Psychological distress, killer lymphocytes and disease severity in HIV/AIDS

A Neighborhood-level analysis of mental health distress and income inequality as quasi-longitudinal risk of reported COVID-19 infection and mortality outcomes in Chicago

Extant literature investigates the impact of COVID-19 on mental health outcomes, however there is a paucity of work examining mental health distress as a risk factor for COVID-19 outcomes. While systemic variables like income inequality relate to both mental health and COVID-19, more work is needed to test theoretically informed models including such variables. Using a social-ecological framework, we aimed to address these gaps in the literature by conducting a neighborhood-level analysis of potential mental health distress and systemic- (income inequality) level predictors of reported COVID-19 infection and mortality over time in Chicago. Neighborhood-level comparisons revealed differences in mental health distress, income inequality, and reported COVID-19 mortality, but not reported COVID-19 infection. Specifically, Westside and Southside neighborhoods generally reported higher levels of mental health distress and greater concentration of poverty. The Central neighborhood showed a decline in reported mortality rates over time. Multi-level negative binomial models established that Zip-codes with greater mental health distress were at increased reported COVID-19 infection risk, yet lower mortality risk; Zip-codes with more poverty were at increased reported COVID-19 infection risk, yet lower mortality risk; and Zip-codes with the highest percentage of People of Color were at decreased risk of reported COVID-19 mortality. Taken together, these findings substantiate Chicago neighborhood-level disparities in mental health distress, income inequality, and reported COVID-19 mortality; identify unique differential associations of mental health distress and income inequality to reported COVID-19 infection and reported mortality risk; and, offer an alternative lens towards understanding COVID-19 outcomes in terms of race/ethnicity.

Examining Depression as a Risk Factor for Cardiovascular Disease in People with HIV: A Systematic Review

BACKGROUND

People with human immunodeficiency virus (HIV) have an increased risk of cardiovascular disease (CVD) not fully accounted for by traditional or HIV-specific risk factors. Successful management of HIV does not eliminate this excess risk. Thus, there is a need to identify novel risk factors for CVD among people with HIV (PWH).

PURPOSE

Our objective was to systematically review the literature on one such candidate CVD risk factor in PWH-depression.

METHODS

A systematic literature search of PubMed, PsycINFO, EMBASE, Web of Science, and CINAHL was performed to identify published English-language studies examining associations of depression with clinical CVD, subclinical CVD, and biological mechanisms (immune activation, systemic inflammation, altered coagulation) among PWH between the earliest date and June 22, 2021.

RESULTS

Thirty-five articles were included. For clinical CVD (k = 8), findings suggests that depression is consistently associated with an increased risk of incident CVD. For subclinical CVD (k = 5), one longitudinal analysis reported a positive association, and four cross-sectional analyses reported null associations. For immune activation (k = 13), systemic inflammation (k = 17), and altered coagulation (k = 5), findings were mixed, and there was considerable heterogeneity in sample characteristics and methodological quality across studies.

CONCLUSIONS

Depression may be an independent risk factor for CVD among PWH. Additional research is needed to confirm depression's association with clinical CVD and to determine whether depression is consistently and meaningfully associated with subclinical CVD and biological mechanisms of CVD in HIV. We propose a research agenda for this emerging area.

Psychological Distress Increases 30-Fold Among People with HIV in the First Year on ART in Nigeria-a Call for Integrated Mental Health Services

BACKGROUND

Few studies have longitudinally assessed psychological distress among people with HIV (PWH) initiating ART in resource-limited settings.

METHOD

Baseline, 6-month, and 12-month psychological distress were measured in a Nigerian cohort newly initiating therapy; the relationship between baseline factors and psychological distress at 12 months was assessed; and the association between psychological distress at 12 months and care retention or immunologic failure was determined.

RESULTS

Among 563 patients, median age was 38 years (IQR: 33-46 years), 62% were female, and 51% were married. Psychological distress increased from 3% at baseline to 34% at 12 months. Age (aOR 1.28, 95% CI 1.06-1.56), female sex (aOR 2.89, 95% CI 1.93-4.33), lack of disclosure (aOR 4.32, 95% CI 2.48-7.51), and time on ART (6 months [aOR 6.91, 95% CI 3.14-15.18] and 12 months [aOR 32.63, 95% CI 16.54-64.36]) were associated with psychological distress while being married (OR 0.42, 95% CI 0.30-0.61) was associated with reduced odds. Tweve-month psychological distress was associated with increased risk of immunologic failure (aOR 2.22, 95% CI 1.31-3.82).

