been observed in some mood disorders (major depression, remitted bipolar disorder); however, ICV has not been examined following stress management. In this secondary analyses of an efficacious randomized clinical trial, we examine how ICV may change after cognitive behavioral stress management (CBSM) among healthy stressed women at risk for breast cancer. Second, we concurrently compare other calculations of cortisol that may change following CBSM.

METHODS

Multilevel modeling (MLM) was applied to estimate ICV and to test for a group by time interaction from baseline, post-intervention, to 1 month following CBSM. Forty-four women were randomized to the CBSM; 47 to the comparison group; mean age of the entire group was 44.2 (SD=10.27).

RESULTS

After controlling for relevant covariates, a significant time by group interaction emerged (β estimate=-.070; p<.05), such that CBSM participants demonstrated a lower ICV following CBSM compared to the comparison group. The interaction for cortisol slope and cortisol output (area under the curve) approached significance (β estimates=-.10 and -.062, respectively; p's<.08), while other cortisol outcomes tested were not significantly changed following CBSM.

CONCLUSION

ICV may represent a novel index of cortisol dysregulation that is impacted by CBSM and may represent a more malleable within-person calculation than other, widely applied cortisol outcomes. Future research should examine these relationships in larger samples, and examine ICV and health outcomes.

CLINICAL TRIALS IDENTIFIER

NCT01048528.

Group Interventions for Patients with Cancer and HIV Disease: Part I: Effects on Psychosocial and Functional Outcomes at Different Phases of Illness

Group interventions for individuals facing cancer or HIV disease have drawn considerable attention among researchers and clinicians over the past 20 years. There is growing evidence that group services may be helpful, but which interventions are most effective for participants at which phases in the trajectory of disease has been less clear. Moreover, professionals working in different intervention settings (e.g., primary prevention vs. clinical care) and different disease sites (cancer vs. HIV disease) often have little awareness of relevant advances in other fields. Efforts to integrate findings in the literature may accelerate research and advance the standard of clinical care. The current article, the first in a series of four special reports, critically evaluates the efficacy of group interventions led by professional or trained facilitators for individuals confronted by cancer or HIV, across the spectrum of illness from elevated risk through advanced disease. We examine psychosocial and functional outcomes for different interventions directed toward different patient subgroups, trace common themes, highlight limitations, and offer recommendations for further research.

The ABCs of Trait Anger, Psychological Distress, and Disease Severity in HIV

BACKGROUND

Trait anger consists of affective, behavioral, and cognitive (ABC) dimensions and may increase vulnerability for interpersonal conflict, diminished social support, and greater psychological distress. The concurrent influence of anger and psychosocial dysfunction on Human Immunodeficiency Virus (HIV) disease severity is unknown.

PURPOSE

The purpose of this study was to examine plausible psychosocial avenues (e.g., coping, social support, psychological distress), whereby trait anger may indirectly influence HIV disease status.

METHODS

Three hundred seventy-seven HIV seropositive adults, aged 18-55 years (58% AIDS-defined), completed a battery of psychosocial surveys and provided a fasting blood sample for HIV-1 viral load and T lymphocyte count assay.

RESULTS

A second-order factor model confirmed higher levels of the multidimensional anger trait, which was directly associated with elevated psychological distress and avoidant coping (p<.001) and indirectly associated with greater HIV disease severity (p<.01) (comparative fit index (CFI)=0.90, root-mean-square error of approximation (RMSEA)=0.06, standardized root-mean-square residual (SRMR)=0.06).

CONCLUSION

The model supports a role for the ABC components of anger, which may negatively influence immune function through various psychosocial mechanisms; however, longitudinal study is needed to elucidate these effects.

The effect of relaxation interventions on cortisol levels in HIV-seropositive women

PURPOSE

Activation of the hypothalamic-pituitary-adrenal axis, assessed in terms of cortisol levels, may enhance the ability of HIV to infect lymphocytes and downregulate the immune system, accelerating disease progression. This study sought to determine the effects of relaxation techniques on cortisol levels in HIV-seropositive women.

