A systematic review of Interventions for anxiety in people with HIV

This article was downloaded by: [King's College London]On: 10 October 2013, At: 02:32Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychology, Health & MedicinePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/cphm20

A systematic review of Interventionsfor anxiety in people with HIVClaudine Clucas a , Elissa Sibley a , Richard Harding b , Liang Liu a ,Jose Catalan c & Lorraine Sherr aa Infection and Population Health , University College London ,London, UKb Department of Palliative Care and Policy , Kings CollegeLondon , London, UKc Central and North West London NHS Foundation Trust , London,UKPublished online: 21 Jul 2011.

To cite this article: Claudine Clucas , Elissa Sibley , Richard Harding , Liang Liu , Jose Catalan& Lorraine Sherr (2011) A systematic review of Interventions for anxiety in people with HIV,Psychology, Health & Medicine, 16:5, 528-547, DOI: 10.1080/13548506.2011.579989

To link to this article: http://dx.doi.org/10.1080/13548506.2011.579989

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

A systematic review of Interventions for anxiety in people with HIV

Claudine Clucasa*, Elissa Sibleya, Richard Hardingb, Liang Liua, Jose Catalanc andLorraine Sherra

aInfection and Population Health, University College London, London, UK; bDepartment ofPalliative Care and Policy, Kings College London, London, UK; cCentral and North WestLondon NHS Foundation Trust, London, UK

(Received 8 December 2010; final version received 6 April 2011)

People with human immunodeficiency virus (HIV) show elevated anxiety levelscompared to the general population. Anxiety can predate HIV infection or betriggered by HIV diagnosis and the many stresses that emerge during thecourse of HIV disease. Many psychological and pharmacological therapieshave been shown to treat anxiety in the general population but a systematicunderstanding of which interventions have been tested in and are effective withHIV-seropositive individuals is needed. This review examines all publishedintervention studies on anxiety and HIV from 1980 to 2009 covered by thedatabases MedLine (1980–2009) and PsycINFO (1980–2009) for a definitiveaccount of effectiveness of interventions and an indication of prevalence ofHIV-related anxiety and measurement within studies. Standard systematicresearch methods were used to gather quality published papers on HIV andanxiety, searching published data bases according to quality inclusion criteria.From the search, 492 papers were generated and hand searched resulting in 39studies meeting adequacy inclusion criteria for analysis. Of these, 30 (76.9%)were implemented in North America (the USA and Canada), with littlerepresentation from developing countries. Thirty-three (84.6%) studiesrecruited only men or mostly men. A total of 50 interventions wereinvestigated by the 39 studies; 13 targeted HIV, symptoms or associatedoutcomes/conditions, 20 directly targeted anxiety and another 17 indirectlytargeted anxiety. Twenty-four (48%) interventions were effective in reducinganxiety (including 11 indirect interventions), 16 (32%) were ineffective and 10(20%) had an unknown effect on anxiety. Sixty-five percent of interventionsdirectly targeting anxiety were effective. Psychological interventions (especiallycognitive behavioural stress management interventions and cognitive beha-vioural therapy) were generally more effective than pharmacological interven-tions. Only three studies provided prevalence rates – these ranged from 13% to80%. Anxiety was measured using 16 different instruments. Our detailed datasuggest that interventions are both effective and available, although furtherresearch into enhancing efficacy would be valuable. Also, the vast majority ofstudies were Western-based, no studies looked at children or adolescents andfew looked specifically at women. An international effort to harmonisemeasurement of anxiety is also missing. There is a need to routinely loganxiety in those with HIV infection during the course of their disease, to

*Corresponding author. Email: [email protected]

Psychology, Health & Medicine

Vol. 16, No. 5, October 2011, 528–547

ISSN 1354-8506 print/ISSN 1465-3966 online

� 2011 Taylor & Francis

DOI: 10.1080/13548506.2011.579989

http://www.tandfonline.com

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

provide specific data on women, young people and those in diverse geographicareas and incorporate management into care protocols.

Keywords: anxiety; HIV; intervention

Introduction

Anxiety is a normal reaction to a stressor. At times, the anxiety human response canbe disproportionate to the stressful situation (or ‘‘trigger’’) and this can result inpsychological problems. Anxiety is seen to be one of the most common psychiatricdisorders in the developed world, with one in four of the adult populationexperiencing anxiety within a life course (Kessler & Wang, 2008). Anxiety levels canbe categorised as a disorder or a mental health burden when the level of experiencedanxiety is debilitating and can lead to chronic stress, when it outweighs the ability tocope or if the anxiety is disproportionate to the stressor. Anxiety is marked bypsychological symptoms such as excessive worry, fear, apprehension and physicalsymptoms such as fatigue, heart palpitations and tension. They appear in a variety offorms such as generalised anxiety disorder, panic disorder, post-traumatic stressdisorders (PTSDs) and specific phobias (DSM, American Psychiatric Association2000). Anxiety disorders are noted as being highly persistent, very often recorded aschronic and frequently coexist with each other and with other psychiatric conditions,as well as other medical conditions (Benninghoven et al., 2006; Roy-Byrne et al.,2008; Sareen et al., 2006; Weiser, 2007).

‘‘Feeling anxious’’ is often characterised by physiological sensations (such asincreased pulse, sweating, feeling sick or light-headed and tightness in the chest) inaddition to the emotional (feeling frightened or having a feeling of dread) andcognitive (worrying, and persistent, intrusive thoughts or images) aspects. The levelof distress that accompanies these symptoms can often be altered. Currentunderstanding of the origins of the ‘‘fight or flight’’ response (responsible for theaffective and physiological changes that occur during an anxiety or panic attack)relates this reaction to earlier stages in human evolution, when perceived threats inthe environment were quite likely to be life threatening. In Western Europe, clinicalanxiety is often diagnosed in individuals who are not facing life-threateningconditions; the ‘‘fight or flight’’ response having become associated with a particular‘‘trigger’’ (such as being in crowded places or using public transport).