CONCLUSION

The risk of psychological distress increased 30-fold in the first year on therapy in PWH in Nigeria.

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.

Alexithymia, Assertiveness and Psychosocial Functioning in HIV: Implications for Medication Adherence and Disease Severity

Psychosocial function and adherence to antiretroviral regimen are key factors in human immunodeficiency virus (HIV) disease management. Alexithymia (AL) is a trait deficit in the ability to identify and describe feelings, emotions and bodily sensations. A structural equation model was used to test whether high levels of AL indirectly relate to greater non-adherent behavior and HIV disease severity via psychosocial dysfunction. Blood draws for HIV-1 viral load and CD4 T-lymphocyte, along with psychosocial surveys were collected from 439 HIV positive adults aged 18-73 years. The structural model supports significant paths from: (1) AL to non-active patient involvement, psychological distress, and lower social support, (2) psychological distress and non-active involvement to non-adherent behavior, and (3) non-adherence to greater HIV disease severity (CFI = .97, RMSEA = .04, SRMR = .05). A second model confirmed the intermediary effect of greater patient assertiveness on the path from AL to social support and non-active patient involvement (CFI = .94, RMSEA = .04, SRMR = .05). Altogether, AL is indirectly linked with HIV disease management through it's association with poor psychosocial function, however greater patient assertiveness buffers the negative impact of AL on relationship quality with healthcare providers and members of one's social support network.

Association of individual and systemic barriers to optimal medical care in people living with HIV/AIDS in Miami-Dade County

Barriers to retention in HIV care are detrimental to patients' progress along the HIV continuum of care. Previous literature has focused on individual, client-level barriers, and interventions to address them. In contrast, less work has examined the role of system-level barriers on HIV care outcomes. This study seeks to understand how individual and systemic barriers individually are associated with clinic appointment attendance and virologic suppression in HIV-infected patients attending the largest HIV clinic in Miami-Dade, FL. In addition, we examined the synergistic effects of these barriers as potential syndemic factors on these health outcomes. Barriers to clinic attendance were determined in a face-to-face study interview with 444 HIV-infected outpatients (187 regular attenders, 191 irregular attenders, and 66 nonattenders) identified from electronic medical records. Compared with the other attendance groups, nonattenders had higher viral loads, were less likely to be virologically suppressed, had lower CD4 counts, had higher depressive symptoms, life chaos, lower quality of life, and higher rates of food insecurity, and recent drug use. Additionally, nonattenders compared with regular attenders had lower physician relationship ratings, had lower medical information clarity and more often reported transportation as a barrier to clinic attendance. When viewed as a syndemic, compared with patients not reporting any barriers, patients with 3 or more individual-level barriers were more likely to have a detectable viral load (odds ratio = 3.60, 95% CI: 1.71 to 7.61). Our findings suggest that patients presenting to the clinic with multiple barriers should be prioritized for assistance and future interventions to improve retention in care. Interventions should address multiple individual and system-level barriers simultaneously with particular attention to addressing depressive symptoms, organizational skills, relationship with the physician, and HIV-related health education.

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.

Neuropathological sequelae of Human Immunodeficiency Virus and apathy: A review of neuropsychological and neuroimaging studies

Apathy remains a common neuropsychiatric disturbance in the Human Immunodeficiency Virus (HIV-1) despite advances in anti-retroviral treatment (ART). The goal of the current review is to recapitulate findings relating apathy to the deleterious biobehavioral effects of HIV-1 in the post-ART era. Available literatures demonstrate that the emergence of apathy with other neurocognitive and neuropsychiatric symptoms may be attributed to neurotoxic effects of viral proliferation, e.g., aggregative effect of Tat and gp120 on apoptosis, transport and other enzymatic reactions amongst dopaminergic neurons and neuroglia. An assortment of neuroimaging modalities converge on the severity of apathy symptoms associated with the propensity of the virus to replicate within frontal-striatal brain circuits that facilitate emotional processing. Burgeoning research into functional brain connectivity also supports the effects of microvascular and neuro-inflammatory injury linked to aging with HIV-1 on the presentation of neuropsychiatric symptoms. Summarizing these findings, we review domains of HIV-associated neurocognitive and neuropsychiatric impairment linked to apathy in HIV. Taken together, these lines of research suggest that loss of affective, cognitive and behavioral inertia is commensurate with the neuropathology of HIV-1.

