C. Andres Bedoya

Association between anxiety and mortality in patients with coronary artery disease: A meta-analysis

BACKGROUND Depression and anxiety are common in patients with coronary artery disease (CAD). Although depression clearly has been associated with mortality in this population, the relationship between anxiety and mortality is less clear. Accordingly, we performed a series of meta-analyses to (1) examine the relationship between anxiety and mortality in patients with established CAD and (2) determine if this relationship differs in patients with stable CAD compared to those who have just had an acute coronary syndrome (ACS). METHODS AND RESULTS Systematic literature searches identified 44 articles (total N = 30,527) evaluating the prospective relationship between anxiety and mortality in individuals with established CAD. A series of 8 adjusted and unadjusted meta-analyses were performed to examine this relationship across all patients, with sensitivity analyses completed in post-ACS and stable CAD cohorts. In unadjusted analyses, anxiety was associated with a moderate increase in mortality risk (odds ratio 1.21 per SD increase in anxiety). However, when adjusting for covariates, nearly all associations became nonsignificant. In sensitivity analyses, anxiety was associated with an increased risk of poor outcomes in the stable CAD-but not post-ACS-cohort. CONCLUSIONS These analyses confirm that anxiety is associated with increased risk of mortality in patients with CAD; however, this relationship is not as strong as that of depression and may be explained partly by other clinical factors. If anxiety screening is performed, it should be performed during a period of clinical stability and should target anxiety disorders rather than anxiety symptoms alone.

Predictors of HIV Transmission Risk Behavior and Seroconversion Among Latino Men Who have Sex with Men in Project EXPLORE

In the US, Latino MSM are disproportionately affected by HIV, yet there is a paucity of data for this risk group. To this end, we examined data on Latino and non-Latino white MSM who participated across six cities in a 2-year randomized behavioral intervention study—Project EXPLORE. At baseline, Latinos reported significantly more serodiscordant unprotected anal intercourse (SDUA) than non-Latinos. Longitudinal predictors of SDUA included marijuana, poppers, amphetamines and heavy drinking, as well as lower self-efficacy, poorer communication skills, weaker safe-sex norms and more enjoyment of risky sex. For HIV infection, Latinos had significantly higher seroconversion rate over follow-up than non-Latinos. Longitudinal predictors of seroconversion among Latinos included poppers and SDUA. Intervention effects did not significantly differ between Latino and non-Latinos. Findings support HIV intervention work with Latino MSM that includes skills training/counseling to address attitudes about safe sex and impact of substance use on HIV-risk behavior and acquisition.ResumenEn los Estados Unidos, el VIH afecta de una manera desproporcionada a los hombres de origen latino que tienen relaciones sexuales con otros hombres. Pero aún hay poca información o datos disponibles que enfocan en este grupo de alto riesgo. A este fin, examinamos los datos de hombres que tienen relaciones sexuales con otros hombres (HSH) quienes participaron en un estudio aleatorizado de dos años de una intervención conductual que se llevó a cabo en seis ciudades – Project EXPLORE. Sólo examinamos los datos de participantes de origen latino y de blancos no de origen latino. En la visita inicial, comparado a los blancos, los hombres de origen latino indicaron significativamente más altos niveles de sexo anal serodiscordante sin protección (SDUA). Al transcurso del estudio, predictores longitudinales de SDUA incluyeron los siguientes: uso de marijuana, poppers (nitritos), anfetaminas, y un nivel alto de consumir el alcohol, y también un nivel bajo de auto-eficacia, pobres destrezas de communicación, bajas normas sobre el sexo seguro, y más disfrutamiento del sexo de alto riesgo. Con respecto a la infección por VIH, los latinos experimentaron significativamente más altos niveles de sero-infección sobre el transcurso del estudio en comparación a los hombres blancos. Los predictores longitudinales de sero-infección para los latinos incluyeron el uso de poppers (nitritos) y SDUA. El efecto de la intervención no fue diferente cuando comparamos a los latinos y los blancos. Los resultados sugieren que, para prevenir el comportamiento de alto riesgo y el sero-infección dentro los latinos HSH, las intervenciones para la prevención del VIH deben de incluir consejería y entrenamiento en destrezas para mejorar las actitudes sobre el sexo seguro y el impacto del uso de drogas callejeras.