Receiving an human immunodeficiency virus positive (HIVþve) diagnosis andsubsequent disease experience may trigger many occasions for anxiety reactions.Receiving notification of HIV-seropositive status can be a very traumatic experience,potentially leading to the development of PTSD and suicide ideation, as well astriggering anxiety and depression (Casadonte, Des Jarlais, Friedman, & Rotrosen,1990). Anxiety can also be a reaction to many of the stresses that emerge during thecourse of HIV disease from diagnosis, treatment and side effects, illness episodes,adjustment and facing HIV disease, including concerns about physical health andfear of mortality (Murphy & Barbaro, 2003; Power, Tate, McGill, & Taylor, 2003).Other stressful challenges experienced by HIV positive groups include social stigma,social isolation and fear of disclosure of HIV status, which may lead to secretsand strain in relationships (Bor, Miller, & Goldman, 1993; Herek, Capitanio, &Widaman, 2002; King, 1990). Yet, social support is important to cope with stressors(Bor et al., 1993). The financial burden often placed on families because ofHIV, AIDS-related bereavement and the risk of transmission of HIV to sexual

Psychology, Health & Medicine 529

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

partners and/or children are also major stressors (Antoni, 2003; Bor et al., 1993;Chesney et al., 1992). Anxiety challenges are reported to accompany many elementsof an HIV diagnosis and represent a continued state during the course of HIVdisease (Pence, 2009). Indeed, studies have shown that mood disorders are 5–10times more common in HIV positive groups than in the general population (Kessleret al., 1994). A study by Vitiello, Burnam, Bing, Beckman, and Shapiro (2003) hasshown that among HIV-infected patients receiving medical care, 20.3% have ananxiety disorder, with 12.3% meeting the criteria for panic disorder, 10.4% forPTSD and 2.8% having generalised anxiety disorder. Another potential complica-tion is caused by the changes in cognitive capacity that may occur as a result of theinfection in the advanced stages of disease; deterioration in function and processingskills reducing the individual’s ability to engage with the therapies that might beavailable to them. Anxiety can also predate HIV infection, showing that therelationship between HIV and anxiety is complex (Whetten, Reif, Whetten, &Murphy-McMillan, 2008). For instance, Reyes et al. (2007) reported an associationbetween anxiety and HIV risk behaviour among Hispanic injection drug users.

Anxiety has been correlated with other poor health outcomes such as chronicconditions, poor quality of life and mortality (O’Cleirigh, Hart, & James, 2007).In HIV, a ‘‘tapestry of adversity’’ (Pence, 2009) has been described where elevatedmental health is related to adherence problems, treatment failure, increasedhospitalisation, increased clinic attendance and ultimately worse outcomes in termsof disease burden, treatment switching and mortality (Leserman et al., 2005).

Different people may employ different strategies for coping. Anxiety meritsattention and care in its own right given the mental health burden experienced by thosesuffering from heightened anxiety. In order to understand the challenges of anxiety andHIV, it is important to monitor the range of anxiety experiences and responses to HIVand examine any interventions aimed at reducing anxiety and their efficacy.

Many therapies, both psychological and pharmacological have been reportedin treating anxiety, however, not all may have been empirically tested inHIV-seropositive individuals. Moreover, to our knowledge, no review exists thatsystematically examines the evidence supporting the effectiveness of the differenttypes of interventions that have directly or indirectly targeted anxiety inHIV-seropositive individuals. For instance, some reviews focus on stress manage-ment interventions in HIVþ adults. One analysed 35 trials and found that stress-management interventions for HIVþ adults significantly improve mental healthand quality of life but did not alter immunological or hormonal processes(Scott-Sheldon, Kalichman, Carey, & Fielder, 2008). A second analysed 21 studiesand concluded that stress management interventions for HIV-infected persons werepromising for positive adjustment, but also recorded measurement problems,research limitations and a narrow focus on HIV-infected men who have sex with men(Brown & Vanable, 2008). HIV affects people across the globe, and people fromdifferent cultures, sub-cultures and backgrounds are likely to respond positively todifferent interventions. To justify continuing usage of a particular interventionmodel, it is necessary to implement methodologically sound, empirically drivenexperimental interventions that target the appropriate social and/or ethnic group toestablish its potential benefits.

This review is interested in examining the evidence supporting the effectiveness ofthe different types of interventions that have attempted to treat anxiety in individualswho are infected with HIV. It is also interested in examining the psychiatric side

530 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

effects of treatments for HIV or HIV-associated conditions and will focus onintervention studies that have used a comparison or control group to meaningfullyresearch the effectiveness of existing studies. It explores the reported prevalence ofanxiety within the HIV-seropositive samples studied and the instruments that wereused to measure anxiety.

Method

Search strategy for identification of studies

On the 24 September 2009, we searched the MedLine (1950–2009) and PsycINFO(1972–2009) databases using the OVID platform. The search strategy specified thatsearch results must include the following as subject terms: HIV infection; anxiety,anxiety disorders, panic or panic disorders; clinical trial, comparative study, controlgroups, double-blind method, single-blind method, placebos, psychotherapy,group psychotherapy or intervention studies. The following were specified askeywords: AIDS, HIV or acquired immunodeficiency syndrome; anxious*1, anxietyor panic; trial or intervention. Slight variations between databases were necessaryin order to match their specified subject terms. The search terms are set out inTables 1 and 2.

Criteria for including studies in this review

Hits generated by the literature searches were imported into a single ReferenceManager file and duplicates were filtered out using the ‘‘check for duplicates’’ tool(journal volume, issue and page number being compared to confirm duplication).

Abstracts were then screened in accordance with four criteria chosen to identifyquality studies of interventions that directly or indirectly targeted anxiety (measuredin a valid and reliable way) in HIVþ individuals. We were also interested in studiesthat investigated psychiatric side effects of treatments for HIV or HIV-associatedconditions.

Studies were retained only if they:

(1) included an intervention,(2) used either a validated or standardised anxiety outcome measure, or a

recognised clinical diagnostic tool (including clinical observation) to assesssubjects’ anxiety,

(3) recruited solely HIV-seropositive participants into the intervention group,or presented data for the infected participants independently to that forparticipants who were not infected, and

(4) included a control or comparison group.

Books, newspaper articles, case studies, literature reviews, narrative papers,unpublished papers (theses or dissertations) and papers that were not written inEnglish were excluded. Full-text versions of the papers that appeared to meet theinclusion criteria were downloaded (full-text was also retrieved in cases whereadherence to these criteria was not clear from the abstract). Full-text versionswere screened and papers that met the inclusion criteria were retained for coding.Where papers were not available data were extracted from the abstracts if possible.This only applied to one study (Shor-Posner et al., 2003).

