Treatment of depressive symptoms in human immunodeficiency virus-positive patients.

BACKGROUND: This randomized clinical trial compared 16-week interventions with interpersonal psychotherapy, cognitive behavioral therapy, supportive psychotherapy, and supportive psychotherapy with imipramine for human immunodeficiency virus (HIV)-positive patients with depressive symptoms. METHODS: Subjects (N = 101; 85 male, 16 female) with known HIV seropositivity for at least 6 months were randomized to 16 weeks of treatment. Inclusion criteria were 24-item Hamilton Depression Rating Scale score of 15 or higher, clinical judgment of depression, and physical health sufficient to attend outpatient sessions. Therapists were trained in manualized therapies specific for HIV-positive patients. Treatment adherence was monitored. RESULTS: Subjects randomized to interpersonal psychotherapy (n = 24) and supportive psychotherapy with imipramine (n = 26) had significantly greater improvement on depressive measures than those receiving supportive psychotherapy (n = 24) or cognitive behavioral therapy (n = 27). Similar results appeared in the completer subsample. CONCLUSIONS: Depressive symptoms appear treatable in HIV-positive patients. Interpersonal psychotherapy may have particular advantages as a psychotherapy for patients who have experienced the significant life events of HIV infection.

Prevalence of axis I disorders in an AIDS cohort: a cross-sectional, controlled study.

The primary purpose of this study was to assess the prevalence of major psychiatric disorders in human immunodeficiency virus-positive (HIV+) men with acquired immune deficiency syndrome (AIDS)-defining conditions. Secondary goals were to identify correlates of distress and psychopathology, and to determine whether there is a gradient of distress associated with progressive HIV illness. One hundred twelve men with AIDS-defining conditions, 61 HIV+ men without AIDS, and 84 HIV-seronegative gay men were assessed. Measures included the Structured Clinical Interview for DSM-IV (SCID), Hamilton Rating Scale for Depression (HAM-D), and other dimensional measures of distress and outlook, as well as laboratory markers of HIV stage, including HIV RNA viral load assays. Rates of major depression, consistent with other findings, were in the 5% to 10% range. Mean scores on dimensional measures of distress and outlook were within the "not depressed" range and did not increase despite increasing HIV illness severity. However, rates of dysthymia were elevated among men with CD4 cell counts less than 500, and the cumulative rates of any current axis I depressive disorder for three of the four study groups were in the range of 15% to 20%. The strongest correlates of dimensional measures of distress were current HIV symptoms and social support, and to a lesser extent, a lifetime history of major depression and current use of antidepressants and/or anxiolytics. Overall, most men displayed effective adaptation to illness, but a significant minority experienced moderate psychological distress, which warrants consideration by health providers who serve this population.

Distress reduction during the structured clinical interview for DSM-III-R.

In an attempt to assess the influence of standardized diagnostic interviews on psychological distress in research volunteers, the Visual Analogue Scale (VAS) was used to measure anxiety and depression during the Structured Clinical Interview for DSM-III-R, Non-patient version (SCID). Subjects were 50 adults with concerns related to the human immunodeficiency virus who were seeking testing and treatment in research trials. Repeated measures analysis of variance showed significant decreases in distress by the end of the interview: 72% of subjects reported diminished anxiety, and 54% reported diminished depression. Thus, the SCID appeared to provide a positive interview experience, a finding that may serve to reassure subjects, their families, and review boards regarding participation in studies that employ structured interviews.

Diagnostic agreement between the SCID-II screening questionnaire and the Personality Disorder Examination.

Instruments to assess personality disorders offer reliability, but at the cost of large amounts of a skilled clinician's time to make assessments. The Structured Clinical Interview for DSM-III Axis II (SCID-II; Spitzer, Williams, Gibbon, & First, 1990), incorporates a self-report screening questionnaire, reducing the number of items needing evaluation by the interviewer. However, false negative responses may cause clinically important areas to be overlooked. To establish the rate of false negative responses, we compared participant self-report on the SCID-II with Axis II diagnostic assessment done by clinicians using the Personality Disorder Examination (Loranger, Susman, Oldham, & Russakoff, 1987). The false negative rate was low for every diagnosis, supporting validity of following up with clinician questioning only those diagnostic elements endorsed in the self-report. Avoidant and dependent personality disorders were accurately self-reported. This, an efficient assessment instrument for personality disorders might combine self-report of those disorders where self-report is reliable, with clinician assessment where needed.

Individual psychotherapies for depressed HIV-positive patients.