Successful coping in urban, community-dwelling older adults with HIV

By 2015, 50% of HIV-infected individuals in the United States will be 50 years of age and older. Examining successful coping in older adults with HIV could expand existing coping toolkits, enhance disease management, and improve overall outcomes. We explored how urban, community-dwelling older adults (N = 40) coped with HIV infection, comorbidities, and related stressors. Participants completed an individual or focus group interview session using open-ended questions formulated from extended participant observation. Data were analyzed for theme development using interpretive hermeneutics and qualitative content analysis. Stressors included HIV, comorbidities, fear, anger, stigma, and finances. Three themes for successful coping were identified: accessing support, helping selves and helping others, and tapping into spirituality. Participants engaged in active, meaning-based strategies to successfully cope with HIV and related stressors. These strategies can be adapted for other older adults with HIV, leading to holistic care and improved outcomes.

Depression, adherence and attrition from care in HIV-infected adults receiving antiretroviral therapy

BACKGROUND

A better understanding of the relationship between depression and HIV-related outcomes, particularly as it relates to adherence to treatment, is critical to guide effective support and treatment of individuals with HIV and depression. We examined whether depression was associated with attrition from care in a cohort of 610 HIV-infected adults in rural Rwanda and whether this relationship was mediated through suboptimal adherence to treatment.

METHODS

The association between depression and attrition from care was evaluated with a Cox proportional hazard model and with mediation methods that calculate the direct and indirect effects of depression on attrition and are able to account for interactions between depression and suboptimal adherence. Depression was assessed with the Hopkins Symptom Checklist-15; attrition was defined as death, treatment default, or loss to follow-up.

RESULTS

Baseline depression was significantly associated with time to attrition after adjustment for receipt of community-based accompaniment, physical functioning quality of life score, and CD4 cell count (HR=2.40, 95% CI 1.27 to 4.52, p=0.005). In multivariable mediation analysis, we found no evidence that the association between depression and attrition after 3 months was mediated by suboptimal adherence (direct effect of depression on attrition: OR=3.90 (1.26 to 12.04), p=0.02; indirect effect: OR=1.07 (0.92 to 1.25), p=0.38).

CONCLUSIONS

Even in the context of high antiretroviral therapy adherence, depression may adversely influence HIV outcomes through a pathway other than suboptimal adherence. Treatment of depression is critical to achieving good mental health and retention in HIV-infected individuals with depression.

The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities

National health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations. Yet, few studies have examined the range of health outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more inclusive research in the area, we present the Health Equity Promotion Model-a framework oriented toward LGBT people reaching their full mental and physical health potential that considers both positive and adverse health-related circumstances. The model highlights (a) heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and environmental context; and (c) both health-promoting and adverse pathways that encompass behavioral, social, psychological, and biological processes. It also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the health-promotion model. By explicating the important role of agency and resilience as well as the deleterious effect of social structures on health outcomes, it supports policy and social justice to advance health and well-being in these communities. Important directions for future research as well as implications for health-promotion interventions and policies are offered.

Psychological stress exerts effects on pathogenesis of hepatitis B via type-1/type-2 cytokines shift toward type-2 cytokine response

BACKGROUND

Psychological and physical stress has been demonstrated to have an impact on health through modulation of immune function. Despite high prevalence of stress among patients with hepatitis B virus (HBV) infection, little is known about whether and how stress exerts an effect on the course of hepatitis B.

METHODS

Eighty patients with chronic hepatitis B(CHB) completed the Perceived Stress Scale-10(PSS-10) and State-Trait Anxiety Inventory(STAI). Fresh whole blood was subject to flow cytometry for lymphocytes count. Plasma samples frozen at -80 °C were thawed for cytokines, alanine aminotransferase (ALT), and virus load. These patients were grouped into high or low perceived stress, state anxiety and trait anxiety groups according to the scale score. Sociodemographic, disease-specific characteristics, lymphocytes count and cytokines were compared.