Psychology, Health & Medicine 531

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Data extraction and analysis

Data extraction was performed using a standardised data extraction sheet: yearof publication, setting/country, aim of the study, study design, description of theintervention, sample size and details, the instruments used to measure anxiety,whether the study directly or indirectly targeted anxiety and measured any otherconstructs of interest (depression, coping, PTSD and suicidal ideation)2 and findings.Relevant data items corresponding to the anxiety measures were recorded, includingwhere appropriate: scores on the measurement instruments, prevalence of anxietyand significance values for within- and between-groups comparisons.

The studies were graded using a hierarchy of evidence based on the ClinicalGuidance Outcomes group (1996) in a manner similar to Harding et al. (2005):

Table 1. HIV and anxiety, search term used – MedLine, search conducted: 24 September2009.

Step Search term Hits

1 exp HIV Infections/ 1860582 (AIDS or HIV or acquired immunodeficiency

syndrome).mp.[mp¼ title, original title, abstract, name ofsubstance word, subject heading word]

283459

3 limit 2 to yr¼ ‘‘2009’’ 114694 1 or 3 1929045 exp Anxiety/or exp Anxiety Disorders/ 901306 (anxious* or anxiety).mp. [mp.title, original title, abstract, name of

substance word, subject heading word]112315

7 6 or 5 1396458 4 and 7 12039 Exp clinical trial/ 59404910 Comparative study/ 1467801011 9 or 10 189812812 exp control groups/or exp double-blind method/or exp single-blind

method/118125

13 Exp Placebos/ 2875614 exp Psychotherapy/or exp Psychotherapy, Group/ 12447915 exp Intervention Studies/ 422916 13 or 10 or 9 or 12 or 15 or 14 202349617 (trial or intervention).mp. [mp¼ title, original title, abstract, name of

substance word, subject heading word]838188

18 16 or 17 227477319 8 and 18 29820 panic.mp. [mp¼ title, original title, abstract, name of substance

word, subject heading word]10883

21 exp Panic/or exp Panic Disorder/ 725022 20 or 21 1088323 22 and 4 9824 23 and 18 1025 24 or 19 303

Note: NB all opportunities to ‘‘explode’’ or to ‘‘include all subheadings’’ were taken.

. Grade I (strong evidence) corresponded to randomised controlled trials(RCTs). These were graded Ia when the experimenter, participants and/orthe interviewer was blinded to the conditions and Ib when no blindingoccurred or was indicated.

532 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

. Grade II (fairly strong evidence) corresponded to non-RCTs, before and afterstudies with control group, time series, good observational studies (prospectivecohort studies with a control group or retrospective cohort studies with acontrol group and effective control for confounding variables). These weregraded IIa when participants in the intervention and control group werematched on key characteristics and the study controlled for confoundingvariables at the analysis stage, IIb when participants in the intervention andcontrol group were matched on key characteristics or the study controlled forconfounding variables at the analysis stage or IIIc when there was no matchingof participants or control for confounding variables.

. Grade III (weaker evidence) corresponded to retrospective studies with acontrol group that did not control for confounding variables or case-controlstudies.

For comparative studies that compared two or more interventions, a similarhierarchy of evidence was developed with grade I corresponding to before and aftercomparative studies with random allocation to the interventions, grade II to beforeand after comparative studies without random allocation to the interventions (IIa ifparticipants came from the same group or IIb if participants came from differentgroups) or observational prospective cohort studies with a group receiving a different

Table 2. HIV and anxiety, search terms used – PsycINFO, search conducted: 24 September2009.

Step Search term Hits

1 Exp HIV/ 220772 exp AIDS Prevention/ 46293 (AIDS or HIV or acquired immunodeficiency syndrome).mp.

[mp¼ title, abstract, heading word, table of contents, keyconcepts]

36726

4 limit 3 to yr¼ ‘‘2009’’ 8785 1 or 4 or 2 237616 exp Generalized Anxiety Disorder/ or exp Anxiety Disorders/ or exp

Anxiety/ or exp Anxiety Management/ or exp Death Anxiety/81249

7 exp Panic Attack/ or exp Panic/ or exp Panic Disorder/ 73588 (anxious* or anxiety).mp. [mp.title, original title, abstract, name of

substance word, subject heading word]112064

9 panic*.mp. [mp¼ title, original title, abstract, name of substanceword, subject heading word]

11885

10 6 or 8 or 7 or 9 13854211 10 and 5 109512 exp Clinical Trials/ 327213 exp Experiment Controls/ 58914 exp Placebo/ 244615 exp Group Intervention/ 31216 exp psychotherapy/ or exp cognitive therapy/ 14999917 exp Treatment Effectiveness Evaluation/ 1102318 13 or 16 or 12 or 17 or 14 or 15 16331519 (trial or intervention).mp. [mp¼ title, abstract, heading word, table

of contents, key concepts]145094

20 18 or 19 28787221 11 and 20 189

Psychology, Health & Medicine 533

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

intervention and grade III to observational retrospective cohort studies with a groupreceiving a different intervention.

Results

Search results and description of studies

Figure 1 shows how the 492 papers were considered at each stage of the literaturesearch and screening process, leading to a final set of 39 papers for analysis. Of these,38 (97.4%)3 were coded from full-text, while one (2.6%) was coded from theabstract. Thirty (76.9%) studies were implemented in North America (the USA andCanada), six (15.4%) in Western Europe, two (5.1%) in Eastern Asia and one(2.6%) in Australia4. Only one intervention was conducted in the UK (Moyle et al.,2004).

Figure 1. Anxiety search results – paper inclusion.

534 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Study participants

Thirteen (33.3%) studies recruited only men and 20 (51.3%) further studies recruitedover 70% male participants. Of the remaining six studies, five (12.8%) recruited amixture of men and women, and one (2.6%) study recruited only women. Seven(17.9%) studies solely recruited men who have sex with men (MSM) and three(9.4%) recruited over 70%MSM (3, 4, 5). Ethnicity varied between studies, with one(2.6%) recruiting 100% Chinese participants (Molassiotis et al., 2002), one studyrecruiting 100% African Americans (Miles et al., 2003), one recruiting over 70%African Americans (Sikkema et al., 2004) and four (10.3%) recruiting over 70%Caucasians (Chesney, Chambers, Taylor, Johnson, & Folkman, 2003; Elliott et al.,1998; Inouye, Flannelly, & Flannelly, 2001; Loutfy et al., 2007). The remainingstudies did not report ethnicity or had a ethnically diverse sample.

