AIDS PATIENT CARE and STDs Volume 21
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AIDS PATIENT CARE and STDs Volume 21, Number 10, 2007 © Mary Ann Liebert, Inc. DOI: 10.1089/apc.2007.0012
Efficacy of Group Psychotherapy to Reduce Depressive Symptoms among HIV-Infected Individuals:
A Systematic Review and Meta-Analysis
SETH HIMELHOCH, M.D., M.P.H., DEBORAH R. MEDOFF, Ph.D., and GLORIA OYENIYI, B.A.
ABSTRACT
Depressed mood is highly prevalent among HIV-infected individuals. Some but not all stud- ies have found group psychotherapy to be efficacious in this population. We performed a sys- tematic review and meta-analysis of double-blinded, randomized controlled trials to exam- ine efficacy of group psychotherapy treatment among HIV infected with depressive symptoms. We used PubMed, the Cochrane database, and a search of bibliographies to find controlled clinical trials with random assignment to group psychotherapy or control condi- tion among HIV infected patients with depressive symptoms. The principal measure of ef- fect size was the standard difference between means on validated depression inventories. We identified 8 studies that included 665 subjects: 5 used cognitive behavioral therapy (CBT), 2 used supportive therapy, and 1 used coping effectiveness training. Three of the 8 studies re- ported significant effects. The pooled effect size from the random effects model was 0.38 (95% confidence interval [CI]: 0.23–0.53) representing a moderate effect. Heterogeneity of effect was not found to be significant (p � 0.69; I2 � 0%). Studies reporting use of group CBT had a pooled effect size from the random effects model of 0.37 (95% CI: 0.18–0.56) and was signif- icant. Studies reporting the use of group supportive psychotherapy had a pooled effect size from the random effects model 0.58 (95% CI: �0.05–1.22) and was nonsignificant. The results of this study suggest that group psychotherapy is efficacious in reducing depressive symp- toms among, HIV-infected individuals. Of note, women were nearly absent from all studies. Future studies should be directed at addressing this disparity.
INTRODUCTION
DEPRESSED MOOD is highly prevalent amongindividuals receiving medical care for HIV.1 Individuals with HIV and depressive disorders, compared to those with HIV alone, have increased HIV related morbidity,2,3 and among women a higher mortality.4,5 Although highly active antiretroviral therapy (HAART) has led to substantial reductions in morbidity
and mortality associated with HIV, studies have shown that individuals with HIV and de- pressive disorders are more likely to encounter greater delays in being prescribed antiretro- viral therapy,6 and have worse adherence to taking antiretroviral medication.7 This is in keeping with research that has shown that de- pression itself is associated with poor adher- ence to medical treatment.8
Recent studies, however, suggest that men-
Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.
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tal health interventions may lead to improved depressive and HIV-related outcomes.9,10 A recent systematic review and meta-analysis found that antidepressants are efficacious tar- geting depression among those with HIV.11 However, antidepressant treatment may be as- sociated with high dropout rates11 and may not be acceptable to all patients.
Psychotherapeutic interventions have also been used to alleviate psychosocial and inter- personal difficulties and distress associated with HIV. Several randomized control trial studies have investigated the efficacy of group therapy techniques to decrease psychological distress, decrease social isolation, and improve coping among HIV-infected people.12–19 Most of these studies used interventions based on cognitive behavioral theory and nearly all these studies were conducted among men. Because some, but not all, studies have found group therapy interventions to be efficacious in de- creasing distress among HIV-infected people, we undertook a meta-analysis of randomized controlled trials to examine whether depressive symptoms respond to group psychotherapy treatment among HIV-infected people.
MATERIALS AND METHODS
Search strategy and study inclusion criteria
Because the term AIDS was introduced in 1981 we searched MEDLINE, PSYCHINFO, and Cochrane databases from 1981–2006 using the key words: psychotherapy and adaptation, psychological with HIV or AIDS and limited to randomized control trials. In an effort to locate both published and unpublished studies the bibliographies of key reviews were examined. Studies were included if they met the follow- ing criteria: (1) prospective, double-blinded, controlled trials with random assignment; (2) report of outcomes of depressive symptoms; (3) report of use of a psychotherapeutic inter- ventions. The three authors independently screened the titles and abstracts of each citation.
