Susan Evans

Fatigue in Hiv Illness: Relationship to Depression, Physical Limitations, and Disability

Objective This study was conducted to investigate the prevalence of clinical fatigue reported by gay/bisexual men at all HIV illness stages, and whether fatigue, while associated with depression, independently contributes to limitations in physical function and disability. Method HIV- men, HIV+ men with CD4 counts >500, HIV+ men with CD4 counts 200 to 500, and men with AIDS were compared on prevalence of clinical fatigue, as defined by a standardized instrument. Among HIV+ men, the relationships among fatigue, depressed mood, major depressive disorder, HIV illness markers (including CD4 count and HIV RNA viral load), physical limitations, and disability were assessed at baseline and after 1 year. Results The prevalence of clinical fatigue in men with CD4 counts <500 was 14%, significantly higher than HIV- men and HIV+ men with CD4 counts >500. However, fatigue was not directly correlated with CD4 count or HIV RNA. Fatigue was a chronic symptom that was associated with depressed mood, major depressive disorder, physical limitations, and disability. After 1 year, an increase in depressive symptoms predicted a small amount of variance in fatigue; however, depressive symptoms were not associated with physical limitations or disability after controlling for fatigue. Conclusion Fatigue is a chronic symptom that is more prevalent in advanced HIV illness, and which, although associated with depression, does not seem to be merely a symptom of depression. Because fatigue contributes independently to physical limitations and disability, it should be assessed and treated.

Pain and Depression in HIV Illness

The purpose of this study was to examine the relationship among pain and depression, hopelessness, and quality of life in human immunodeficiency virus (HIV)-infected gay men, taking into account the role of HIV symptoms. One hundred sixty-one HIV+ gay men were assessed, with 40 men endorsing HIV-related pain. The HIV+ men with pain had a modal rating of pain within the mild range. They had significantly more advanced disease, more physical and depressive symptoms, and reported less life satisfaction than the men without pain. However, when HIV illness variables are accounted for, the higher depression scores in the men with pain were largely accounted for by somatic rather than cognitive symptoms. While pain is associated with greater physical distress in this cohort of HIV-seropositive gay men, it does not appear to be independently associated with cognitive symptoms of depression. These findings apply to HIV-infected men with mild pain and may not apply to those who experience more severe pain. Nonetheless, these observations highlight the overlap between symptoms of depression and pain and the challenge that clinicians face in assessing patients suffering from pain.

Coping strategies of HIV patients with peripheral neuropathy

Abstract The aim of this study was to evaluate the association between coping strategies and reports of with pain and distress in patients with HIV-related peripheral neuropathy. Seventy-eight HIV seropositive subjects completed the Coping Strategies Questionnaire (CSQ), a self-report measure that assesses seven factors, the Brief Pain Inventory (BPI), the Brief Symptom Inventory (BSI) and the Beck Depression Inventory (BDI). Bivariate correlations revealed that younger patients used more Praying-Hoping (r=−.23, p<.04) and Catastrophizing (r=−.30, p<.007). t-tests demonstrated that women used more Praying-Hoping (t(76) = 3.42, p<.01), while Hispanic and African American patients used more Praying-Hoping more than Caucasians (F (1,77) = 22.11, p=.0005). Catastrophizing significantly predicted higher scores on the BDI (t=2.968, p=.004), the Global Severity Index (GSI) of the Brief Symptom Inventory BSI (t=2.400, p=.02); and pain interference on the Brief Pain Inventory BPI (t=2.996, p=.004) controlling for age, gender, and ethnic background. These results demonstrate that coping strategies may differ according to age, gender, and ethnic background in an HIV population, and that Catastrophizing predicts distress and interference with functioning in this sample.

Health locus of control, distress, and utilization of protease inhibitors among HIV-positive men

OBJECTIVE To investigate the relationship between health locus of control (HLOC), distress, and protease inhibitor (PI) utilization in gay/bisexual men in all stages of HIV illness. METHOD A total of 173 men participating in a longitudinal study of the psychological effects of HIV illness were administered a number of psychological distress measures and the HLOC scale. The association between the HLOC subscales, distress, and PI utilization was evaluated. RESULTS In addition to physical symptoms, the attribution of health status to chance or fate significantly predicted depressive symptoms, feelings of hopelessness, and recent life stress. Results also demonstrated a significant relationship between strong, positive beliefs in doctors and other health care professionals and PI utilization. CONCLUSION The results of this study point to a strong association between beliefs that health status is related to chance or fate and distress. In addition, beliefs in physicians and other health care providers appear to contribute to decisions to initiate PI therapy.

Social-vocational adjustment in unipolar mood disorders: results of the DSM-IV field trial

430 patients participating in the DSM-IV field trial receiving a DSM-III-R SCID-derived diagnosis of episodic major depression (n = 131), dysthymic disorder (n = 37) and double depression (n = 262) completed the social adjustment scale-self-report (Weissman and Bothwell, 1976). Patients with double depression demonstrated greater social morbidity than those suffering from episodic major depression or dysthymic disorder (P < 0.05). Significant predictors of high social morbidity in double depressives included severity of symptoms (P < 0.0001), followed by age of onset of first major depression (P < 0.04). Subscale analysis revealed that double depressives were significantly more impaired in work outside the home and in terms of their financial status (P < 0.05).