Prevalence

Three (7.7%) studies reported the prevalence of anxiety within their samples.Clifford et al. (2005) reported a prevalence of 80% at both baseline and follow-up.Robiner et al. (1993) recorded a baseline anxiety prevalence of 13% within theintervention group and 4% in the control group (this difference between groups wasnon-significant), while Shor-Posner et al. (2003) reported a prevalence of 68% forState anxiety and 70% for Trait anxiety.

Measurement5

The 39 studies used 14 instruments to measure anxiety (see Table 3). Twelve (30.8%)studies used the Profile of Mood States (POMS; including one (2.6%) each of theChinese, Japanese and Dutch versions). The State-Trait Anxiety Inventory (STAI)was used by 12 (30.8%) studies, three studies used the Hospital Anxiety andDepression Scale (HADS) and two used the Hamilton Anxiety Rating Scale(HARS). Two (5.1%) studies used the Symptom Checklist-90-Revised (SCL-90-R).The following instruments were each used by one (2.6%) study: the Brief SymptomInventory, Depression Anxiety Stress Scales (DASS), Health-related Anxiety Scale,Mental Health Inventory, the Structured Interview Guide for the Hamilton Anxietyand Depression rating scale (SIGH-AD), a non-specific clinical evaluation, theSpielberger Trait Anxiety Inventory for Children A-State Anxiety sub-scale, TraumaSymptom Inventory Scales, Visual Analogue Scales and a Non-Somatic AnxietyScale (based on the HARS). See Table 3 for references.

Interventions and effectiveness

Table 4 displays information about the interventions used and their effectiveness intreating anxiety. An intervention was coded as effectively reducing anxiety if post-testscores for the intervention group indicated either a significant reduction in anxietycompared to baseline, or a significant difference to the comparison group at post-test.

The 39 studies reported results for 50 interventions. An intervention effect onanxiety outcomes was not reported for 10 (20%) of these, resulting in a sample of40 interventions for which effectiveness in reducing anxiety could be ascertained.Out of these 50 interventions, 43 had a placebo or control group and six were

Psychology, Health & Medicine 535

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Table 3. Instruments used, either partially or in their entirety, to obtain an independentmeasure of anxiety at post-test.

Measurement toolNumber ofstudies Studies

Profile of Mood States(POMS)

12 Antoni et al. (2000); Cruess, Antoni, Kumar, &Schneiderman (2000a); Cruess et al. (2000b);Esterling et al. (1992); Fukunishi et al. (1997)(Japanese version); Galantino et al. (2005);Inouye et al. (2001); Lutgendorf et al. (1997);Lutgendorf et al. (1998); Miles et al. (2003)(POMS-ANXa); Molassiotis et al. (2002)(Chinese version); Mulder et al. (1994)(Dutch version)

State-Trait AnxietyInventory (STAI)

12 Bormann et al. (2006); Burack et al. (1996);Carrico et al. (2009); Chesney et al. (2003);Clifford et al. (2005); Ireland (1998)(Spielberger Trait Anxiety Inventory forchildren, A-State Anxiety subscale); Margolinet al. (2005); Rao et al. (2009); Robiner et al.(1993); Shor-Posner et al. (2003); Vidrine et al.(2006) (STAI state form); Weber et al. (1999(STAI)

Hospital Anxiety andDepression Scale(HADS)

3 Berger et al. (2008); Loutfy et al. (2007); Moyleet al. (2004)

Hamilton AnxietyRating Scale(HARS)

2 Elliott et al. (1998); Ferrando et al. (1997)

Symptom Checklist-90-Revised (SCL-90-R)

2 De Wit et al. (1999); Kelly et al. (1993)

Brief SymptomInventory

1 O’Leary et al. (2005)

Clinical evaluation 1 Quereda et al. (2008)Depression Anxiety

Stress Scales(DASS)

1 Thein et al. (2007)

Health-related AnxietyScale

1 Murphy et al. (2002)

Mental HealthInventory

1 Smith et al. (2002)

Nonsomatic AnxietyScale (based onHARS)

1 Elliott et al. (1998)

Structured InterviewGuide for theHamilton Anxietyand Depressionrating scale(SIGH-AD)

1 Goodkin et al. (1999)

Trauma SymptomInventory Scales

1 Sikkema et al. (2004)

Visual Analogue Scale 1 Cote and Pepler (2002)

Note: aPapers identified as using POMS-ANX may have used the entire scale (reporting scores for theanxiety subscale), or just used the anxiety subscale. SIGH-AD, Structured Interview Guide for theHamilton Anxiety and Depression rating scale.

536 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

evaluated against another or other intervention(s) in comparative studies. The effectof one intervention was compared in HIVþ patients and HIV7 patients (Theinet al., 2007).

Out of the 43 interventions with a placebo or control group, eight (19%) wereclassified as grade Ia, 32 (74%) were classified as grade Ib, two (4.6%) were classifiedas grade IIa and one (2.3%) was classified as grade IIb. Out of the interventionsevaluated against another or other intervention(s) in comparative studies, two wereclassified as grade I (De Wit et al., 1999), three were classified as grade IIa (Ferrando,Goldman, & Charness, 1997) and one was classified as grade IIb (Sikkema et al.,2004). The intervention whose effect was compared in HIVþ and HIV7 patients(Thein et al., 2007) was classified as grade II (before and after comparative studywithout matching of participants in both groups on key characteristics).

Interventions directly targeting HIV, symptoms or associated outcomes/conditions

Some interventions were designed to target anxiety in HIV-positive individuals,while others primarily sought to treat HIV or related factors such as lipoatrophy(localised loss of fat tissue). Thirteen (26%) interventions targeted HIV-relatedoutcomes.