RESULTS

Firstly, a negative association between ALT and stress (t =  -4.308; p =  .000), state anxiety (t =  -3.085; p =  .003) and trait anxiety (t =  -4.925; p =  .000) were found. As ALT is a surrogate marker of hepatocytes injury, and liver injury is a consequence of immune responses. Next, we tested the relationship between stress/anxiety and lymphocytes. No statistical significance were found with respect to counts of total T cells, CD4+ T cell, CD8+ T cell, NK cell, and B cell count between high and low stress group. Type-2 cytokine interleukin-10 (IL-10) level was significantly higher in high stress group relative to lower counterpart (t = 6.538; p = 0.000), and type-1 cytokine interferon-gamma (IFN-γ) level shown a decreased tendency in high stress group (t =  -1.702; p = 0.093). Finally, INF-γ:IL-10 ratio displayed significant decrease in high perceived stress(t =  -4.606; p = 0.000), state anxiety(t =  -5.126; p = 0.000) and trait anxiety(t =  -4.670; p = 0.000) groups relative to low counterparts.

CONCLUSION

Our data show stress is not related to the lymphocyte cells count in CHB patients, however, stress induces a shift in the type-1/type-2 cytokine balance towards a type-2 response, which implicated a role of psychological stress in the course of HBV related immune-pathogenesis.

Demographic and clinical factors correlating with high levels of psychological distress in HIV-positive women living in Ontario, Canada

The concept of psychological distress includes a range of emotional states with symptoms of depression and anxiety and has yet to be reported in HIV-positive women living in Ontario, Canada, who are known to live with contributing factors. This study aimed to determine the prevalence, severity, and correlates of psychological distress among women accessing HIV care participating in the Ontario HIV Treatment Network Cohort Study using the Kessler Psychological Distress Scale (K10). The K10 is a 10-item, five-level response scale. K10 values range from 10 to 50 with values less than or equal to 19 categorized as not clinically significant, scores between 20 and 24 as moderate levels, 25-29 as high, and 30-50 as very high psychological distress. Correlates of psychological distress were assessed using the Pearson's chi-square test and univariate and multivariate logistic regression analysis. Moderate, high, and very high levels of psychological distress were experienced by 16.9, 10.4, and 15.1% of the 337 women in our cohort, respectively, with 57.6% reporting none. Psychological distress levels greater than 19, correlated with being unemployed (vs. employed/student/retired; AOR = 0.33, 95% CI: 0.13-0.83), living in a household without their child/children (AOR = 2.45, 95% CI: 1.33-4.52), CD4 counts < 200 cells/mm(3) (AOR = 2.07, 95% CI: 0.89-4.80), and to a lesser degree an education of some college or less (vs. completed college or higher; AOR=1.71, 95% CI: 0.99-2.95). Age and ethnicity, a priori variables of interest, did not correlate with psychological distress. Findings suggest that socioeconomic factors which shape the demography of women living with HIV in Ontario, low CD4 counts, and losing the opportunity to care for their child/children has a significant relationship with psychological distress. Approaches to manage psychological distress should address and make considerations for the lived experiences of women since they can act as potential barriers to improving psychological well-being.

Age, stress, and isolation in older adults living with HIV

People living with HIV (PLWH) have increasingly longer life spans. This age group faces different challenges than younger PLWH, which may include increased stress and social isolation. The purpose of this study was to determine whether the age and sex of PLWH are associated with measures of physiologic stress, perceived stress, and social isolation. In this cross-sectional study, we enrolled 102 PLWH equally into four groups divided by age (younger or older than 50 years) and gender. Participants completed well-validated survey measurements of stress and isolation, and their heart rate variability over 60 minutes was measured by Holter monitor. The mean (SD) Perceived Stress Scale score was 17.4 (6.94), mean Visual Analog Stress Scale score was 3.51 (2.79), and mean Hawthorne Friendship Scale score, a measure of social isolation, was 17.03 (4.84). Mean heart rate variability expressed as the SD of successive N-N intervals was 65.47 (31.16) msec. In multivariable regression models that controlled for selected demographic variables, there was no relationship between the Perceived Stress Scale and age (coefficient = -0.09, p =-0.23) or female gender (coefficient = -0.12, p = 0.93); however, there was a modest relationship between female gender and stress using the Visual Analog Stress Scale (coefficient = 1.24, p = 0.05). Perceived Stress was negatively associated with the Hawthorne Friendship score (coefficient = -0.34, p = 0.05). Hawthorne Friendship score was positively associated with younger age (coefficient = 0.11, p = 0.02). Age was the only independent predictor of physiologic stress as measured by heart rate variability (coefficient = -1.3, p < 0.01). Our findings suggest that younger PLWH may experience more social isolation; however, age-related changes in heart rate variability do not appear to be related to perceived stress or social isolation. Future longitudinal research is required to more thoroughly understand this relationship and its impact on the health of PLWH.

Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Symptom Severity: Stress Management Skills are Related to Lower Illness Burden

BACKGROUND

The onset of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) typically involves reductions in activities of daily living and social interactions (jointly referred to as "illness burden"). Emotional distress has been linked to increased reported symptoms, and stress management skills have been related to lower fatigue severity in CFS patients. Symptom severity and illness burden are highly correlated. The ability to manage stress may attenuate this relationship, allowing individuals to feel less burdened by the illness independent of the severity of their symptoms.

PURPOSE

This study aimed to evaluate if perceived stress management skills affect illness burden via emotional distress, independent of ME/CFS symptom severity.

METHODS

A total of 117 adults with ME/CFS completed measures of perceived stress management skills, emotional distress, ME/CFS symptom severity and illness burden.

RESULTS

Regression analyses revealed that greater perceived stress management skills related to less social and fatigue-related illness burden, via lower emotional distress. This relationship existed independent of the association of symptom severity on illness burden, and was stronger among those not currently employed.

CONCLUSIONS

Ability to manage stress is associated with a lower illness burden for individuals with ME/CFS. Future studies should evaluate the efficacy of psychosocial interventions in lowering illness burden by targeting stress management skills.

Cognitive vulnerability for depression in HIV

Biased inhibitory processing, frequency and valence of automatic thoughts, and inability to use positive schemas to regulate negative mood are cognitive factors linked to depression. These processes may underlie the established link between adaptive cognitive coping strategies (acceptance and positive reframing) and depression in persons with HIV. How individual differences in HIV-related neurocognitive deficits moderate such effects is unknown. In a secondary analysis, we tested the direct effects of coping on depressed affect as mediated by the frequency and valence of automatic thoughts and how this model was moderated by neurocognitive function in a cohort of HIV+ men and women.

METHODS

HIV+ adults (mage=39.8, SD=9.5) provided data for the baseline assessment of a randomized trial that investigated the effects of a cognitive-behavioral stress management intervention. Measures included coping, depressive symptoms, positive (PAT) and negative automatic thoughts (NAT), and HIV-dementia.

RESULTS

After controlling for covariates, cognitive coping was related to depressed mood as mediated via NAT (β=-.92) and PATs (β=.61), (R(2)=.42, F(7, 325)=33.50, p<.0001). The indirect effect of coping on depressive symptoms via NAT and PAT was moderated by neurocognitive function.

LIMITATION

Cross-sectional design does not allow for the inference of causation among the variables.

CONCLUSION

Results support a cognitive vulnerability model for depression whereby HIV-related neurocognitive deficits interfere with the ability to use acceptance and positive reframing strategies to increase the frequency of PAT and decrease NAT in adults living with symptoms of depression.

A multinational study of self-compassion and human immunodeficiency virus-related anxiety

AIM

This study represents an initial effort at examining the association between the construct of self-compassion and human immunodeficiency virus (HIV)-related anxiety in a multinational population with HIV disease.

BACKGROUND

Previous studies have found that self-compassion is a powerful predictor of mental health, demonstrating positive and consistent linkages with various measures of affect, psychopathology and well-being, including anxiety.

METHODS

Cross-sectional data from a multinational study conducted by the members of the International Nursing Network for HIV Research (n = 1986) were used. The diverse sample included participants from Canada, China, Namibia, the United States of America and the territory of Puerto Rico. Study measures included the anxiety subscale of the Symptom Checklist-90 instrument, the Brief Version Self-Compassion Inventory and a single item on anxiety from the Revised Sign and Symptom Checklist.

FINDINGS

Study findings show that anxiety was significantly and inversely related to self-compassion across participants in all countries. We examined gender differences in self-compassion and anxiety, controlling for country. Levels of anxiety remained significantly and inversely related to self-compassion for both males (P = 0.000) and females (P = 0.000). Levels of self-compassion and anxiety varied across countries.