Anger and Posttraumatic Stress Disorder in Disaster Relief Workers Exposed to the September 11, 2001 World Trade Center Disaster : One-Year Follow-Up Study

Although anger is an important feature of posttraumatic stress disorder (PTSD) it is unclear whether it is simply concomitant or plays a role in maintaining symptoms. A previous study of disaster workers responding to the terrorist attacks of September 11, 2001 (Evans et al., 2006) indicated that those with PTSD evidenced more severe anger than those without. The purpose of this study was to conduct a 1-year follow-up to assess the role of anger in maintaining PTSD. Workers with PTSD continued to report more severe anger than those without; there were statistically significant associations between changes in anger, PTSD severity, depression, and psychiatric distress. Multiple regression analysis indicated initial anger severity to be a significant predictor of PTSD severity at follow-up, which is consistent with the notion that anger maintains PTSD. One implication is that disaster workers with high anger may benefit from early intervention to prevent chronic PTSD.

Mindfulness‐based stress reduction (MBSR) and distress in a community‐based sample.

BACKGROUND Numerous studies have found Mindfulness-based stress reduction (MBSR) to be useful for a wide range of problems including anxiety, pain and coping with a medical illness. The primary goal of this study was to evaluate the effectiveness of an 8-week MBSR programme in relieving distress in a community based sample. METHODS Subjects (n = 14) were participants in the MBSR programme at a major academic medical center and completed the Profile of Mood States (POMS) and the Mindful Attention Awareness Scale (MAAS) prior to starting the class and at the end of the 8-week course. Means and standard deviations were computed for the pre-and post-POMS total and subscale measures and the MAAS. Wilcoxon Signed Ranks Test was conducted. RESULTS There were significant reductions on multiple dimensions of distress on the POMS as well as a significant increase in mindful awareness as measured by the MAAS. CONCLUSION These results suggest that MBSR appears to be associated with a reduction of distress and increased awareness of everyday life experiences in a sample of residents living in a large urban community. 

Cognitive Behavioral Therapy in Practice: Treatment Delivered by Trainees at an Outpatient Clinic Is Clinically Effective.

Cognitive-behavioral therapy (CBT) is known to be effective for a number of disorders, and can be delivered effectively by trainees in controlled settings. However, the effectiveness of trainee therapists in general practice compared to that of more experienced therapists is unknown. In this study, the authors used a benchmarking strategy to compare the outcomes of naturalistic CBT delivered by trainee therapists to those of efficacy and effectiveness studies using primarily professional therapists. Patients (N=249) with mood and anxiety disorders were treated by trainees (primarily by interns and postdocs) using nonstandardized nonmanualized CBT at an outpatient clinic in an urban academic medical center. Changes in anxiety and depression were assessed using effect sizes, reliable and clinically significant change, and benchmarked to efficacy and effectiveness studies. Symptoms of anxiety and depression significantly improved from start to end of treatment. Rates of improvement and recovery compared favorably to those achieved in other studies, with the exception of recovery rates in severe depression. Effect sizes were in the medium to large range, but generally lower than those achieved in other studies. Results suggest that CBT can be delivered effectively by trainees in an outpatient setting.

Predictors of attrition in HIV-positive subjects with peripheral neuropathic pain

The objective of this paper was to identify predictors of attrition in a study designed to assess whether cognitive behavioural therapy (CBT) was more helpful than supportive therapy (SP) in reducing pain associated with peripheral neuropathy in HIV-positive patients. Sixty-one subjects were randomized into either CBT or SP for six weekly one-hour sessions. Twenty-eight subjects dropped out before week six. Demographic variables such as age, gender, ethnicity, socioeconomic status and level of education were not predictive of attrition. However, higher scores on the Hamilton Depression Inventory (HAM-D, 17-item) (t (59)=−0.09, p<0.05) were predictive. These findings suggest that while dropouts were not more physically ill (e.g. CD4 counts, viral loads and opportunistic infections were not statistically higher), they reported greater psychological distress.

Disability and posttraumatic stress disorder in disaster relief workers responding to september 11, 2001 World Trade Center Disaster

Empirical evidence suggests that social and occupational disability plays a significant role in posttraumatic stress disorder (PTSD). The purpose of this study was to assess the role of social/occupational disability and to identify predictors of the development of PTSD in a group of disaster relief workers (DRWs) who had been deployed to the World Trade Center (WTC) following September 11, 2001. Eight hundred forty-two utility workers completed a battery of comprehensive tests measuring PTSD and social occupational functioning. Results indicated a significant association between PTSD symptoms and impaired social/occupational functioning. Symptomatic workers were also more likely to have a history of trauma, panic disorder, and depression. Those with a history of trauma, depression, generalized anxiety disorder or panic reported significantly more disability than those without a psychiatric history. Careful screening of PTSD and social/occupational functioning in DRWs following a disaster is warranted so that early treatment can be undertaken to prevent a chronic and disabling course.