Directly targeting HIV: Two (4%) pharmaceutical interventions sought to treatHIV-infection (Clifford et al., 2005; Robiner et al., 1993). Robiner et al. (1993)found zidovudine to be effective in reducing anxiety. Clifford et al. (2005) didnot find anxiety to be exacerbated by the use of efavirenz.Targeting HIV symptoms: Two studies used Chinese herbs to treat HIV-relatedsymptoms (Burack, Cohen, Hahn, & Abrams, 1996; Weber et al., 1999). Neitherwas effective.Cosmetic interventions to treat lipoatrophy: Two studies injected polyalkilamidegel (PAIG) or polylactic acid (PLA) to treat lipoatrophy (Loutfy et al., 2007;Moyle et al., 2004); only one was effective in reducing anxiety.Targets factors associated with HIV: Five (10%) interventions employededucational methods. Two aimed to reduce transmission risk (Carrico et al.,2009; O’Leary et al., 2005), of which one was effective. One interventionimproved symptom management and reduced anxiety (Miles et al., 2003) andone was effective in increasing highly active antiretroviral therapy (HAART)adherence but did not reduce anxiety (Murphy, Lu, Martin, Hoffman, &Marelich, 2002). The final educational intervention sought to improve paincommunication; its effect in reducing anxiety could not be ascertained (Smith,Egert, Winkel, & Jacobson, 2002).Targeting Hepatitis C infection: Two (4%) interventions aimed to treat HepatitisC infection (Quereda et al., 2008; Thein et al., 2007), the first did not have anegative effect on anxiety and the effect of the intervention on anxiety could notbe ascertained for the second.

Interventions targeting anxiety

Twenty (39%) interventions were coded as directly targeting anxiety6: 15 (29%)used psychological methods and three (6%) were psychosocial interventions, whileone (2%) intervention used physical touch and another provided a nutritionalsupplement.

Psychology, Health & Medicine 537

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Cognitive behavioural (CB) stress management: There were seven (14%) CBstress management interventions (see Table 4 for references), of which five wereeffective in reducing anxiety. For the remaining two, the effectiveness inreducing anxiety could not be ascertained.Other psychological interventions: Four (8%) interventions targeted coping (seeTable 4), one of which successfully reduced subjects’ anxiety levels (Chesneyet al., 2003). For two of the interventions, the effectiveness in reducing anxietycould not be ascertained (see Table 4). Another two (4%) interventionsprovided Cognitive Behaviour Therapy (CBT; Molassiotis et al., 2002; Mulderet al., 1994) and both of these were effective. In addition, one (2%) interventionused Experiential Therapy (Mulder et al., 1994) and another used a form of CBapproach (Kelly et al., 1993). Neither of these was associated with animprovement in anxiety levels.Psychosocial interventions: Three (6%) interventions used psychosocial meth-ods: Art therapy (Rao et al., 2009), peer support counselling (Molassiotis et al.,2002) and relaxation training (Fukunishi et al., 1997). Each of these wasassociated with a significant reduction in anxiety.Physical: One (2%) intervention used ‘‘Therapeutic Touch’’ (Ireland, 1998); thiswas effective.Nutritional supplementation: The final intervention directly targeting anxietyprovided selenium as a nutritional supplement to treat anxiety, depression andmood (Shor-Posner et al., 2003). This did have a significant positive effect.

Interventions indirectly targeting anxiety

Of the remaining 17 (34%) interventions, five psychological or psychosocialinterventions were coded as indirectly targeting anxiety, while seven usedpharmaceutical methods to treat depression and recorded the effects on anxiety.

Psychological interventions: Three (8%) used psychological methods: neitherpsychotherapy to improve psychiatric symptoms (Fukunishi et al., 1997) nor aCB- based smoking cessation intervention (Vidrine, Arduino, & Gritz, 2006)were effective in reducing anxiety, while social support to improve emotionaldistress (Kelly et al.,1993) was successful in doing so.Psychosocial interventions: Two (4%) used psychosocial methods: Neithermantra training to improve psychological, affective and existential well-being(Bormann et al., 2006) nor a bereavement support group to decrease grief anddistress (Goodkin et al., 1999) were associated with improvements in anxiety.Pharmaceutical interventions: Seven (14%) interventions sought to medicallytreat depression (within three studies: De Wit et al., 1999; Elliott et al., 1998;Ferrando et al., 1997). Three of these were effective in reducing anxiety(Ferrando et al., 1997). The effect of the intervention in reducing anxiety couldnot be ascertained for two of these.Physical interventions: Five physical interventions sought to improve quality oflife using: Tai Chi and aerobics (Galantino et al., 2005; both of which wereeffective), exercise (Esterling et al., 1992), and a drug dependency treatmentusing acupuncture (Margolin, Avants, & Arnold, 2005). The effect of theintervention in reducing anxiety could not be ascertained for the latter two. Amixed methods study combined acupuncture with psychotherapy to treat drugdependency (Margolin et al., 2005). This showed a positive effect on anxiety.

538 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Table 4. Effectiveness of interventions in treating anxiety.

InterventionaStudies implementing

interventionEffectively treats

anxietyb

Targets HIV infection: PharmaceuticalEfavirenz Clifford et al. (2005) NoZidovudine (or placebo) Robiner et al. (1993) Yes

Targets HIV-related symptoms: SubstancesChinese herbs Burack et al. (1996);

Weber et al. (1999)No

Targets lipoatrophy: CosmeticPAIG injection Loutfy et al. (2007) YesPLA injection Moyle et al. (2004) No

Targets factors associated with HIV: Educational/Psycho-educationalTransmission risk reduction Carrico et al. (2009);

O’Leary et al. (2005)No/Yes

Symptom management Miles et al. (2003) YesHAART adherence: Coping skills Murphy et al. (2002) NoPain communication Smith et al. (2002) n/a

Targets anxiety: PsychologicalCognitive–BehaviouralStress Management (CBSM)

Antoni et al. (2000);Berger et al. (2008);Cruess et al. (2000b);Lutgendorf et al. (1997);Lutgendorf et al. (1998)

Yes

CBSM Cruess et al. (2000a);Esterling et al. (1992)

n/a

Coping effectiveness training Chesney et al. (2003) YesSelf-management and coping skills Inouye et al. (2001) NoCognitive Behavioural Kelly et al. (1993) NoStress/coping Sikkema et al. (2004) n/aCoping skills Cote & Pepler, (2002) n/aExperiential therapy Mulder et al. (1994) NoCBT Molassiotis et al. (2002);