Data extraction
Data were independently extracted from the studies by the three authors. Discrepancies
were resolved by formal review and then by consensus. Our outcome of interest was de- pressive symptoms. Depression inventories that were specific for depressive symptoms were abstracted. These inventories included the Hamilton Depression Inventory (Ham-D), Center for Epidemiogic Studies-Depression (CES-D), and Beck Depression Inventory (BDI).
The standardized difference in means (Co- hen d), the effect size, was calculated from means and standard deviations from these scales. When data on means or standard devi- ations were lacking we contacted the authors of the manuscripts. The one author contacted did not respond to our inquiry for requested information. We also compiled information re- garding demographics, study characteristics, and type of psychotherapy intervention re- ported.
Quality of clinical trials
As variation in quality of clinical trials can result in biased estimates of reported interven- tion effectiveness, we evaluated the quality of the clinical trials using a 15-item scale devel- oped by Detsky et al.20 Each author indepen- dently rated the quality of the clinical studies. Discrepancies were resolved by formal review and then by consensus.
Statistical analysis
We calculated effect sizes and pooled esti- mates of effect across studies (Stat 8.0: metan command) using analysis of variance models for standardized mean differences (Cohen d). A random effects model was used. We chose to use a random effects model because it takes into account both within and between-study variation leading to a more conservative weighting estimates. Heterogeneity, or the be- tween study variation in outcomes, was mea- sured using the Q statistic.21 The Q statistic is considered to have a low power as a test of het- erogeneity; therefore, heterogeneity was con- sidered present with a p � 0.10. If heterogene- ity was found to be present the I2 statistic was used to describe the percentage of variation due to heterogeneity across studies. In the ab- sence of heterogeneity (i.e., Q statistic, p � 0.10), pooled results were reported. Publication
bias was evaluated using a funnel plot as well as Eggers and Beggs tests.21
RESULTS
Search findings
We identified 18 randomized clinical tri- als.12–19,22–31 Of these, 8 trials12–19 met inclusion criteria (Fig. 1). These 8 trials included 665 pa- tients randomly assigned to psychotherapy or a parallel control arm (Table 1). Depression was required at baseline for only one study14 and two studies excluded those with major depres- sion.15,17 With respect to the type of psycho- therapeutic treatment all of the studies used a group format. One study had two intervention arms—a CBT group intervention and a sup- portive therapy group intervention.14 Five of the treatment interventions were described as cognitive behavioral therapy (CBT),12–16 one was described as coping effectiveness training (CET),17 and two were described as supportive psychotherapy.14,18 Finally one study reported
results that combined two treatment arms (emotional expressive and CBT therapy) to- gether.19 Length of treatment ranged between 7–15 sessions. The length of the intervention ranged between 90 and 150 minutes. All inter- ventions were directed at improving psycho- logical distress and improving mood. Two interventions were also directed at reducing grief.16,18 Six trials occurred in the United States, one trial occurred in Amsterdam19 and one occurred in Hong Kong.13 With respect to demographics all but one16 study was con- ducted on men (Table 1). All studies were rated as reflecting good quality.
Depressive symptom outcome
Three of the 8 studies reported significant ef- fects. Of the 3 studies that found significant ef- fects, one used cognitive behavioral treatment intervention,16 one used supportive psycho- therapy,14 and one reported the results of a combination of emotional expressive and CBT therapy.19 The pooled effect size from the ran- dom effects model was 0.38 (95% CI: 0.23–0.53;
HIMELHOCH ET AL.734
FIG. 1. Flow diagram of randomized control trials included and excluded in meta-analysis.
GROUP PSYCHOTHERAPY TO REDUCE DEPRESSIVE SYMPTOMS 735
Fig. 2) representing a small-moderate effect size. Heterogeneity of effect was not found to be significant (p � 0.69; I2 � 0% of variability in effect sizes due to heterogeneity).
We were interested in investigating whether intervention type (i.e., CBT versus non-CBT group therapy interventions) moderated the ef- fect between psychotherapy and depressive symptoms. Studies reporting use of group CBT had a pooled effect size from the random ef- fects model of 0.37 (95% CI: 0.18–0.56]) and was significant representing a moderate effect size. Studies reporting the use of group supportive psychotherapy had a pooled effect size from the random effects model 0.58 (95% CI: �0.05–1.22]) and was nonsignificant. In the one study that used CET, the effect size from the random effects model was 0.16 (95% CI: �0.27–0.59]) and was not…
