Stress management therapy can improve quality-of-life for people with HIV

A substantial proportion of HIV-positive patients taking antiretroviral therapy have significant levels of anxiety, depression, and psychological distress, according to a study published in the March 30^th edition of AIDS. The trial suggests that a few months of weekly cognitive-behavioural stress management (CBSM) can improve mental and physical well-being in these patients.

Psychosocial factors, such as having depression, stress, or a lack of social support are known to influence the course of HIV infection. Such factors can affect the working of the immune system, and impact on adherence to anti-HIV treatment.

Previous randomised trials have shown that a kind of psychotherapy called cognitive-behavioural stress management can improve well-being and may possibly influence overall mental health in people with HIV. However, most of these studies were conducted before potent anti-HIV treatment became available.

So a Swiss team, led by Jens Gaab, of the University of Zurich, conducted a randomised controlled trial of CBSM at four outpatient clinics. At total of 104 HIV-positive patients were randomised to participate in twelve group sessions of CBSM lasting two hours every week, or to receive standard medical care. CD4 cell count, viral load, adherence to drug therapy, and well-being were studied on entry to the study and up to a year after the study ended.

All participants were taking antiretroviral therapy, had CD4 cell counts greater than 100 cells/mm³ and no opportunistic infections. Patients who were intravenous drug users or on methadone maintenance and those who had had recent psychotherapy or a current major psychiatric disorder were excluded.

In the 77 people who completed the trial, no differences were found between the therapy and control groups’ CD4 cell count and viral load. Also, no difference was seen in drug adherence between the groups.

However, significant benefits were reported by the CBSM group in mean change of quality of life scores compared with the control group: physical health 2.9 versus -0.2 (p = 0.05); mental health 4.8 versus -0.5 (p = 0.02); anxiety -2.1 versus 0.3 (p = 0.002); and depression -2.1 versus 0.02 (p = 0.001).

The effect on anxiety and depression was further examined by separating the groups according to their scores on the Hospital Anxiety and Depression Scale (HADS).

“Alleviation of depression and anxiety symptoms were most pronounced among participants with high psychological distress at baseline”, write the investigators. Indeed, only participants in the CBSM group who had HADS scores above the standard cut-off levels for anxiety or depression at baseline showed significant improvement at twelve months.

The authors suggest that psychosocial factors may make little impact on HIV viral load and CD4 cell count amongst patients taking effective anti-HIV treatment. However, in individuals with high psychological stress, CBSM training might impact on their physical and mental health over a longer period. The authors suggest that screening for psychological distress should become part of routine HIV management. However, as group therapy is not acceptable to all patients, other proven strategies, such as individual psychotherapy might be more accessible.