Intimacy and Sexual Decision Making: Exploring the Perspective of HIV Positive Women Over 50

Due to advances made in HIV treatment, the population of individuals with HIV over the age of 50 is growing. Aging women face many developmental challenges and some of these challenges, including having or maintaining intimate partner relationships, may be particularly pronounced for aging women living with HIV. However, research exploring the psychosocial needs of aging women with HIV is limited. Thus, the aim of this study was to explore factors that impact intimate partner relationships for older women with HIV. Nineteen women (mean age=56.79, SD=4.63 years) referred from Boston-area community organizations and hospitals completed in-depth individual interviews. Forty-seven percent of participants identified themselves as Black/African American, and 37% as White/Caucasian. Average time since diagnosis was 16.32 years (SD=5.70). Interviews continued until saturation of content was reached. Inclusion criteria included: biologically born female; aged 50 years or older; diagnosis of HIV/AIDS; and English speaking. Qualitative interviews were coded by two raters and content analyses were conducted using NVivo 9 software. The findings are described across the following three main themes: (1) stigma; (2) body image concerns; and (3) the disclosure dilemma. The themes and issues identified by this study may help guide sexual health-related interventions for older HIV-infected women.

Cognitive behavioural therapy for adherence and depression in patients with HIV: a three-arm randomised controlled trial

BACKGROUND Depression is highly prevalent in people with HIV and has consistently been associated with poor antiretroviral therapy (ART) adherence. Integrating cognitive behavioural therapy (CBT) for depression with adherence counselling using the Life-Steps approach (CBT-AD) has an emerging evidence base. The aim of this study was to test the efficacy of CBT-AD. METHODS In this three-arm randomised controlled trial in HIV-positive adults with depression, we compared CBT-AD with information and supportive psychotherapy plus adherence counselling using the Life-Steps approach (ISP-AD), and with enhanced treatment as usual (ETAU) including Life-Steps adherence counselling only. Participants were recruited from three sites in New England, USA (two hospital settings and one community health centre). Patients were randomly assigned (2:2:1) to receive CBT-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), ISP-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), or ETAU (one Life-Steps session and five assessment visits roughly every 2 weeks), randomisation was done with allocation software, in pairs, and stratified by three variables: study site, whether or not participants had been prescribed antidepressant medication, and whether or not participants had a history of injection drug use. The primary outcome was ART adherence at the end of treatment (4 month assessment) assessed via electronic pill caps (Medication Event Monitoring System [MEMS]) with correction for pocketed doses, analysed by intention to treat. FINDINGS Patients were recruited from Feb 26, 2009, to June 21, 2012. Patients who were assigned to CBT-AD (94 randomly assigned, 83 completed assessment) had greater improvements in adherence (estimated difference 1·00 percentage point per visit, 95% CI 0·34 to 1·66, p=0·003) and depression (Center for Epidemiological Studies depression [CESD] score estimated difference -0·41, -0·66 to -0·16, p=0·001; Montgomery-Asberg depression rating scale [MADRS] score -4·69, -8·09 to -1·28, p=0·007; clinical global impression [CGI] score -0·66, -1·11 to -0·21, p=0·005) than did patients who had ETAU (49 assigned, 46 completed assessment) after treatment (4 months). No significant differences in adherence were noted between CBT-AD and ISP-AD (97 assigned, 87 completed assessment). No study-related adverse events were reported. INTERPRETATION Integrating evidenced-based treatment for depression with evidenced-based adherence counselling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate effective psychosocial depression treatments such as CBT-AD to people living with HIV/AIDS and examine the cost-effectiveness of such approaches. FUNDING National Institute of Mental Health, National Institute of Allergy and Infectious Diseases.Summary Background Depression, highly prevalent in HIV, is consistently associated with worse ART adherence. Integrating CBT for depression with adherence counseling using the “Life-Steps” approach (CBT-AD) has an emerging evidence base. The aim of the current study was to test the efficacy of CBT-AD. Methods We conducted a three-arm RCT (N=240 HIV-positive adults with depression), comparing CBT-AD to Life-Steps integrated with information and supportive psychotherapy (ISP-AD) (both 12 sessions), and to ETAU (1 session Life-Steps). Participants were recruited from three sites in New England area, two being hospital settings, and one being a community health center. Randomization was done via a 2:2:1 ratio, using random allocation software by the data manager, in pairs, stratified by three variables: site, whether or not the participant was prescribed antidepressant medications, and history of injection drug use. The primary outcome was adherence assessed via electronic pill caps (MEMs) with correction for “pocketed” doses. Secondary outcomes included depression, plasma HIV RNA and CD4. Follow-ups occurred at 4, 8 and 12 months. We used intent-to treat analyses with ANCOVA for independent-assessor pre-post assessments of depression and mixed effects modeling for longitudinal assessments. Clinical Trial Registration: NCT00951028, https://clinicaltrials.gov/ct2/show/NCT00951028), closed to new participants. Findings The period of recruitment was February 26, 2009 to June 21, 2012, with the 12-month follow-up period extending until April 29, 2013. There were no study-related adverse events. CBT-AD (n=94 randomized, 83 retained) had greater improvements in adherence (Est.=1·00, CI=0·34, 1·66, p=0·003) and depression (CES-D Est.=−0·41, CI=−0·66, −0·16, p=0·001; MADRS Est.=−4·69, CI=−8·09, −1·28, p=0·007; CGI Est.=−0·66, CI=−1·11,-0·21, p=0·005) than ETAU (49 randomized, 46 retained) at post-treatment (4-month). Over follow-ups, CBT-AD (84 retained) maintained higher adherence (Est.=8·93, CI=1·90, 15·97, p=0·013) and lower depression on the CES-D (Est=−3·56, CI=−6·08, −1·05, p=·005) and CGI (Est.=−0·39, CI=−0·77, −0·18, p=·04) than ETAU (86 retained); however, not for the MADRS. There were no significant differences between CBT-AD and ISP-AD (97 randomized, 87 retained) for the post-treatment or follow-up (86 retained) analyses. There were no intervention effects on HIV RNA or CD4, though a higher percentage (91·4%) than expected was virally suppressed at baseline. Interpretation Integrating evidenced-based treatment for depression with evidenced-based adherence counseling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate of effective psychosocial depression treatments such as CBT-AD to individuals living with HIV/AIDS, as well as examine the cost-effectiveness of such approaches. Funding National Institute of Mental Health (R01MH084757) and some author time from NIAID 5P30AI060354, and P30AI042853.

