CATIE News

Since 1996, the widespread availability of potent combination anti-HIV therapy (commonly called ART or HAART) in high-income countries such as Canada, Australia, the U.S. and in Western Europe has had an enormous impact on the health of many HIV-positive people. Deaths from AIDS-related illness are now uncommon among people who begin ART early in the course of HIV disease and who are engaged in their care and treatment. Furthermore, the most recent calculations by researchers suggest that the life expectancy of some ART users is very likely to exceed 80 years. This increase in life expectancy is the subject of a future CATIE News bulletin.

Emotional and mental well-being

Thanks to ART, although tremendous progress has been made in preventing AIDS-related illness, from time to time HIV-positive people can experience changes in their emotional and mental health. In particular, feelings of excessive worry and depression can occur. There are many reasons why such issues can arise, and studies have found that the following events may sometimes incite or accelerate the development of depression in people:

Stressful life events

• ongoing stigmatization and discrimination
• the death of friends and loved ones
• social isolation

HIV

• HIV infects cells of the immune system and these cells can travel to the brain where they release HIV-associated proteins and chemical signals that can impair the functioning of brain cells. These problems are greatly diminished in ART users.

Other health-related conditions

• serious cardiovascular disease – reduced flow of fresh oxygen- and nutrient-rich blood to the brain can affect this vital organ. Some survivors of heart attacks and stroke may develop emotional issues after these events.
• type 2 diabetes
• abnormal hormone levels – thyroid hormones, testosterone deficiency (in men)
• co-infections – including hepatitis C virus and, in rare cases, syphilis
• the time leading up to and during menopause in women

Medication-related events

Doctors have found that some medicines can, in very rare cases, play a potential role in the onset of depression in some people. Here are some commonly used classes of medicines with this potential:

• drugs to treat higher-than-normal blood pressure
• cholesterol-lowering medicines
• drugs to treat abnormal heart rhythms
• corticosteroids
• prescription pain relievers
• drugs to prevent seizures

Bear in mind that most drugs in the above-listed categories do not cause depression in the vast majority of people who use them.

• One drug that is used by some HIV-positive people—efavirenz (sold as Sustiva, Stocrin and in the fixed-dose combination, Atripla)—is associated with changes in mood. In most cases, such changes are temporary. Another drug, interferon (used to treat hepatitis C), can cause a range of effects, including anxiety, irritability and depression.

Behaviour

• not enough sleep and/or exercise
• substance use

Environment

• changes in season, particularly reduced amounts of daylight

Nutrition

• deficiencies of several nutrients, including protein, B vitamins, magnesium, zinc and perhaps essential fatty acids

These are just a few factors that have been linked to an increased risk for depression in some studies. It is important that emotional and mental health issues be identified and addressed right away as they can degrade quality of life and affect overall health.

Here are several approaches that health professionals may recommend and/or prescribe to help HIV-positive people deal with emotional and mental health issues:

• laboratory testing of blood for some of the conditions mentioned earlier
• regular counselling
• increased levels of exercise
• meditation, yoga, Tai Chi and other relaxation exercises
• medication – anti-anxiety agents, antidepressants

A study in Spain

Scientists in Barcelona, Spain, have been investigating the impact of a cognitive behavioural therapy on the quality of life, emotional, mental and immunologic health of HIV-positive people. The research team found that mindfulness-based cognitive therapy (MBCT) quickly and significantly improved the emotional health of participants. Intriguingly, MBCT also appeared to raise their CD4+ cell counts.

About mindfulness-based therapy

According to Canadian psychologist Scott Bishop, PhD, mindfulness-based therapy was “adapted from traditional mindfulness meditation practices” originating from Buddhism. It was originally developed to help prevent relapse in people who had recovered from depression by reducing psychological distress.

In mindfulness-based therapy, Dr. Bishop says, therapists teach participants to become more aware of “thoughts and feelings and to change their relationship with them. Mindfulness allows the participants to step back from thoughts and feelings during stressful situations rather than engaging in anxious worry or other negative thinking patterns that might otherwise escalate a cycle of stress reactivity and contribute to heightened emotional distress.”

During mindfulness-based therapy, participants learn a variety of meditation practices, including seated and walking meditations, a body scan that is done lying down and yoga. Many practices begin with focusing attention on breathing. As their attention wanders, participants are encouraged to accept and acknowledge their thoughts and feelings and redirect their attention back to their breathing. As the course progresses, participants develop a more direct exploration of difficult sensations, feelings and thoughts.

Typically, mindfulness-based therapy consists of eight to 10 weekly sessions, during which participants are guided through a meditation practice. Participants are taught about the effects of stress and emotions on their mind and body and how to handle stressful situations using mindfulness. They also practice meditating at home each day using CDs that help guide them. There is more than an hour of practice and homework each day.

According to Dr. Bishop, mindfulness-based therapy “involves a reflective, warm, accepting and contemplative approach to situations, open-mindedness and a tendency towards curious introspection.”