METHODS

Women (n = 150) were randomized to a group cognitive-behavioral stress management (CBSM) condition or an individual information condition and underwent 3 types of relaxation training (progressive muscle relaxation, imagery, and autogenic training). Cortisol levels were obtained pre- and postrelaxation.

RESULTS

Guided imagery was effective in reducing cortisol in the group condition (t = 3.90, P < .001), and muscle relaxation reduced cortisol in the individual condition (t = 3.1 I, P = .012). Among participants in the group condition attending all sessions, the magnitude of pre- to postsession reduction became greater over time.

CONCLUSIONS

Results suggest that specific relaxation techniques may be partially responsible for cortisol decreases associated with relaxation and CBSM.

A minority stress--emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men

OBJECTIVE

Sexual compulsivity represents a significant public health concern among gay and bisexual men, given its co-occurrence with other mental health problems and HIV infection. The purpose of this study was to examine a model of sexual compulsivity based on minority stress theory and emotion regulation models of mental health among gay and bisexual men.

METHOD

Gay and bisexual men in New York City reporting at least nine past-90-day sexual partners (n = 374) completed measures of distal minority stressors (i.e., boyhood gender nonconformity and peer rejection, adulthood perceived discrimination), hypothesized proximal minority stress mediators (i.e., rejection sensitivity, internalized homonegativity), hypothesized universal mediators (i.e., emotion dysregulation, depression, and anxiety), and sexual compulsivity.

RESULTS

The hypothesized model fit the data well (RMSEA = 0.05, CFI = 0.98, TLI = 0.95, SRMR = 0.03). Distal minority stress processes (e.g., adulthood discrimination) were generally found to confer risk for both proximal minority stressors (e.g., internalized homonegativity) and emotion dysregulation. Proximal minority stressors and emotion dysregulation, in turn, generally predicted sexual compulsivity both directly and indirectly through anxiety and depression.

CONCLUSIONS

The final model suggests that gay-specific (e.g., internalized homonegativity) and universal (e.g., emotion dysregulation) processes represent potential treatment targets to attenuate the impact of minority stress on gay and bisexual men's sexual health. Tests of interventions that address these targets to treat sexual compulsivity among gay and bisexual men represent a promising future research endeavor.

Cognitive reappraisal increases neuroendocrine reactivity to acute social stress and physical pain

Cognitive reappraisal can foster emotion regulation, yet less is known about whether cognitive reappraisal alters neuroendocrine stress reactivity. Some initial evidence suggests that although long-term training in cognitive behavioral therapy techniques (which include reappraisal as a primary training component) can reduce cortisol reactivity to stress, some studies also suggest that reappraisal is associated with heightened cortisol stress reactivity. To address this mixed evidence, the present report describes two experimental studies that randomly assigned young adult volunteers to use cognitive reappraisal while undergoing laboratory stressors. Relative to the control condition, participants in the reappraisal conditions showed greater peak cortisol reactivity in response to a socially evaluative speech task (Experiment 1, N=90) and to a physical pain cold pressor task (Experiment 2, N=94). Participants in the cognitive reappraisal group also reported enhanced anticipatory psychological appraisals of self-efficacy and control in Experiment 2 and greater post-stressor self-efficacy. There were no effects of the reappraisal manipulation on positive and negative subjective affect, pain, or heart rate in either experiment. These findings suggest that although cognitive reappraisal fosters psychological perceptions of self-efficacy and control under stress, this effortful emotion regulation strategy in the short-term may increase cortisol reactivity. Discussion focuses on promising psychological mechanisms for these cognitive reappraisal effects.

Effect of combined cognitive-behavioural therapy and endurance training on cortisol and salivary alpha-amylase in panic disorder

Current data point to an alteration of both the hypothalamo-pituitary-adrenal (HPA)-system and the peripheral transmission of catecholamines in anxiety disorders. There is also some evidence for the effect of several components of cognitive-behavioural interventions such as coping and control and for an effect of exercise training on the neuroendocrine stress response in healthy subjects as well as patients suffering from distinct (mental) disorders. This double-blind, controlled study investigated the effect of cognitive-behavioural therapy (CBT) in combination with either high-level endurance training or low-level exercise on salivary cortisol (sC) and on levels of salivary alpha-amylase (sAA) in patients suffering from panic disorder (PD) with and without agoraphobia. In comparison to the low-level exercise condition, there were significantly lower sC-levels in the experimental group performing high-level endurance training at a 7-month follow-up. In contrast, there were no group differences in sAA levels during the study period. In this trial, we found evidence for a decelerated effect of endurance-training on HPA-system's functioning in PD. Further studies addressing the alteration of sAA levels in this population might investigate physical exercise different in intensity and duration.

