Punishment Beliefs Tied to Depression in Those With HIV

Despite all the scientific evidence about how the AIDS virus is transmitted and devastates its victims’ immune systems, some people infected with HIV believe it somehow is a form of punishment. And data from a recent study strongly suggest that people who hold this belief are more likely to suffer from depression and have a poorer outcome and quality of life.

As a result of this finding, psychiatrists and mental health professionals may be of far more value to HIV-infected individuals if they focus therapy on a person’s punishment-related HIV beliefs instead of the more obvious, though severe, stressful life events that these patients usually have endured, the researchers suggested.

Along with the stigma-driven belief that their illness is a form of punishment, three other factors—pessimism about the benefits of HIV treatment, poor problem-solving skills, and inadequate social supports—are linked with depression in many HIV-positive individuals, according to a study by Steven Safren, M.D., of Massachusetts General Hospital and colleagues in Boston and Vancouver, Canada.

The researchers found a strong relationship between these same psychological factors and measures of quality of life and self-esteem.

These factors are especially critical in HIV-infected individuals taking the powerful combination of AIDS-fighting drugs, because they can compromise adherence to the complex medication regimen required for the drugs to be effective.

In a study reported in the December 2002 issue of Psychosomatics, Safren’s team evaluated 76 men and eight women who had HIV infection and were taking or about to begin taking the combination of antiretroviral medications known as highly active antiretroviral therapy (HAART). Those who were already taking the medications were eligible if they were about to change their medication regimen “or were having subjective difficulties with their current regimen.” The large number of medications and the need to take them at precise times throughout the day—and night—make HAART itself a stressful undertaking, the researchers noted.

Participants were aged 23 to 68 (the mean age was 41.5) and were ethnically diverse; 80 percent were gay. Subjects were recruited through newspaper ads and posters in a primary care clinic in which a substantial number of HIV-infected individuals seek care.

Now that the length of survival has increased substantially for HIV-infected people, they and their therapists are able to focus on issues of quality of life, self-esteem, and adaptive coping behaviors.

With almost all people with HIV infection having experienced considerable life stressors, especially those on HAART, the researchers decided to assess the impact of several cognitive and behavioral variables on the psychological well-being of individuals on this type of therapy.

The researchers used a variety of assessment measures including the Beck Depression Inventory, Quality of Life Inventory, Life Experience Survey, Social Support Questionnaire, and the coping-style measurement COPES.

A key finding of the study, Safren and his colleagues noted, is that “punishment beliefs about HIV infection had a significant negative association with self-esteem, a significant positive association with depression, and a nonsignificant negative association with quality of life.”

Their analysis indicated that other relationships were in the expected directions; that is, social-support satisfaction was positively associated with quality of life and self-esteem and negatively associated with depression, while maladaptive coping was negatively associated with quality of life and self-esteem and positively associated with depression.

“Stressful life events initially accounted for a significant portion of the variance associated with depression and perceived quality of life,” Safren and his team pointed out. “However, once additional variables pertaining to perceived social support, adaptive coping, and punishment beliefs about HIV were included in the model, the contribution of negative life events lost its significance.”

In light of these findings, the researchers concluded that “in patients taking HAART, psychosocial variables that are amenable to intervention efforts may be better predictors of psychological well-being than stressful life events per se.”

Thus, they pointed out, clinicians “may offer substantially larger benefit to quality of life” by focusing on critical well-being factors such as social support, development of positive coping strategies, and punishment-related beliefs about HIV disease.

“Psychoeducation or referral to cognitive-behavioral therapy, which actively targets adaptive coping strategies,” could be effective in achieving these therapy goals, they added. ▪