Mulder et al. (1994)Yes

Targets anxiety: PsychosocialArt therapy Rao et al. (2009) YesPeer support counselling Molassiotis et al. (2002) YesRelaxation training Fukunishi et al. (1997) Yes

Targets anxiety: Nutritional supplementSelenium Shor-Posner et al. (2003) Yes

Targets anxiety: physicalTherapeutic touch Ireland (1998) Yes

PsychologicalPsychotherapy Fukunishi et al. (1997) NoSocial support Kelly et al. (1993) YesCB-based smoking cessation Vidrine et al. (2006) No

PsychosocialMantra training Bormann et al. (2006) NoBereavement support group Goodkin et al. (1999) No

Pharmaceutical: DepressionTrazodone De Wit et al. (1999) NoClorazepate De Wit et al. (1999) NoParoxetine Elliott et al. (1998) n/aParoxetine Ferrando et al. (1997) YesImipramine Elliott et al. (1998) n/a

(continued)

Psychology, Health & Medicine 539

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Summary

Intervention effectiveness varied between and within modalities. Psychologicalinterventions were generally more effective in reducing anxiety than werepharmaceutical or physical interventions. Nine of the 18 psychological interventionswere successful in reducing anxiety: five of the seven CB stress management (CBSM)interventions, both CBT interventions, one of the coping interventions and one ofthe three indirect psychological interventions proved effective. Four of the 11pharmacological interventions reduced anxiety, in addition to three of the fivepsychosocial interventions and three of the five interventions that targeted physicalactivity or manipulation. Two of the five psycho-educational interventions and oneof the two cosmetic interventions also achieved a reduction in anxiety. Finally, thenutritional supplement intervention and the mixed intervention (physical andpsychological) were both effective.

In total, four of the 13 interventions targeting HIV-related outcomes wereeffective in reducing anxiety. In addition, 13 of the 20 interventions that directlytargeted anxiety, one of the three indirect psychological interventions, three ofthe seven antidepressant interventions, two indirect physical interventions thatsought to improve quality of life, and the combined acupuncture/ psychotherapyintervention that aimed to reduce drug dependency also significantly improvedanxiety relative either to baseline or the comparison group. Twenty-four (48%)interventions were effective in reducing anxiety (including 11 indirect interven-tions), 16 (32%) were ineffective and 10 (20%) had an unknown effect onanxiety.

Twenty-one of the 43 interventions with a placebo or control group were effectivein reducing anxiety. Of these 21, three (14%) were classified as grade Ia, 16 (76%)were classified as grade Ib, one was classified as grade IIa and one as grade IIb.Three out of the six interventions that were evaluated against another or otherintervention(s) in comparative studies were effective (from Ferrando et al, 1997).There were classified as grade IIa.

Table 4. (Continued ).

InterventionaStudies implementing

interventionEffectively treats

anxietyb

Sertraline Ferrando et al. (1997) YesFluoxetine Ferrando et al. (1997) Yes

Targets hepatitis C virus (HCV)PEG-IFN a-2a Thein et al. (2007) n/aEfavirenz Quereda et al. (2008) No

PhysicalTai chi Galantino et al. (2005) YesAerobics Galantino et al. (2005) YesAcupuncture Margolin et al. (2005) n/aExercise Esterling et al. (1992) n/a

Mixed: Physical and psychologicalAcupuncture psychotherapy Margolin et al. (2005) Yes

Note: aInterventions that are unique within the study; where the comparison group is a reduced version ofthe intervention group, the comparison group’s intervention is not identified here. bStudies marked ‘‘n/a’’did not report anxiety outcomes. Studies in italics were comparative.

540 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Thirty-two of the studies measured depression in addition to anxiety, fivemeasured coping in addition to anxiety, one measured PTSD in addition to anxietyand none of the studies measured suicidality. The only intervention study in the UK(Moyle et al, 2004) did not find polylactic acid injections for the cosmeticmanagement of facial lipoatrophy to have an effect on depression.

Discussion

Fifty interventions with HIV-infected patients as participants and an outcome ofanxiety were identified. Thirty-nine percent of the studies directly targeted anxiety;the other studies targeted other outcomes such as HIV infection or symptoms,HIV-associated conditions or HIV-related factors (e.g. risk behaviour, HAARTadherence), depression, quality of life, drug dependency, well-being, emotionaldistress or grief. The interventions directly targeting anxiety were varied; they usedpsychological methods (CB stress management interventions, coping interventions,CB therapy, experiential therapy), were psychosocial (art therapy, peer supportcounselling, relaxation training), physical (physical touch) or used substances(nutritional supplementation). Twenty-four (48%) interventions were effective inreducing anxiety (including 11 indirect interventions), 16 (32%) were ineffective and10 (20%) had an unknown effect on anxiety. Sixty-five percent of interventionsdirectly targeting anxiety were effective.

Effectiveness in reducing anxiety varied both between types of intervention andbetween studies that used apparently similar intervention protocols. This may be due todifferences in study design or to sampling differences. The studies retrieved represent abroad range of modalities and protocols, making it impossible to draw overallconclusions. However, individual scrutiny of outcomes shows a range of effectiveinterventions – either directly targeting anxiety or targeting other stressors which mayindirectly affect anxiety outcomes. The evidence base particularly supported theeffectiveness of CB stress management interventions in reducing anxiety. This is in linewith previous reviews of stress management interventions in HIV (Brown & Vanable,2008; Scott-Sheldon et al., 2008). The evidence also supports the effectiveness ofphysical interventions in reducing anxiety. Interventions that investigated the effects oftreatments for HIV and HIV-associated conditions on anxiety generally found thatthese treatments did not increase but sometimes decreased anxiety, which is positive.Interestingly, despite reports of psychiatric complications following administration ofthe antiretroviral drug efavirenz (Lochet et al., 2003), Clifford et al. (2005) and Queredaet al. (2008) did not find anxiety to be exacerbated by the use of efavirenz.

In this review, population samples varied, with the majority of studies focussingon males. Approximately one quarter of the studies had a focus towards men whohave sex with men. The ethnicity of samples was generally mixed. Only one studyexclusively recruited women and one study recruited only African Americans.Geographically, the studies clustered in North America (over 75%) indicating a vastover-representation of samples from this area. Few studies looked at people in theUK, Africa, Asia or South America. No studies looked at children or adolescents.