A revised Self- and Family Management Framework

BACKGROUND

Research on self- and family management of chronic conditions has advanced over the past 6 years, but the use of simple frameworks has hampered the understanding of the complexities involved.

PURPOSE

We sought to update our previously published model with new empirical, synthetic, and theoretical work.

METHODS

We used synthesis of previous studies to update the framework.

DISCUSSION

We propose a revised framework that clarifies facilitators and barriers, processes, proximal outcomes, and distal outcomes of self- and family management and their relationships.

CONCLUSIONS

We offer the revised framework as a model that can be used in studies aimed at advancing self- and family management science. The use of the framework to guide studies would allow for the design of studies that can address more clearly how self-management interventions work and under what conditions.

Mindfulness-based stress reduction for people living with HIV/AIDS: preliminary review of intervention trial methodologies and findings

In the context of successful antiretroviral therapy (ART) for the management of HIV infection, the harmful effects of stress remain a significant threat. Stress may increase viral replication, suppress immune response, and impede adherence to ART. Stressful living conditions of poverty, facing a chronic life-threatening illness and stigma all exacerbate chronic stress in HIV-affected populations. Stress-reduction interventions are urgently needed for the comprehensive care of people living with HIV. Mindfulness-based stress reduction (MBSR) is one approach that has shown promise as an intervention for patients facing other medical conditions for reducing disease progression, psychological distress and maladaptive behaviours. In this systematic review, we identified 11 studies that have examined MBSR as an intervention for HIV-positive populations. Of the studies, six were randomised designs, one was a quasi-experimental design, and the remaining four were pre- and post-test designs. The preliminary outcomes support MBSR to decrease emotional distress with mixed evidence for impact on disease progression. Effect sizes were generally small to moderate in magnitude. The early findings from this emerging literature must be considered preliminary and support moving forward with more rigorous controlled trials, evaluated with objective assessments in longer-term follow-ups to determine the efficacy of MBSR for people living with HIV.

Cognitive-behavioural interventions for mood and anxiety disorders in HIV: a systematic review

BACKGROUND

Mood and anxiety disorders are highly prevalent and comorbid with HIV/AIDS. However, there is a paucity of research on the effectiveness of cognitive-behavioural interventions (CBI) for common mental disorders in HIV-infected adults. The present study sought to review the existing literature on the use of CBI for depression and anxiety in HIV-positive adults and to assess the effect size of these interventions.

METHODS

We did duplicate searches of databases (from inception to 17-22 May 2012). The following online databases were searched: PubMed, The Cochrane Central Register of Controlled Trials and PsychArticles.

RESULTS

We identified 20 studies suitable for inclusion. A total of 2886 participants were enroled in these studies, of which 2173 participants completed treatment. The present review of the literature suggests that CBI may be effective in the treatment of depression and anxiety in individuals living with HIV/AIDS. Significant reductions in depression and anxiety were reported in intervention studies that directly and indirectly targeted depression and/or anxiety. Effect sizes ranged from 0.02 to 1.02 for depression and 0.04 to 0.70 for anxiety.

LIMITATIONS

Some trials included an immediate postintervention assessment but no follow-up assessments of outcome. This omission makes it difficult to determine whether the intervention effects are sustainable over time.

CONCLUSION

The present review of the literature suggests that CBI may have a positive impact on the treatment of depression and anxiety in adults living with HIV/AIDS.

Randomized controlled trial of mindfulness-based stress reduction delivered to human immunodeficiency virus-positive patients in Iran: effects on CD4⁺ T lymphocyte count and medical and psychological symptoms

OBJECTIVE

To evaluate the immediate and long-term effectiveness of mindfulness-based stress reduction (MBSR) on biological and symptomatological markers of health among human immunodeficiency virus-positive (HIV+) patients in Tehran, Iran.