Future Directions for Interventions Targeting PTSD in HIV-infected Adults

&NA; Although studies consistently report high rates of comorbid posttraumatic stress disorder (PTSD) and HIV infection, development and testing of PTSD treatment interventions in HIV‐infected adults is limited. As such, the purpose of this review was twofold. First, this review augments the three existing reviews of research for PTSD in HIV‐infected adults conducted within the past 10 years. We found two empirically supported cognitive‐behavioral therapy‐based interventions for the treatment of trauma‐related symptoms in HIV‐infected adults. Due to the continued limited number of effective interventions for this population, a second aim of our review was to draw from the expansive field of effective PTSD interventions for the general population to propose ways that future clinical intervention research may be tailored for HIV‐infected adults. Therefore, in addition to a review, we conceptualized this paper as an opportunity to generate an ideal preview of the field of intervention research in this population.

Reflections on living with HIV over time: exploring the perspective of HIV-infected women over 50

Objectives: Approximately 32.7% of people living with HIV/AIDS (PLWHA) in the USA are now over the age of 50. Women comprise a significant percentage of the US HIV epidemic and the percentage of women diagnosed with HIV continues to grow; however, little is known about womens experiences living and coping with HIV over time. The goal of this study was to explore the experiences of US women over 50 living with HIV to better understand how they make sense of their diagnosis and cope with their illness over time and during the aging process. Method: Nineteen women (mean age = 56.79, SD = 4.63) referred from Boston-area organizations and hospitals completed one-time, in-depth individual interviews, out of which 47% of the participants were identified as Black/African Americans, and 37% as White. The average time since diagnosis was 16.32 years (SD = 5.70). Inclusion criteria included: (1) female sex, (2) aged 50 or older, (3) HIV diagnosis, and (4) English speaking. Transcribed interviews were analyzed using a grounded theory approach and NVivo 9 software. Results: Findings are described across the following themes: (1) experiences at diagnosis, (2) uncertainty of disease course, (3) acceptance, and (4) living ‘well’ with HIV. Participants appeared to be well adjusted to their HIV diagnosis and described a progression to acceptance and survivorship; they identified strategies to ‘live well’ in the context of HIV. For some, health-related uncertainty about the future remained. These findings were organized into a model of coping with HIV. Conclusion: Themes and issues identified by this study may help guide interventions across the lifespan for women with HIV.