Anxiety is commonly experienced by people with HIV/AIDS (Kessler et al., 1994;Vitiello et al., 2003), which was further supported by our review. For the studies thatwere retrieved, anxiety prevalence was three times greater in HIV-positive groupsthan among HIV-negative controls. For the few studies that reported anxietyprevalence rates, these ranged from 13 to 80%. It thus appears that anxiety is well

Psychology, Health & Medicine 541

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

established as a mental health burden for people with HIV infection, with rateshigher than control groups. Prevalence data indicated a clear need for monitoringand service provision to manage or alleviate anxiety for HIV-positive patients.

It is clear that anxiety is a well-recognised phenomenon that has been measuredusing a range of well validated instruments. For the exception of the four-itemhealth-related anxiety scale used by Murphy et al. (2002) and the non-somaticanxiety scale (based on items from the HARS) with good internal consistency butunknown validity and test–retest reliability, all the measures have been widely usedto measure anxiety and have been shown to have good internal consistency, test–retest reliability and construct validity and have often shown sensitivity to treatmentchange (McNair & Lorr, 1964; Roemer, 2001; Shear et al., 2001; Kelly et al., 1993;Derogatis & Melisaratos, 1983). However, it is not clear whether these have allpreviously been validated within HIV-seropositive samples and only one studysought to measure specifically non-somatic anxiety. The potential for symptoms ofHIV infection (or side effects of medication) to mimic those of clinical anxiety mayperhaps have confounded the results and led to an overestimation of the extent ofthis disorder among the samples studied (Elliott et al., 1998). In addition, themeasures tend to be Western based and may not be valid among migrants in Westerncountries or in African and Asian countries with high HIV prevalence.

There are several limitations to this review. Given the wide variety of measuresused and the lack of harmony between studies, meta-analytic techniques wouldhave been inappropriate. Long-term effectiveness of interventions was not availableand thus sustained impact over time is not clearly demonstrated. This may misslong-term efficacy of some interventions. Restricting the sample to interventionstudies may have skewed the data without providing a global review of anxietyprevalence.

This systematic review clearly shows that anxiety in people with HIV can bereduced by using a variety of interventions. It is important that further research isdone in order to identify who benefits most from which interventions and at whatstage these interventions are most effective. This should help those taking care ofHIV-positive individuals to recognise in which cases an intervention would bebeneficial and the most appropriate time for participation. The data gap on womenis lamentable, as is the data gap from resource poor countries where the majorburden of HIV is carried. Future research needs to establish the potential for theseinterventions to travel to the UK and to less affluent countries. The non-HIVliterature shows that gender is an important factor in the prevalence and treatmentof anxiety and this gap should be urgently filled. With a success rate of 48% acrossall interventions (65% for those that directly targeted anxiety), further research intomaking these interventions more effective would be highly valuable. Anxiety appearsto be a pervasive problem for people with HIV.

The evidence base suggests that there are a number of effective interventions andpoints to the need for future refinement and routine logging of anxiety parametersfor people with HIV during the course of their disease. Given the availability ofeffective interventions, these should be put incorporated into standard carepackages. What is missing is an international effort to harmonise measurement ofanxiety, a clear understanding of anxiety triggers and the course of anxiety over time.Some combination interventions are used and these make it difficult to tease outindividual components and their efficacy. Ongoing research and evaluation is neededto differentiate interventions for specific anxiety triggers and more generalised

542 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

anxiety management. There is also a need to not only offer interventions to treatanxiety once present but to also offer interventions to avoid anxiety problems in thefirst place, by reducing stigma for instance. It is clear from the studies that mentalhealth generally, and anxiety specifically, needs to be consistently examined andunderstood in the management of HIV infection.

Acknowledgement

This study was carried out under an unrestricted educational grant by Abbott.

Notes

1. The asterisk instructs OVID to search for all words that include ‘‘anxious’’ in order tocapture ‘‘anxiousness’’.

2. This review was undertaken alongside several others; potential relevance to those studieswas noted for cross-validation purposes and to ensure as broad a reach as possible.

3. Where given, percentage values always relate to the total number of studies (or totalnumber of interventions, as appropriate).

4. Ten American, two Canadian and one Western European studies were coded according tothe country of author affiliation. For one additional study identified as American,‘‘country’’ was coded according to the country identified in the database record (only theabstract was retrieved).

5. Only those instruments that were used to obtain outcome measures of anxiety are reportedhere. Instruments that were used only at baseline, or that were not used to obtain ameasure of anxiety independent of depression, are not reported.

6. An intervention was rated as directly targeting anxiety if the paper reported it as such, ifthe intervention targeted stress or fear or if the intervention clearly targeted physical orcognitive symptoms of anxiety. This was intended to distinguish between studies thatsought to influence participants’ anxiety levels and those that only measured anxiety as anoutcome. Twenty interventions directly targeted anxiety.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mentaldisorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.

Antoni, M.H. (2003). Stress management effects on psychological, endocrinological, andimmune functioning in men with HIV infection: Empirical support for a psychoneur-oimmunological model. Stress, 6(3), 173–188.

Antoni, M.H., Cruess, D.G., Cruess, S., Lutgendorf, S., Kumar, M., Ironson, G., . . .Schneiderman, N. (2000). Cognitive-behavioral stress management intervention effects onanxiety, 24-hr urinary norepinephrine output, and T-cytotoxic/suppressor cells over timeamong symptomatic HIV-infected gay men. Journal of Consulting & Clinical Psychology,68(1), 31–45.

Benninghoven, D., Kaduk, A., Wiegand, U., Specht, T., Kunzendorf, S., & Jantschek, G.(2006). Influence of anxiety on the course of heart disease after acute myocardial infarctionrisk factor or protective function? Psychotherapy Psychosomatics, 75, 56–61.

Berger, S., Schad, T., von Wyl, V., Ehlert, U., Zellweger, C., Furrer, H., . . . Gaab, J. (2008).Effects of cognitive behavioral stress management on HIV-1 RNA, CD4 cell counts andpsychosocial parameters of HIV-infected persons. AIDS, 22(6), 767–775.