METHODS

Using a randomized controlled trial design, data from 173 HIV+ patients (CD4 count > 250) not yet receiving antiretroviral therapy, who participated in either an 8-week MBSR (n = 87) or a brief education and support condition (n = 86) at the Imam Khomeini Hospital, were analyzed. Assessments included CD4 count, Symptom Checklist-90-Revised (SCL-90R), and Medical Symptom Checklist (MSCL) at baseline, immediate post-treatment, and at the 3-, 6-, 9-, and 12-month follow-up periods.

RESULTS

The treatment-adherent sample had a mean (standard deviation) age of 35.1 (6.5) years and 69% were male. Linear mixed-model estimates indicated that, in the MBSR condition, the mean CD4 count increased from baseline up to 9 months after treatment and then returned to baseline level at 12 months. Improvements in mean SCL-90R (up to 6 months) and MSCL (up to 12 months) scores were observed for the MBSR condition, whereas education and support condition scores remained the same over time; however, only MSCL improvements significantly differed between groups and these changes lasted up to the final assessment.

CONCLUSIONS

Findings suggest that among treatment-adherent Iranian HIV+ patients not yet receiving antiretroviral drug treatment, MBSR seems to have the strongest potential to improve self-reported medical symptoms.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials: IRCT201106084076N2.

Anticipated stigma and quality of life among people living with chronic illnesses

OBJECTIVES

We examined the process by which anticipated stigma relates to quality of life among people living with chronic illnesses. We hypothesized that stress, social support and patient satisfaction mediate the relationships between three sources of anticipated stigma and quality of life.

METHODS

Data were collected from adults living with chronic illnesses recruited from support groups and online communities, and were analysed with path analysis.

RESULTS

Results demonstrated that stress mediated the relationships between anticipated stigma from friends and family, and work colleagues with quality of life; social support mediated the relationships between anticipated stigma from friends and family, and work colleagues with quality of life; and patient satisfaction mediated the relationship between anticipated stigma from healthcare providers with quality of life. The final path model fit the data well (χ (2) (8) = 8.66, p = 0.37; RMSEA = 0.02; CFI = 0.99; SRMR = 0.03), and accounted for 60% of the variance in participants' quality of life.

DISCUSSION

This work highlights potential points of intervention to improve quality of life. It calls attention to the importance of differentiating between sources of anticipated stigma in clinical settings, interventions and research involving people living with chronic illnesses.

Allostasis model facilitates understanding race differences in the diurnal cortisol rhythm

The concept of allostasis suggests that greater cumulative stress burden can influence stress-responsive physiology. Dysregulation of allostatic mediators, including the hypothalamic-pituitary-adrenal (HPA) axis, is thought to precede many other signs of age-related pathology as the persistent burden of stressors accumulates over the individual's life span. We predicted that even in young adulthood, HPA regulation would differ between Blacks and Whites, reflecting, in part, higher rates of stressor exposure and greater potential for stressors to "get under the skin." We examined whether stressor exposure, including experiences with racism and discrimination, explained race differences in waking cortisol and the diurnal rhythm. We also examined whether HPA functioning was associated with mental health outcomes previously linked to cortisol. Salivary cortisol was assayed in 275 young adults (127 Blacks, 148 Whites, 19 to 22 years old), four times a day across 3 days. Hierarchical linear models revealed flatter slopes for Blacks, reflecting significantly lower waking and higher bedtime cortisol levels compared to Whites. Associations of HPA functioning with stressors were typically more robust for Whites such that more stress exposure created an HPA profile that resembled that of Black young adults. For Blacks, greater stressor exposure did not further impact HPA functioning, or, when significant, was often associated with higher cortisol levels. Across both races, flatter slopes generally indicated greater HPA dysregulation and were associated with poor mental health outcomes. These differential effects were more robust for Whites. These findings support an allostatic model in which social contextual factors influence normal biorhythms, even as early as young adulthood.