Impact of a Culturally Focused Psychiatric Consultation on Depressive Symptoms Among Latinos in Primary Care

OBJECTIVE A culturally focused psychiatric (CFP) consultation service was implemented to increase engagement in mental health care and reduce depressive symptoms among adult Latino primary care patients. The aim of this study was to assess preliminary efficacy of the CFP consultation service to reduce depressive symptoms. METHODS In a randomized controlled study, primary care clinics were randomly selected to provide either the two-session CFP intervention or enhanced usual care. For CFP intervention participants, study clinicians (psychologists or psychiatrists) provided a psychiatric assessment, psychoeducation, cognitive-behavioral tools, and tailored treatment recommendations; primary care providers were provided a consultation summary. Depressive symptoms (as measured by the Quick Inventory of Depressive Symptomatology-Self Rated [QIDS-SR]) were assessed at baseline and six-month follow-up. Multiple regression analysis was conducted to evaluate whether CFP intervention participants showed greater improvement in depressive symptoms at follow-up, with control for baseline depression, clinic site, and significant covariates. RESULTS Participants (N=118) were primarily Spanish-monolingual speakers (64%). Although depressive symptoms remained in the moderate range for both groups from baseline to six months, symptom reduction was greater among CFP intervention participants (mean±SD change in QIDS-SR score=3.46±5.48) than those in usual care (change=.09±4.43). The final multiple regression model indicated that participation in the CFP intervention predicted lower depressive symptoms at follow-up (unstandardized beta=-3.09, p=.008), independent of baseline depressive symptoms, clinic site, age, gender, and employment status. CONCLUSIONS Results suggest that Latinos experiencing depressive symptoms may benefit from a short-term CFP consultation. Findings also support the integration of psychiatric interventions for Latinos in the primary care setting.

Association of Race, Ethnicity and Language with Participation in Mental Health Research Among Adult Patients in Primary Care

Racial and ethnic minorities remain underrepresented in clinical psychiatric research, but the reasons are not fully understood and may vary widely between minority groups. We used the Z-test of independent proportions and binary logistic regression to examine the relationship between race, ethnicity or primary language and participation in screening as well as interest in further research participation among primary care patients being screened for a depression study. Minorities were less likely than non-Hispanic Whites to complete the initial screening survey. Latinos and Blacks were more likely to agree to be contacted for research than non-Hispanic Whites. Among Latinos, primary language was associated with willingness to be contacted for research. Associations between research participation and race, ethnicity and language are complex and vary across different enrollment steps. Future research should consider stages of the research enrollment process separately to better understand barriers and identify targets for intervention.

Psychological Co-morbidities of HIV/AIDS

Individuals with HIV/AIDS are disproportionately affected by mental health problems relative to the general population, including mood, anxiety, and substance abuse disorders. Psychological factors have been implicated in less effective disease management and advanced disease progression among human immunodeficiency virus (HIV)-positive individuals. Thus, it is critical that mental healthcare providers are aware of the intricate relationship between comorbid psychological disorders and the physical health of individuals living with HIV. To this end, this chapter will provide an overview of the epidemiology and pathophysiology of various Axis I disorders and HIV, including clinical considerations for assessment and treatment, and a review of existing evidence supporting the efficacy of psychotherapy interventions. When reviewing each of these disorders, particular care is taken to address practical considerations for assessment and treatment, as well as the broader nature of the relationship between physical symptoms associated with HIV/AIDS and various psychosocial concerns. The chapter concludes with a discussion of cultural considerations for the clinician working with HIV-positive individuals.

A multilevel examination of sleep, depression, and quality of life in people living with HIV/AIDS:

Sleep problems are prevalent in people living with HIV/AIDS; however, few studies examine how poor sleep affects mental health and quality of life longitudinally. A sample of people living with HIV/AIDS from a randomized trial (N = 240; mean age = 47.18; standard deviation = 8.3; 71.4% male; 61.2% White) completed measures of depression (Montgomery–Åsberg Depression Rating Scale), health-related quality of life (AIDS Clinical Trial Group Quality of Life Measure), and life satisfaction (Quality of Life Inventory) at baseline and 4, 8, and 12 months. Controlling for time, condition, and relevant interactions, sleep problems significantly predicted worse outcomes over time (ps < 0.001). Findings have implications for the importance of identifying and treating sleep problems in people living with HIV/AIDS to improve mental health and quality-of-life outcomes.