CONCLUSIONS

Self-compassion is a robust construct with cross-cultural relevance. A culturally based brief treatment approach aimed at increasing self-compassion may lend itself to the development of a cost effective adjunct treatment in HIV disease, including the management of anxiety symptoms.

Family adversity and autonomic reactivity association with immune changes in HIV-affected school children

OBJECTIVE

To explore whether primary school entry is associated with changes in immune system parameters in HIV-affected children. HIV-affected children are vulnerable to psychosocial stressors, regardless of their own HIV serological status.

METHODS

Data from 38 HIV-positive and 29 HIV-negative children born to seropositive women were obtained. Measures included family adversity questionnaires, autonomic nervous system (ANS) reactivity, and enumerative and functional changes in peripheral blood immune parameters.

RESULTS

In comparison with children who were HIV-negative, children who were HIV-positive at baseline had fewer CD4(+) T lymphocytes (mean [M] = 916 versus 1206 cells/mm(3) × 10(3); F = 7.8, p = .007), more CD8(+) cells (M = 1046 versus 720 cells/mm(3) × 10(3); F = 7.98, p = .006), and diminished natural killer cell cytotoxicity (M = -0.29 versus 0.41; F = 8.87, p = .004). School entry was associated with changes in immune parameters, but HIV status was not associated with the magnitude of changes. Changes in immune parameters after school entry were associated with family stress and preschool entry ANS reactivity. Highly ANS reactive children had either the greatest increase in CD8(+) cells after school entry or the greatest decrease, depending on reported levels of family adversity (B = 215.35; t = 3.74, p < .001). Changes in functional immune assays were significantly associated with the interactions between HIV status and ANS reactivity.

CONCLUSIONS

These results suggest that autonomic reactivity is associated with increased immunological sensitivity to adverse or challenging social contexts among children affected by HIV.

Sexual orientation and disclosure in relation to psychiatric symptoms, diurnal cortisol, and allostatic load

OBJECTIVES

Lesbian, gay, and bisexual (LGB) individuals-particularly those who have not disclosed their sexual orientation-are believed to experience increased chronic stress in comparison with heterosexuals. This interdisciplinary study assessed whether psychiatric symptoms (self-rated anxiety, depression, and burnout), stress hormone profiles (diurnal cortisol), and physiological dysregulations (allostatic load [AL]) would differ for a) LGBs versus heterosexuals and b) disclosed LGBs versus nondisclosed LGBs.

METHODS

The study included 87 healthy participants (mean [SD] age=24.6 [0.6] years; LGB n=46, 43% women; and heterosexual n=41, 49% women). Diurnal cortisol sampled at five time points was averaged for 2 days. AL indices were based on an algorithm incorporating 21 biomarkers representing neuroendocrine, immune/inflammatory, metabolic, and cardiovascular functioning. Psychological measures were assessed with well-validated questionnaires.

RESULTS

Between-group results revealed no significant differences in symptoms of anxiety and burnout, nor among diurnal cortisol levels between sexual orientations. By contrast, gay/bisexual men unexpectedly had lower depressive symptoms (p=.003) and AL levels (p=.043) compared with heterosexual men. Within-group results revealed that disclosed LGBs had fewer psychiatric symptoms (p values<0.01) and lower cortisol levels +30 minutes upon awakening (p=.004) compared with nondisclosed LGBs. Disclosure was not significantly related to AL levels.

CONCLUSIONS

LGBs did not manifest more stress-related problems than did heterosexuals. Life transitions like disclosing to one's family and friends may be protective against psychopathologies and hyperactive cortisol awakening responses. Our novel findings underline the roles disclosure processes have on positive health and well-being for sexual minorities.