HIV and depression--a systematic review of interventions

HIV-positive individuals are more likely to be diagnosed with major depressive disorder than HIV-negative individuals. Depression can precede diagnosis and be associated with risk factors for infection. The experience of illness can also exacerbate depressive episodes and depression can be a side effect to treatment. A systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review aims to provide a comprehensive understanding of evaluated interventions related to HIV and depression and provide some insight on questions of prevalence and measurement. Standard systematic research methods were used to gather quality published papers on HIV and depression. From the search, 1015 articles were generated and hand searched resulting in 90 studies meeting adequacy inclusion criteria for analysis. Of these, 67 (74.4%) were implemented in North America (the US and Canada) and 14 (15.5%) in Europe, with little representation from Africa, Asia and South America. Sixty-five (65.5%) studies recruited only men or mostly men, of which 31 (35%) recruited gay or bisexual men. Prevalence rates of depression ranged from 0 to 80%; measures were diverse and rarely adopted the same cut-off points. Twenty-one standardized instruments were used to measure depression. Ninety-nine interventions were investigated. The interventions were diverse and could broadly be categorized into psychological, psychotropic, psychosocial, physical, HIV-specific health psychology interventions and HIV treatment-related interventions. Psychological interventions were particularly effective and in particular interventions that incorporated a cognitive-behavioural component. Psychotropic and HIV-specific health psychology interventions were generally effective. Evidence is not clear-cut regarding the effectiveness of physical therapies and psychosocial interventions were generally ineffective. Interventions that investigated the effects of treatments for HIV and HIV-associated conditions on depression generally found that these treatments did not increase but often decreased depression. Interventions are both effective and available, although further research into enhancing efficacy would be valuable. Depression needs to be routinely logged in those with HIV infection during the course of their disease. Specific data on women, young people, heterosexual men, drug users and those indiverse geographic areas are needed. Measurement of depression needs to be harmonized and management into care protocols incorporated.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

A pilot study of cognitive behavioral stress management effects on stress, quality of life, and symptoms in persons with chronic fatigue syndrome

OBJECTIVE

The present pilot study was designed to test the effects of a 12-week group-based cognitive behavioral stress management (CBSM) intervention on stress, quality of life, and symptoms in chronic fatigue syndrome (CFS). We hypothesized that participants randomized to CBSM would report improvements in perceived stress, mood, quality of life, and CFS symptomatology from pre- to postintervention compared to those receiving a psychoeducational (PE) seminar control.

METHOD

We recruited 69 persons with a bona fide diagnosis of CFS and randomized 44 to CBSM and 25 to PE. Participants completed the Perceived Stress Scale (PSS), Profile of Mood States (POMS), Quality of Life Inventory (QOLI), and a Centers for Disease Control (CDC)-based CFS symptom checklist pre- and postintervention.

RESULTS

Repeated measures analysis of variance revealed a significant Group×Time interaction for PSS, POMS-total mood disturbance (TMD), and QOLI scores, such that participants in CBSM evidenced greater improvements than those in PE. Participants in CBSM also reported decreases in severity of CFS symptoms vs. those in PE.

CONCLUSIONS

Results suggest that CBSM is beneficial for managing distress, improving quality of life, and alleviating CFS symptom severity.

Impact of stress on cancer metastasis

The influence of psychosocial factors on the development and progression of cancer has been a longstanding hypothesis since ancient times. In fact, epidemiological and clinical studies over the past 30 years have provided strong evidence for links between chronic stress, depression and social isolation and cancer progression. By contrast, there is only limited evidence for the role of these behavioral factors in cancer initiation. Recent cellular and molecular studies have identified specific signaling pathways that impact cancer growth and metastasis. This article provides an overview of the relationship between psychosocial factors, specifically chronic stress, and cancer progression.

