Gail Ironson

Mood Disorders in the Medically Ill: Scientific Review and Recommendations

OBJECTIVE The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Posttraumatic Stress Symptoms, Intrusive Thoughts, Loss, and Immune Function after Hurricane Andrew

Objective To examine the impact of and relationship between exposure to Hurricane Andrew, a severe stressor, posttraumatic stress symptoms and immune measures. Methods Blood draws and questionnaires were taken from community volunteer subjects living in the damaged neighborhoods between 1 and 4 months after the Hurricane. Results The sample exhibited high levels of posttraumatic stress symptoms by questionnaire (33% overall; 76% with at least one symptom cluster), and 44% scored in the high impact range on the Impact of Events (IES) scale. A substantial proportion of variance in posttraumatic stress symptoms could be accounted for by four hurricane experience variables (damage, loss, life threat, and injury), with perceived loss being the highest correlate. Of the five immune measures studied Natural Killer Cell Cytotoxicity (NKCC) was the only measure that was meaningfully related (negatively) to both damage and psychological variables (loss, intrusive thoughts, and posttraumatic stress disorder (PTSD). White blood cell counts (WBCs) were significantly positively related with the degree of loss and PTSD experienced. Both NKCC (lower) and WBC were significantly related to retrospective self-reported increase of somatic symptoms after the hurricane. Overall, the community sample was significantly lower in NKCC, CD4 and CD8 number, and higher in NK cell number compared to laboratory controls. Finally, evidence was found for new onset of sleep problems as a mediator of the posttraumatic symptom - NKCC relationship. Conclusions Several immune measures differed from controls after Hurricane Andrew. Negative (intrusive) thoughts and PTSD were related to lower NKCC. Loss was a key correlate of both posttraumatic symptoms and immune (NKCC, WBC) measures.

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patients life space.

The ironson-woods spirituality/religiousness index is associated with long survival, health behaviors, less distress, and low cortisol in people with HIV/AIDS

The purpose of this study was to determine the reliability and validity of an instrument that measures both spirituality and religiousness, to examine the relation between spirituality and religiousness and important health outcomes for people living with HIV, and to examine the potential mediators of these relations. One aim was to determine whether subscales of spirituality, religiousness, or both would be independently related to long survival in people living with AIDS. The Ironson-Woods Spirituality/Religiousness (SR) Index is presented with evidence for its reliability and validity. Four factors were identified on the Ironson-Woods SR Index (Sense of Peace, Faith in God, Religious Behavior, and Compassionate View of Others). Each subscale was significantly related to long survival with AIDS. That is, the long-term survivor (LTS) group (n = 79) scored significantly higher on these factors than did the HIV-positive comparison (COMP) group (n = 200). Long survival was also significantly related to both frequency of prayer (positively) and judgmental attitude (negatively). In addition, the Ironson-Woods SR Index yielded strong and significant correlations with less distress, more hope, social support, health behaviors, helping others, and lower cortisol levels. The relation between religious behavior and health outcomes was not due to social support. Further analyses were conducted, which identified urinary cortisol concentrations and altruistic behavior as mediators of the relation between SR and long survival.

Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment.

Objective: Most previous longitudinal studies demonstrating relationships between psychosocial variables and human immunodeficiency virus (HIV) disease progression utilized samples of gay men accrued before the era of highly active antiretroviral treatment (HAART), without including viral load (VL) as an indicator of disease progression or assessing the impact of medication adherence. This study sought to determine whether psychosocial variables would predict both CD4 and VL changes in a diverse sample assessed entirely during the era of HAART and accounting for adherence effects. Methods: This longitudinal study assessed a multiethnic HIV+ sample (n = 177) of men and women in the midrange of illness (CD4 number between 150 and 500; no previous acquired immunodeficiency syndrome [AIDS]–defining symptom) every 6 months for 2 years. Hierarchical linear modeling was used to model change in CD4 and VL controlling for sociodemographics (age, gender, ethnicity, education) and medical variables (baseline CD4/VL, antiretroviral medications at each time point, adherence). Results: Baseline depression, hopelessness, and education predicted the slope of CD4 and VL. Avoidant coping and life event stress predicted VL change. Cumulative variables produced stronger relationships (depression, avoidant coping, and hopelessness with CD4/VL slope and life events stress with VL slope). High cumulative depression and avoidant coping were associated with approximately twice the rate of decline in CD4 as low scorers and greater relative increases in VL. Social support was not significantly related to CD4 or VL slope. Conclusions: Psychosocial factors contribute significantly to the variance in HIV disease progression (assessed through CD4 number and VL) in a diverse sample, accounting for adherence and do so in the era of HAART. HAART = highly active antiretroviral treatment; VL = viral load; HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome; PI = protease inhibitor; HLM = hierarchical linear modeling; DR = decline ratio; SES = socioeconomic status; BDI = Beck Depression Inventory; BHS = Beck Hopelessness Scale; N/A = not applicable.

Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS.