OBJECTIVE: The authors present preliminary data from two treatment modalities of a randomized clinical trial in which they compared 16-week interventions of interpersonal psychotherapy to supportive psychotherapy. METHOD: HIV-positive patients who were not acutely medically ill and had scores of 15 or higher on the Hamilton Depression Rating Scale were randomly assigned to one of four treatment modalities. They were assessed by the Hamilton scale and Beck Depression Inventory at 8 and 16 weeks. Most subjects who underwent either interpersonal psychotherapy (N = 16) or supportive psychotherapy (N = 16) were male, gay or bisexual, white, and college educated. RESULTS: Results of last-observation-carried-forward and completer analyses showed that scores on the Hamilton scale and Beck Depression Inventory decreased significantly for both treatments. Differential improvement for interpersonal psychotherapy appeared by midtreatment (week 8) and persisted at termination. CONCLUSIONS: This is the first controlled study of individual psychotherapies for depressed HIV-positive patients. Results suggest that a specific antidepressant psychotherapy, interpersonal psychotherapy, has advantages over a supportive therapy.

Axis II diagnoses among volunteers for HIV testing and counseling.

OBJECTIVE: The authors' goal was to investigate the rate of personality disorders (axis II diagnoses in DSM-III-R) among adults at risk for AIDS. METHOD: The Personality Disorder Examination was administered to 260 volunteers for HIV testing and counseling. RESULTS: Thirty-seven percent of the subjects who subsequently tested seropositive for HIV and 20% of those who tested seronegative were given DSM-III-R axis II diagnoses on the Personality Disorder Examination. Thirty percent of the HIV-positive subjects who knew their serostatus before they were tested were given DSM-III-R axis II diagnoses. CONCLUSIONS: The meaningful rates of axis II diagnoses that preexisted determination of HIV status and the relation of these diagnoses to subsequently determined serostatus underscore the importance of adequately assessing the occurrence of personality disorder in individuals at risk for HIV infection.

Self-disclosure of HIV infection to sexual partners after repeated counseling.

This study, with the objective of examining voluntary self-disclosure of HIV infection after repeated counseling, was conducted in a private setting, and designed to operate in conjunction with HIV testing. Counseling was provided at entry, and then at 3 months, 6 months, and every six months thereafter. The study was conducted among 129 HIV-positive adults; the primary risk factor was history of: males having sex with males (n = 104); injection drug use (n = 19); or heterosexual contact (n = 6). Results showed that after a mean of 2.3 years since initial HIV-positive notification, 29 percent of subjects had not disclosed the HIV infection to any present partner, and 30 percent to any past sex partner. Casual sex and lower perceived social support were significantly associated with nondisclosure. The authors conclude that even after repeated individual counseling and at least several months to inform others, about one-third of the sexually active subjects did not disclose their HIV infection to any present sex partner. Clinical and public health implications are covered.

Self-disclosure of HIV infection to dentists and physicians.

We prospectively examined self-disclosure of HIV infection by 129 men and women to dentists and physicians. After an average of 2.3 years since initial HIV-positive notification and repeated individual counseling, only 53 percent of subjects had told their dentists of HIV infection compared to 89 percent who had told their physicians. This high rate of non-disclosure despite extensive counseling raises concern about effectiveness of education alone in promoting voluntary self-disclosure. Our findings further support recommended universal precautions.

Severity of psychiatric symptoms after HIV testing.

OBJECTIVE: The authors were interested in the psychiatric effects of serological testing for HIV and what information feasibly available at intake might predict more severe psychiatric symptoms 1 year later. METHOD: HIV testing in a private office setting was offered to adults at perceived risk for HIV infection but without AIDS. At entry, then 6 and 12 months later, subjects were counseled by psychiatric nurses and assessed by the Hamilton Rating Scale for Depression, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, and Brief Symptom Inventory. RESULTS: Mean scores on all measures of psychiatric symptoms were lower at follow-up among both 106 HIV-positive and 222 HIV-negative adults. One year after HIV testing, 121 (37%) of the 328 subjects had scores associated with psychopathology. These elevated scores were not predicted by serostatus but by initial psychopathological scores (N = 150), annual income less than +15,000 (N = 114), being female (N = 46), and history of injection drug use (N = 32) and heterosexual risk factors (N = 60) as compared to males having sex with males (N = 236). CONCLUSIONS: Before the development of more severe physical symptoms, on average, knowledge of HIV infection does not increase psychiatric morbidity; however, regardless of serostatus, a notable percentage of at-risk adults have sustained high levels of psychiatric symptoms. Counseling during the HIV testing process provides an opportunity to identify these individuals for closer study and indicated psychiatric treatment.

Predictors of posttraumatic stress disorder after burn injury.