Perceived discrimination, social support, and perceived stress among people living with HIV/AIDS in China

Perceived stress among people living with HIV/AIDS (PLWH) was associated with severe mental health problems and risk behaviors. Discrimination toward PLWH in China is prevalent. Both perceived discrimination and social supports are determinants of the stress level among PLWH. Psychological support services for PLWH in China are scarce. It is unknown whether social support is a buffer between the perceived discrimination and perceived stress. With written consent, this study surveyed 258 PLWH recruited from multiple sources in two cities in China. Instruments were validated in previous or the present study, including the perceived stress scale for PLWH (PSSHIV), the perceived social support scale (PSSS), and the perceived discrimination scale for PLWH (PDSHIV). Pearson correlations and multiple regression models were fit. PDSHIV was associated with the Overall Scale and all subscales of PSSHIV, whilst lower socioeconomic status in general and lower scores of PSSS were associated with various subscales of PSSHIV. The interaction item (PSSS×PSDHIV) was nonsignificant in modeling PSSHIV, hence no significant moderating effect was detected. Whilst perceived discrimination is a major source of stress and social support can reduce stress among PLWH in China, improved social support cannot buffer the stressful consequences due to perceived discrimination. The results highlight the importance to reduce discrimination toward PLWH and the difficulty to alleviate its negative consequences. It is warranted to improve mental health among PLWH in China and it is still important to foster social support among PLWH as it has direct effects on perceived stress.

Childhood trauma and health outcomes in HIV-infected patients: an exploration of causal pathways

OBJECTIVE

Traumatic life histories are highly prevalent in people living with HIV/AIDS and predict sexual risk behaviors, medication adherence, and all-cause mortality. Yet the causal pathways explaining these relationships remain poorly understood. We sought to quantify the association of trauma with negative behavioral and health outcomes and to assess whether those associations were explained by mediation through psychosocial characteristics.

METHODS

In 611 outpatient people living with HIV/AIDS, we tested whether trauma's influence on later health and behaviors was mediated by coping styles, self-efficacy, social support, trust in the medical system, recent stressful life events, mental health, and substance abuse.

RESULTS

In models adjusting only for sociodemographic and transmission category confounders (estimating total effects), pasttrauma exposure was associated with 7 behavioral and health outcomes including increased odds or hazard of recent unprotected sex [odds ratio (OR) = 1.17 per each additional type of trauma, 95% confidence interval = 1.07 to 1.29], medication nonadherence (OR = 1.13, 1.02 to 1.25), hospitalizations (hazard ratio = 1.12, 1.04 to 1.22), and HIV disease progression (hazard ratio = 1.10, 0.98 to 1.23). When all hypothesized mediators were included, the associations of trauma with health care utilization outcomes were reduced by about 50%, suggesting partial mediation (eg, OR for hospitalization changed from 1.12 to 1.07), whereas point estimates for behavioral and incident health outcomes remained largely unchanged, suggesting no mediation (eg, OR for unprotected sex changed from 1.17 to 1.18). Trauma remained associated with most outcomes even after adjusting for all hypothesized psychosocial mediators.

CONCLUSIONS

These data suggest that past trauma influences adult health and behaviors through pathways other than the psychosocial mediators considered in this model.

PTSD and HIV in women: the role of gender in this dual diagnosis

This article is based on the authors findings from a cross-sectional descriptive study of men (n = 116) and women (n = 68) who were receiving HIV/AIDS counseling from four different community centers across New York state from March-July 2010. To ascertain the prevalence of post-traumatic stress in this population, a checklist (PCL) was employed. The responses from females and males were compared to detect gender differences in the common dual diagnosis of HIV and PTSD. The genders differed regarding several manifestations of PTSD: (1) women reported a significantly higher mean score on "feeling very upset when something reminded" them of a stressful experience from the past; (2) while not statistically significant, but noteworthy, men reported they were more likely to feel "distant or cut off" depending on their employment status. These and other findings suggested that the genders may manifest PTSD differently. Implications for those in the health care field and the trauma field are provided.

Self-care behaviors and activities for managing HIV-related anxiety

The goal of this study was to identify the baseline prevalence and effectiveness of anxiety self-management strategies in a convenience sample of persons living with HIV (PLWH; n = 343) in the United States, Puerto Rico, Kenya, and South Africa who reported HIV-related anxiety symptoms. Relationships between demographics and anxiety characteristics were determined, as was the effectiveness of self-care activities/behaviors to reduce anxiety. We found that the use of anxiety self-management strategies varied by gender and that ratings of effectiveness varied by country. Highest anxiety intensity scores were found in participants who were taking antiretroviral medications and who had undetectable viral loads. Forty-five percent of the persons with a diagnosis of AIDS reported anxiety symptoms. As HIV increases in areas of the world where self-care is the primary approach to managing HIV, additional research will be needed to address the effectiveness of cross-cultural differences in strategies for self-managing HIV-related anxiety.