Numerous studies have linked social support to better medication adherence among illness groups, but few have examined potential mechanisms for this relationship. Relationships were examined between social support, depression, positive states of mind (PSOM), and medication adherence among HIV positive men who have sex with men (n = 61) and women (n = 29) on highly active antiretroviral therapy. Depression and PSOM were evaluated as potential mediators of the relationship between support and adherence. Cross-sectional data showed that greater social support and PSOM related to better adherence whereas higher depression scores related to nonadherence. PSOM partially mediated the relationship between social support and adherence. PSOM may be an important mechanism through which social support is related to better medication adherence in this population.

Massage therapy is associated with enhancement of the immune system's cytotoxic capacity.

Twenty-nine gay men (20 HIV+, 9 HIV-) received daily massages for one month. A subset of 11 of the HIV+ subjects served as a within subject control group (one month with and without massages). Major immune findings for the effects of the month of massage included a significant increase in Natural Killer Cell number, Natural Killer Cell Cytotoxicity, soluble CD8, and the cytotoxic subset of CD8 cells. There were no changes in HIV disease progression markers (CD4, CD4/CD8 ratio, Beta-2 microglobulin, neopterin). Major neuroendocrine findings, measured via 24 hour urines included a significant decrease in cortisol, and nonsignificant trends toward decrease of catecholamines. There were also significant decreases in anxiety and increases in relaxation which were significantly correlated with increases in NK cell number. Thus, there appears to be an increase in cytotoxic capacity associated with massage. Implications for HIV+ men as those with other illnesses, particularly cancer, are discussed.

Effects of anger on left ventricular ejection fraction in coronary artery disease

This study examined the comparative potency of several psychological stressors and exercise in eliciting myocardial ischemia as measured by left ventricular (LV) ejection fraction (EF) changes using radionuclide ventriculography. Twenty-seven subjects underwent both exercise (bicycle) and psychological stressors (mental arithmetic, recall of an incident that elicited anger, giving a short speech defending oneself against a charge of shoplifting) during which EF, blood pressure, heart rate and ST segment were measured. Eighteen subjects had 1-vessel coronary artery disease (CAD), defined by greater than 50% diameter stenosis in 1 artery as assessed by arteriography. Nine subjects served as healthy control subjects. Anger recall reduced EF more than exercise and the other psychological stressors (overall F [3.51] = 2.87, p = .05). Respective changes in EF for the CAD patients were -5% during anger recall, +2% during exercise, 0% during mental arithmetic and 0% during the speech stressor. More patients with CAD had significant reduction in EF (greater than or equal to 7%) during anger (7 of 18) than during exercise (4 of 18). The difference in EF change between patients with CAD and healthy control subjects was significant for both anger (t25 = 2.23, p = 0.04) and exercise (t25 = 2.63, p = 0.01) stressors. In this group of patients with CAD, anger appeared to be a particularly potent psychological stressor.

An Increase in Religiousness/Spirituality Occurs After HIV Diagnosis and Predicts Slower Disease Progression over 4 Years in People with HIV

BackgroundMost studies on religion/spirituality predicting health outcomes have been limited to church attendance as a predictor and have focused on healthy people. However, confronting a major medical crisis may be a time when people turn to the sacred.ObjectiveThe purpose of this study was to determine the extent to which changes in spirituality/religiousness occur after HIV diagnosis and whether changes predict disease progression.Design/participantsThis longitudinal study examined the relationship between changes in spirituality/religiousness from before with after the diagnosis of HIV, and disease progression (CD4 and viral load [VL] every 6 months) over 4 years in 100 people with HIV. Measures included change in religiousness/spirituality after diagnosis of HIV, religiousness/spirituality at various times in one’s life, church attendance, depression, hopelessness, optimism, coping (avoidant, proactive), social support, CD4/VL, and health behaviors.ResultsForty-five percent of the sample showed an increase in religiousness/spirituality after the diagnosis of HIV, 42% remained the same, and 13% decreased. People reporting an increase in spirituality/religiousness after the diagnosis had significantly greater preservation of CD4 cells over the 4-year period, as well as significantly better control of VL. Results were independent of (i.e., held even after controlling for) church attendance and initial disease status (CD4/VL), medication at every time point, age, gender, race, education, health behaviors (adherence, risky sex, alcohol, cocaine), depression, hopelessness, optimism, coping (avoidant, proactive), and social support.ConclusionsThere is an increase in spirituality/religiousness after HIV diagnosis, and this increase predicts slower disease progression; medical personnel should be aware of its potential importance.

A general measure of work stress: The Stress in General scale.

The present study focused on the development and validation of scores on the Stress in General scale. Three diverse samples of workers (n = 4,322, n = 574, n = 34) provided psychometric and validity evidence. All evidence converged on the existence of two distinct subscales, each of which measured a different aspect of general work stress. The studies also resulted in meaningful patterns of correlations with stressor measures, a physiological measure of chronic stress (blood-pressure reactivity), general job attitude measures, and intentions to quit.