OBJECTIVE: The authors' goal was to examine subjective and objective predictors of posttraumatic stress disorder (PTSD). METHOD: Hospitalized burn patients were assessed 1 week after injury with both objective predictors (percent of burned area and facial disfigurement) and subjective predictors (emotional distress and perceived social support). The patients were then assessed 2, 6, and 12 months later for development of PTSD. RESULTS: Among 51 patients, 18 (35.3%) met PTSD criteria at 2 months. High rates of PTSD were also found at 6 months (N = 16, 40.0% of the 40 available patients) and 12 months (N = 14, 45.2% of the 31 available patients). PTSD was predicted by subjective variables assessed at baseline, but patients with more severe burns were not more likely to develop PTSD. CONCLUSIONS: The DSM-III-R diagnosis of PTSD relies on an objective evaluation of the stressor's severity. The prospective data in this study support those who argue that evaluations of the severity of the stressor might also take into account subjective factors.

Relationships over 1 year between lymphocyte subsets and psychosocial variables among adults with infection by human immunodeficiency virus.

To examine relationships between immune and psychosocial variables among adults infected with human immunodeficiency virus type 1, 221 subjects without acquired immunodeficiency syndrome were assessed for degree of depression, anxiety, psychiatric symptoms, social support, stressful life events, hardiness, hopelessness, bereavement, and intrusive and avoidant thoughts about acquired immunodeficiency syndrome. At entry, none of 22 psychosocial variables significantly correlated with lymphocyte subsets. Among subjects seen 6 and 12 months later, severity of physical symptoms was associated with greater emotional distress, but the CD4 cell count was predicted by neither clinical ratings of psychopathology and global functioning nor by standardized self-report measures of constructs used in psychoimmune research. We conclude that among our sample, physical symptoms contributed to emotional distress, but emotional distress did not contribute to the CD4 cell count, a marker of disease progression.

Detection of alcoholism among burn patients.

To determine the prevalence of alcoholism among patients at a large inpatient burn center, a semistructured interview for diagnosing alcoholism--the CAGE questionnaire--was administered. Of 124 patients interviewed, 24 (19 percent) were found to have an alcohol problem based on responses to the CAGE questionnaire. However, when patients' charts were reviewed at discharge, only seven of the 24 subjects were described as having an alcohol-related problem. Of the 22 subjects whose alcoholism was detected by the CAGE questionnaire and for whom blood alcohol screens had been obtained on admission, only seven had a positive screen. About 70 percent of the patients with alcoholism were missed by blood alcohol screens on admission and by the usual procedures for gathering patient information on admission and during hospitalization. The study found that use of the CAGE questionnaire greatly increased the detection of alcoholism in burn patients.

Medical management of AIDS patients. Psychiatric disturbances.

Despite the complexity and magnitude of the psychiatric disturbances associated with HIV illness, a good deal is understood about their clinical presentation. Techniques for psychopharmacologic and psychotherapeutic management have been well established and are readily available. The expertise developed for management of psychiatric disturbances in other medical illnesses applies quite well to HIV-related conditions. Although the HIV epidemic challenges us with new difficulties, our experience with other illnesses provides us with a basis to respond.

Effectiveness of psychoeducational interventions in reducing emotional distress after human immunodeficiency virus antibody testing.

To examine the effectiveness of three psychoeducational interventions in reducing emotional distress after voluntary serologic testing for human immunodeficiency virus-1,307 physically asymptomatic adults were randomly assigned to standard counseling, counseling plus a three-session interactive video program, or counseling plus six individual sessions of stress prevention training. Subjects were evaluated using five standardized distress measures at entry and 3 months later. Among the 204 human immunodeficiency virus-seronegative subjects, mean distress measures decreased significantly after all three interventions without differential treatment effects. Among the 103 human immunodeficiency virus-seropositive subjects, mean distress measures decreased significantly after the stress prevention training and did not significantly increase in the other two interventions. We conclude that stress prevention training is particularly helpful after notification of human immunodeficiency virus seropositivity.

Voluntarily informing others of positive HIV test results: patterns of notification by infected gay men.

Forty gay men who had recently learned that they were infected with human immunodeficiency virus (HIV) were interviewed to determine the frequency with which they voluntarily informed physicians, dentists, friends, family members, and current and past sexual partners of their positive test results. Ninety percent of the subjects informed a personal physician, and 48 percent of the subjects who sought dental care informed the dentist. Sixty-six percent of subjects with at least one current sexual partner notified every current sexual partner, although notification was not associated with a greater likelihood of safer sex practices. Ninety percent of the subjects who had past sexual partners made no attempt to inform them. Sixty-eight percent confided in at least one friend, but only 35 percent told a family member.