Brain Matters

Psychosocial influences such as stress, depression, and trauma have been neglected in biomedical and treatment studies involving people infected with HIV, yet they are now known to have significant health impacts on such individuals and the spread of AIDS, according to a University of North Carolina at Chapel Hill scientist.

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'No one argues about the importance of following the numbers immune cell counts and levels of the virus in the blood nor should they. But there is substantial and consistent evidence that depression, stressful life events, and trauma account for some of the variability in HIV disease course. That can't be ignored.'

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Now, a comprehensive update on those influences in the current issue of the journal Psychosomatic Medicine offers a wake-up call and should give infectious disease physicians and other health care practitioners working with HIV-infected people information to improve patient outcomes, says Jane Leserman, Ph.D., a sociologist and professor of psychiatry in the UNC School of Medicine. Leserman is coeditor of the special journal issue subtitled 'Psychosocial Influences in HIV/AIDS: Biobehavioral Mechanisms, Interventions, and Clinical Implications.' 'A huge amount of research has been done in our field around these psychosocial influences, yet we felt not all medical professionals working with HIV-infected persons were aware of this body of knowledge,' she says. 'Our goal was to publish a comprehensive yet succinct review of the important biobehavior research and its impact on patient care.' 'We hope this special issue will serve as a catalyst for health care providers to address these problems as part of standard HIV care and to stimulate collaborations between biomedical and biobehavioral clinicians and researchers working as a team to address the quantity and quality of life for these patients.' Psychosomatic Medicine is the journal of the American Psychosomatic Society. The contents of this special issue are available as an open-access document, free of charge to all interested parties. The special issue contains 13 peer-reviewed articles addressing five overarching themes: > Depression, anxiety, and stressful and traumatic life events occur in epidemic proportions in HIV-infected people. > These psychosocial factors (e.g., depression, trauma, and coping with stress) have consistent and clinically relevant influences on HIV disease progression. > The effects of psychosocial factors may be mediated biologically through changes in the sympathetic nervous system and 'stress hormones' and the immune system as well as behaviorally through changes in such behaviors as nonadherence to medications. > Interventions to address depression, stress, and coping may help to ameliorate some of the negative health and behavioral effects associated with poor psychological functioning. > Asking about past trauma, current stress, depression, and coping need to become routine aspects of a multidisciplinary and comprehensive approach to HIV treatment. Recent large, long-term studies show that HIV patients with chronic depression and trauma are about twice as likely to die from AIDS-related causes, according to Leserman. 'No one argues about the importance of following the numbers immune cell counts and levels of the virus in the blood nor should they,' Leserman says. 'But there is substantial and consistent evidence that depression, stressful life events, and trauma account for some of the variability in HIV disease course. That can't be ignored.' Leserman cites the clinical significance of addressing the psychosocial issues that exist in epidemic proportions in HIV-infected populations. One study of men and women being treated in infectious disease clinics in the southeastern United States found that more than 70% of those patients had suffered at least two major lifetime traumas about half had been sexually or physically abused. 'Asking about past trauma and current life issues brings a fuller, truer focus on the patient and should be a routine practice in any multidisciplinary and comprehensive approach to HIV treatment.' Such inquiries could have a positive impact on patient care if they lead to appropriate referrals for psychological and behavioral treatment, Leserman says. 'In these populations with high psychosocial disturbance, there is also a documented higher proportion of risky behaviors such as lack of adherence to treatment that translates into a higher likelihood of developing drug resistance,' Leserman says. 'Patients developing drug resistance become harder to treat and more likely to pass on a resistant strain of the virus.' Leserman believes more research is needed to investigate the biological and behavioral mediators of the relationship between psychosocial issues and the immune system and the types of interventions that could lessen the negative health impact of chronic depression and trauma. 'We need ways to integrate what we're learning into the routine practice of medicine,' Leserman says. 'At one time, psychosocial issues may have seemed irrelevant, but now a wealth of research is indicating that we must pay attention to these factors. Although psychosocial research in HIV is fast becoming a well-accepted and traveled road, many questions remain. This field is not yet a superhighway.'