Study details

In the Spanish study, researchers held MBCT classes for 8 weeks, 2½ hours per week. The CDs that participants received contained information on mindfulness exercises, meditation and yoga.

Researchers analysed blood samples from participants and used previously validated questionnaires to assess participants’ emotional and mental health.

In total, 40 HIV-positive participants were randomly assigned to be in one of the following groups:

• intervention group – 20 people who engaged in MBCT
• control group – 20 people who received regular medical care but no MBCT

Participants were monitored for up to 20 weeks.

The average profile of participants at the start of the study was as follows:

• age – 49 years
• gender – 51% men, 49% women
• occupational status – 21% were unemployed, 28% were employed and 51% were retired
• HIV risk behaviours – participants were more or less evenly divided among three groups: men who have sex with men (MSM), injection drug users and heterosexuals
• length of HIV infection – 20 years
• length of time taking ART – 15 years
• current CD4+ count – 523 cells/mm³
• proportion with a viral load less than 20 copies/ml (the lower limit of quantification of viral load tests used in this study) – 97%

Results—Recovery from depression

At the start of the study, researchers found that about 80% of participants had symptoms of depression. Over the course of the study, rates of depression fell significantly among participants who received MBCT, and by the 20^th week of the study, only 20% of participants who had received MBCT had symptoms of depression. Furthermore, by this time, the intensity of their residual symptoms of depression was graded by the research team as mostly “minimal.”

In contrast, rates and intensity of depression remained relatively high among participants who did not receive MBCT.

Results—Recovery from anxiety

The researchers found that anxiety levels fell significantly among participants who received MBCT but not in people in the control group. By the 20^th week of the study symptoms of anxiety continued to be low among participants who received MBCT.

Results—Perceived stress and quality of life

As with symptoms of anxiety and depression, researchers found that levels of perceived stress among participants were high at the start of the study. Only in the MBCT group did levels of perceived stress fall significantly at week 8 and remain low at week 20.

Assessments of health-related quality of life showed a large and significant improvement among participants who received and practiced MBCT but not among control participants.

Results—Viral load and CD4+ count

There were no significant changes in viral load during the study. However, researchers found that the CD4+ counts of participants who received MBCT rose—starting at 555 cells/mm³, then increasing to 614 cells/mm³ at week 8 and 681 cells/mm³ at week 20. Although this increase was not statistically significant, it is worth noting that the CD4+ count remained stable in the control group.

Participants did not change ART during the study. Also, there were no significant changes to diet or smoking habits among participants during the study.

Overall

The Spanish study found that MBCT significantly reduced symptoms of depression and anxiety. Furthermore, participants had improved health-related quality of life. These effects persisted after the end of MBCT classes. These results are similar to what has been reported from studies of MBCT in HIV-positive and HIV-negative people.

What might have caused the increase in CD4+ cells?

The change in CD4+ cell count among MBCT participants was unexpected. During the study there were no changes in ART or in the proportion of participants whose viral load fell below the 20-copy/ml mark. Such changes, had they occurred, could have had an impact on the CD4+ count.

As a possible explanation for the increase in CD4+ cell counts, the Spanish team points to previous studies in the U.S. that have found that mindfulness exercises are associated with decreased levels of proteins in the blood that are linked to inflammation. Examples of these proteins include the following:

• interleukin-6 (IL-6)
• D-dimer
• high-sensitivity C-reactive protein (hsCRP)

The Spanish researchers propose that by improving the emotional health of participants with MBCT, levels of inflammatory substances were likely reduced, which in turn could have helped raise CD4+ cell counts. This idea requires proof from a study specifically designed to assess the impact of MBCT on inflammatory proteins and the immune system.

For the future

The results of the present study are exciting and confirm that training in mindfulness-based exercises and then practising such exercises can be effective at relieving depression and anxiety in some HIV-positive people. Due to the relatively small size of the Spanish trial we cannot be certain that mindfulness-based approaches will work for every HIV-positive person with depression and anxiety. However, such approaches are extremely promising and have much potential for improving quality of life and relieving emotional distress, when done under medical supervision.

A note about mindfulness and HIV

A larger and longer study is needed to explore and extend the intriguing findings on increased CD4+ cell counts that were observed in the present study. Mindfulness-based approaches to health are best used in addition to ART for HIV-positive people.

Connecting the brain and immune system

The brain and immune system are connected both directly and indirectly in people. However, precisely how this connection works or how to successfully manipulate it is not well understood. Through research projects such as the present Spanish study, scientists are making some headway in learning how to harness the brain and help relieve depression and anxiety. Other experiments will be needed to better understand and manipulate the connection between the immune system and the brain in people living with HIV and other chronic conditions.

Resources

HIV and emotional wellness

Ask the Experts: Anxiety – The Positive Side

Mindfulness-based stress reduction for HIV-positive men – a randomized trial – CATIE News

Canadian Mental Health Association

—Sean R. Hosein

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