Stress effects on FosB- and interleukin-8 (IL8)-driven ovarian cancer growth and metastasis

A growing number of studies indicate that chronic stress can accelerate tumor growth due to sustained sympathetic nervous system activation. Our recent findings suggest that chronic stress is associated with increased IL8 levels. Here, we examined the molecular and biological significance of IL8 in stress-induced tumor growth. Norepinephrine (NE) treatment of ovarian cancer cells resulted in a 250-300% increase in IL8 protein and 240-320% increase in its mRNA levels. Epinephrine treatment resulted in similar increases. Moreover, NE treatment resulted in a 3.5-4-fold increase in IL8 promoter activity. These effects were blocked by propranolol. Promoter deletion analyses suggested that AP1 transcription factors might mediate catecholamine-stimulated up-regulation of IL8. siRNA inhibition studies identified FosB as the pivotal component responsible for IL8 regulation by NE. In vivo chronic stress resulted in increased tumor growth (by 221 and 235%; p < 0.01) in orthotopic xenograft models involving SKOV3ip1 and HeyA8 ovarian carcinoma cells. This enhanced tumor growth was completely blocked by IL8 or FosB gene silencing using 1,2-dioleoyl-sn-glycero-3-phosphatidylcholine nanoliposomes. IL8 and FosB silencing reduced microvessel density (based on CD31 staining) by 2.5- and 3.5-fold, respectively (p < 0.001). Our findings indicate that neurobehavioral stress leads to FosB-driven increases in IL8, which is associated with increased tumor growth and metastases. These findings may have implications for ovarian cancer management.

Insulin resistance, obesity, inflammation, and depression in polycystic ovary syndrome: biobehavioral mechanisms and interventions

OBJECTIVE

To summarize physiological and psychological characteristics that are common among women diagnosed with polycystic ovary syndrome (PCOS) and provide evidence suggesting that addressing psychological disturbances can reduce or alleviate physical symptoms of PCOS through behavioral pathways and physiological pathways.

METHOD(S)

Empirical studies and expert consensuses pertaining to physiological, psychological, and medical management aspects of PCOS were identified and presented in this review. Articles were identified by searching Pubmed, PsycInfo, Medline ISI, CINAHL, or a Web browser (i.e., Google) using numerous combinations of terms pertaining to physiological, psychological, and medical management aspects of PCOS. An article was chosen to be included in this review if it reported findings and/or provided information that related to and helped support the main purpose(s) of this review article.

RESULT(S)

Available literature on the physiological (i.e., hyperandrogenism, central obesity, inflammation, insulin resistance) and psychological (i.e., depression, anxiety, eating disorders) factors among women with PCOS provides evidence that these various aspects of PCOS are strongly interrelated.

CONCLUSION(S)

The existence of these relationships among physiological and psychological factors strongly suggests that medical management of PCOS would greatly benefit from inclusion of psychological and behavioral approaches.

Stress biomarkers as outcomes for HIV+ prevention: participation, feasibility and findings among HIV+ Latina and African American mothers

Mothers living with HIV (MLH) are at high risk for acute and chronic stress, given challenges related to their HIV status, ethnicity, economic and urban living conditions. Biomarkers combined into a composite index show promise in quantifying psychosocial stress in healthy people, but have not yet been examined among MLH. According, we examined potential biomarker correlates of stress [cortisol and catecholamines from home-collected urine and basic health indicators (blood pressure, height and weight, waist-to-hip ratio) measured during an interview] among 100 poor African American and Latina mothers MLH and demographic-matched control mothers without HIV (n = 50). Participants had been enrolled in a randomized controlled trial about 18 months earlier and had either received (MLH-I) or were awaiting (MLH-W) the psychosocial intervention. Participation was high, biomarkers were correctly collected for 93% of cases, and a complete composite biomarker index (CBI) calculated for 133 mothers (mean age = 42). As predicted, MLH had a significantly higher CBI than controls, but there was no CBI difference across ethnicity or intervention group. CBI predicted CD4 counts independently after controlling for age, years since diagnosis, prior CD4 counts, medication adherence, and depression symptoms. The study demonstrates acceptability, feasibility and potential utility of community-based biomarker collections in evaluating individual differences in psychosocial stress.

Positive affect and psychobiological processes relevant to health

Empirical evidence suggests that there are marked associations between positive psychological states and health outcomes, including reduced cardiovascular disease risk and increased resistance to infection. These observations have stimulated the investigation of behavioral and biological processes that might mediate protective effects. Evidence linking positive affect with health behaviors has been mixed, though recent cross-cultural research has documented associations with exercising regularly, not smoking, and prudent diet. At the biological level, cortisol output has been consistently shown to be lower among individuals reporting positive affect, and favorable associations with heart rate, blood pressure, and inflammatory markers such as interleukin-6 have also been described. Importantly, these relationships are independent of negative affect and depressed mood, suggesting that positive affect may have distinctive biological correlates that can benefit health. At the same time, positive affect is associated with protective psychosocial factors such as greater social connectedness, perceived social support, optimism, and preference for adaptive coping responses. Positive affect may be part of a broader profile of psychosocial resilience that reduces risk of adverse physical health outcomes.

Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres

Understanding the malleable determinants of cellular aging is critical to understanding human longevity. Telomeres may provide a pathway for exploring this question. Telomeres are the protective caps at the ends of chromosomes. The length of telomeres offers insight into mitotic cell and possibly organismal longevity. Telomere length has now been linked to chronic stress exposure and depression. This raises the question of mechanism: How might cellular aging be modulated by psychological functioning? We consider two psychological processes or states that are in opposition to one another-threat cognition and mindfulness-and their effects on cellular aging. Psychological stress cognitions, particularly appraisals of threat and ruminative thoughts, can lead to prolonged states of reactivity. In contrast, mindfulness meditation techniques appear to shift cognitive appraisals from threat to challenge, decrease ruminative thought, and reduce stress arousal. Mindfulness may also directly increase positive arousal states. We review data linking telomere length to cognitive stress and stress arousal and present new data linking cognitive appraisal to telomere length. Given the pattern of associations revealed so far, we propose that some forms of meditation may have salutary effects on telomere length by reducing cognitive stress and stress arousal and increasing positive states of mind and hormonal factors that may promote telomere maintenance. Aspects of this model are currently being tested in ongoing trials of mindfulness meditation.

Effects of faith/assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with HIV: a randomized trial

OBJECTIVES

Previous research among HIV-infected individuals suggests that spiritual well-being is inversely related to psychological distress and rates of disease progression. Use of a mantram, a spiritual word or phrase repeated frequently and silently throughout the day, has been associated with decreased psychological distress and increased spiritual well-being. This study compared the effects of 2 interventions-a spiritually-based mantram intervention versus an attention-matched control group-on faith/assurance and average salivary cortisol levels among HIV-infected individuals.

METHODS

Using a randomized design, HIV-infected adults were assigned to the intervention (n = 36) or control condition (n = 35). Faith scores and saliva (collected at 7 a.m., 11 a.m., 4 p.m., and 9 p.m.) were assessed at preintervention, postintervention, and 5-week follow-up. Path analyses tested competing models that specify both concurrent and sequential relationships between faith and average daily cortisol levels while comparing groups.

RESULTS

Faith levels increased among mantram participants from pre- to postintervention. Greater faith at preintervention was significantly associated with lower average cortisol at postintervention in the mantram group but not in the controls. The associations between faith at postintervention and cortisol levels at 5-week follow-up were significant among both groups but weaker than the pre- to postintervention association identified in the mantram group.

CONCLUSIONS

These results suggest the presence of lagged or antecedent consequent relationships between faith and cortisol, which may be enhanced by mantram use. Decreased cortisol could potentially benefit immune functioning among HIV-infected individuals.

Stress management effects on perceived stress and cervical neoplasia in low-income HIV-infected women

OBJECTIVE

Risk for developing cervical neoplastic disease is greatly increased in women infected with oncogenic sexually transmitted human papillomaviruses (HPVs) and who have lowered cellular immunity due to coinfection with human immunodeficiency virus (HIV) infection. The majority of these individuals are low-income minority women. Factors associated with promotion of HPV to cervical neoplasia in HIV-infected populations include degree of immunosuppression as well as behavioral factors such as tobacco smoking and psychological stress. This study examined the effects of a cognitive behavioral stress management (CBSM) intervention on life stress and cervical neoplasia in HIV+ minority women.

METHODS

Participants were 39 HIV+ African-American, Caribbean, and Hispanic women with a recent history of an abnormal Papanicolaou smear. Participants underwent colposcopic examination, psychosocial interview, and peripheral venous blood draw at study entry and 9 months after being randomly assigned to either a 10-week CBSM group intervention (n=21) or a 1-day CBSM workshop (n=18).