Post-discharge hospital utilization among adult medical inpatients with depressive symptoms

BACKGROUND

Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service.

OBJECTIVE

We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services.

DESIGN

A secondary analysis was performed using data from 738 English-speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety-net hospital.

MEASUREMENTS

We used the nine-item Patient Health Questionnaire (PHQ-9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables.

RESULTS

Of the 738 subjects included in the analysis, 238 (32%) screened positive for depressive symptoms. The unadjusted hospital utilization within 30 days of discharge was 56 utilizations per 100 depressed patients compared with 30 utilizations per 100 non-depressed patients, incident rate ratio (IRR) (confidence interval [CI]), 1.90 (1.51-2.40). After controlling for potential confounders, a higher rate of post-discharge hospital utilization was observed in patients with depressive symptoms compared to patients without depressive symptoms (IRR [CI], 1.73 [1.27-2.36]).

CONCLUSIONS

A positive screen for depressive symptoms during an inpatient hospital stay is associated with an increased rate of readmission within 30 days of discharge in an urban, academic, safety-net hospital population.

Adverse psychosocial factors predict poorer prognosis in HIV disease: a meta-analytic review of prospective investigations

There is a growing epidemiological literature focusing on the association between psychosocial stress and human immunodeficiency virus (HIV) disease progression or acquired immunodeficiency syndrome (AIDS), but inconsistent findings have been published. We aimed to quantify the association between adverse psychosocial factors and HIV disease progression. We searched Medline; PsycINFO; Web of Science; PubMed up to 19 January 2009, and included population studies with a prospective design that investigated associations between adverse psychosocial factors and HIV disease progression or AIDS. Two reviewers independently extracted data on study characteristics, quality, and estimates of associations. The overall meta-analysis examined 36 articles including 100 psychosocial and disease related relationships. It exhibited a small, but robust positive association between adverse psychosocial factors and HIV progression (correlation coefficient as combined size effect 0.059, 95% confidence interval 0.043-0.074, p<0.001). Notably, sensitivity analyses showed that personality types or coping styles and psychological distress were more strongly associated with greater HIV disease progression than stress stimuli per se, and that all of the immunological and clinical outcome indicators (acquired immunodeficiency syndrome stage, CD4+ T-cell decline, acquired immunodeficiency syndrome diagnosis, acquired immunodeficiency syndrome mortality, and human immunodeficiency virus disease or acquired immunodeficiency syndrome symptoms) except for viral load exhibited detrimental effects by adverse psychosocial factors. In conclusion, the current review reveals a robust relationship between adverse psychosocial factors and HIV disease progression. Furthermore, there would appear to be some evidence for particular psychosocial factors to be most strongly associated with HIV disease progression.

The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS

Potent antiretroviral therapy (ART) has transformed HIV from a death sentence to a chronic illness. Accordingly, the goal of HIV care has shifted from delaying death to achieving optimal health outcomes through ART treatment. ART treatment success hinges on medication adherence. Extensive research has demonstrated that the primary barriers to ART adherence include mental illness, especially depression and substance abuse, as well as histories of traumatic experiences such as childhood sexual and physical abuse. These psychosocial factors are highly prevalent in people living with HIV/AIDS (PLWHA) and predict poor ART adherence, increased sexual risk behaviours, ART treatment failure, HIV disease progression and higher mortality rates. The efficacy of standard mental health interventions, such as antidepressant treatment and psychotherapy, has been well-defined, and a small but growing body of research demonstrates the potential for such interventions to improve ART adherence and reduce sexual risk behaviours. Despite this evidence, mental disorders in PLWHA frequently go undiagnosed and untreated. Challenges to the provision of mental healthcare for PLWHA in HIV clinical settings include time and resource constraints, lack of expertise in psychiatric diagnosis and treatment, and lack of available mental health referral services. Future research should prioritize the evaluation of mental health interventions that are cost-effective and feasible for widespread integration into HIV clinical care; the impact of such interventions on ART adherence and clinical outcomes; and interventions to identify individuals with histories of traumatic experiences and to elucidate the mechanisms through which such histories pose barriers to effective HIV treatment.

Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care

The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective-disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional-economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions. Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so. Clinical psychologists' failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today's clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student-faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge. A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands high-quality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer high-quality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.