RESULTS

Women assigned to the 10-week group-based CBSM intervention reported decreased perceived life stress and had significantly lower odds of cervical neoplasia over a 9-month follow-up. CBSM effects on life stress and neoplasia appeared independent of presence of neoplasia at study entry, HPV type, CD4+CD3+ cell count, HIV viral load, and substance use. Furthermore, CBSM intervention effects on cervical neoplasia were especially pronounced among women with residual life stress at follow-up.

CONCLUSION

These findings suggest that stress management decreases perceived life stress and may decrease the odds of cervical neoplasia in women with HIV and a history of abnormal Papanicolaou smears. Although preliminary, these findings suggest the utility of stress management as a cancer prevention strategy in this high-risk population.

Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006

OBJECTIVE

Numerous studies document that stress accelerates disease processes in a variety of diseases including HIV. As a result, investigators have developed and evaluated interventions to reduce stress as a means to improve health among persons living with HIV. Therefore, the current meta-analysis examines the impact of stress-management interventions at improving psychological, immunological, hormonal, and other behavioral health outcomes among HIV+ adults.

DESIGN

This meta-analytic review integrated the results of 35 randomized controlled trials examining the efficacy of 46 separate stress management interventions for HIV+ adults (N=3,077).

MAIN OUTCOME MEASURES

Effect sizes were calculated for stress processes (coping and social support), psychological/psychosocial (anxiety, depression, distress, and quality of life), immunological (CD4+ counts and viral load), hormonal (cortisol, dehydroepiandrosterone sulfate [DHEA-S], cortisol/DHEA-S ratio, and testosterone) and other behavioral health outcomes (fatigue).

RESULTS

Compared to controls, stress-management interventions reduce anxiety, depression, distress, and fatigue and improve quality of life (d+s=0.16 to 0.38). Stress-management interventions do not appear to improve CD4+ counts, viral load, or hormonal outcomes compared with controls.

CONCLUSION

Overall, stress-management interventions for HIV+ adults significantly improve mental health and quality of life but do not alter immunological or hormonal processes. The absence of immunological or hormonal benefits may reflect the studies' limited assessment period (measured typically within 1-week postintervention), participants' advanced stage of HIV (HIV+ status known for an average of 5 years), and/or sample characteristics (predominately male and White participants). Future research might test these hypotheses and refine our understanding of stress processes and their amelioration.

Depressed and anxious mood and T-cell cytokine expressing populations in ovarian cancer patients

The adaptive immune response of ovarian cancer patients has been linked to survival, and is known to be impaired in the tumor microenvironment. Little is known about relationships between biobehavioral factors such as depressed mood and anxiety and the adaptive immune response in ovarian cancer. Thirty-seven patients with epithelial ovarian cancer and 14 patients with benign ovarian neoplasms completed psychosocial questionnaires pre-surgery. Lymphocytes from peripheral blood, tumor, and ascites (fluid around the tumor), were obtained on the day of surgery. Expression of the Type-1 cytokine interferon-gamma (IFN gamma), and the Type-2 cytokine interleukin-4 (IL-4) by T-helper (CD4(+)) and T-cytotoxic (CD8(+)) cells was measured under autologous tumor-stimulated, polyclonally-stimulated, or unstimulated conditions. Links with mood were examined. Among cancer patients, marked elevations in unstimulated and tumor-stimulated Type-2 responses were seen, particularly in ascites and tumor-infiltrating lymphocytes (P values<0.01). With polyclonal stimulation, lymphocytes from all compartments expressed elevated Type-1 cytokines (P values<0.014). Depressed and anxious mood were both associated with significantly lower ratios of polyclonally-stimulated CD4(+) cells producing IFN gamma (TH(1) cells) vs. IL-4 (TH(2) cells) in all compartments (depressed mood: P=0.012; anxiety: P=0.038) and depressed mood was also related to lower ratios of polyclonally-stimulated CD8(+) cells producing IFN gamma (TC(1)) vs. IL-4 (TC(2)) (P=0.035). Although effects of polyclonal stimulation should be generalized with caution to the in vivo immune response, findings suggest that depressed and anxious mood are associated with greater impairment of adaptive immunity in peripheral blood and in the tumor microenvironment among ovarian cancer patients.