Bor, R., Miller, R., & Goldman, E. (1993). HIV/AIDS and the family: A review of research inthe first decade. Journal of Family Therapy, 15, 187–204.

Bormann, J.E., Gifford, A.L., Shively, M., Smith, T.L., Redwine, L., Kelly, A., . . . Belding, W.(2006). Effects of spiritual mantram repetition on HIV outcomes: A randomizedcontrolled trial [erratum appears in J Behav Med. 2006 Oct;29(5):499]. Journal ofBehavioral Medicine, 29(4), 359–376.

Bormann, J.E., Gifford, A.L., Shively, M., Smith, T.L., Redwine, L., Kelly, A., . . . Belding, W.(2006). Erratum: Effects of spiritual mantram repetition on HIV outcomes: A randomizedcontrolled trial. Journal of Behavioral Medicine, 29(5), 499.

Psychology, Health & Medicine 543

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Brown, J.L., & Vanable, P.A. (2008). Cognitive-behavioral stress management interventionsfor persons living with HIV: A review and critique of the literature. Annals of BehavioralMedicine, 35(1), 26–40.

Burack, J.H., Cohen, M.R., Hahn, J.A., & Abrams, D.I. (1996). Pilot randomized controlledtrial of Chinese herbal treatment for HIV-associated symptoms. Journal of AcquiredImmune Deficiency Syndromes & Human Retrovirology, 12(4), 386–393.

Carrico, A.W., Chesney, M.A., Johnson, M.O., Morin, S.F., Neilands, T.B., Remien,R.H., . . . NIMH Healthy Living Project Team. (2009). Randomized controlled trial of acognitive-behavioral intervention for HIV-positive persons: An investigation of treatmenteffects on psychosocial adjustment. AIDS & Behavior, 13(3), 555–563.

Casadonte, P.P., Des Jarlais, D.C., Friedman, S.R., & Rotrosen, J.P. (1990). Psychologicaland behavioral impact among intravenous drug users of learning HIV test results. TheInternational Journal of the Addictions, 25(4), 409–426.

Chesney, M., Folkman, S., Cooke, M., Bocellari, A., Coates, T., & Collette, L. (1992). Effectof partner death on CD4 levels in HIV positive and HIV negative caregiving men. Abstractsof the VIIth International Conference on AIDS, Amsterdam.

Chesney, M.A., Chambers, D.B., Taylor, J.M., Johnson, L.M., & Folkman, S. (2003). Copingeffectiveness training for men living with HIV: Results from a randomized clinical trialtesting a group-based intervention. Psychosomatic Medicine, 65(6), 1038–1046.

Clifford, D.B., Evans, S., Yang, Y., Acosta, E.P., Goodkin, K., Tashima, K., . . . Gulick, R.M.(2005). Impact of efavirenz on neuropsychological performance and symptoms in HIV-infected individuals [summary for patients in Ann Intern Med. 2005 Nov 15;143(10):I43;PMID: 16287787]. Annals of Internal Medicine, 143(10), 714–721.

Clinical Guidance Outcomes group. (1996). Guidance on commissioning cancer services – theresearch evidence. Leeds: NHS Executive.

Cote, J.K., & Pepler, C. (2002). A randomized trial of a cognitive coping intervention foracutely ill HIV-positive men. Nursing Research, 51(4), 237–244.

Cruess, D.G., Antoni, M.H., Kumar, M., & Schneiderman, N. (2000a). Reductions in salivarycortisol are associated with mood improvement during relaxation training amongHIV-seropositive men. Journal of Behavioral Medicine, 23(2), 107–122.

Cruess, S., Antoni, M., Cruess, D., Fletcher, M.A., Ironson, G., Kumar, M., . . . Schneider-man, N. (2000b). Reductions in herpes simplex virus type 2 antibody titers aftercognitive behavioral stress management and relationships with neuroendocrine function,relaxation skills, and social support in HIV-positive men. Psychosomatic Medicine, 62(6),828–837.

Derogatis, L.R., & Melisaratos, N. (1983). The brief symptom inventory: An introductoryreport. Psychological Medicine, 13(3), 595–605.

De Wit, W.S., Cremers, L., Hirsch, D., Zulian, C., Clumeck, N., & Kormoss, N. (1999).Efficacy and safety of trazodone versus clorazepate in the treatment of HIV-positivesubjects with adjustment disorders: A pilot study. Journal of International MedicalResearch, 27(5), 223–232.

Elliott, A.J., Uldall, K.K., Bergam, K., Russo, J., Claypoole, K., & Roy-Byrne, P.P. (1998).Randomized, placebo-controlled trial of paroxetine versus imipramine in depressedHIV-positive outpatients. American Journal of Psychiatry, 155(3), 367–372.

Esterling, B.A., Antoni, M.H., Schneiderman, N., Carver, C.S., Laperriere, A., Ironson,G., . . . Fletcher, M.A. (1992). Psychosocial modulation of antibody to Epstein-Barr viralcapsid antigen and human herpesvirus type-6 in HIV-1-infected and at-risk gay men.Psychosomatic Medicine, 54(3), 354–371.

Ferrando, S.J., Goldman, J.D., & Charness, W.E. (1997). Selective serotonin reuptakeinhibitor treatment of depression in symptomatic HIV infection and AIDS. Improvementsin affective and somatic symptoms. General Hospital Psychiatry, 2, 89–97.

Fukunishi, I., Hosaka, T., Matsumoto, T., Hayashi, M., Negishi, M., & Moriya, H. (1997).Liaison psychiatry and HIV infection (II): Application of relaxation in HIV positivepatients. Psychiatry & Clinical Neurosciences, 51(1), 5–8.

Galantino, M.L., Shepard, K., Krafft, L., LaPerriere, A., Ducette, J., Sorbello, A., . . . Farrar,J.T. (2005). The effect of group aerobic exercise and t’ai chi on functional outcomes andquality of life for persons living with acquired immunodeficiency syndrome. The Journal ofAlternative and Complementary Medicine, 11(6), 1085–1092.

544 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Goodkin, K., Blaney, N.T., Feaster, D.J., Baldewicz, T., Burkhalter, J.E., & Leeds, B. (1999).A randomized controlled clinical trial of a bereavement support group intervention inhuman immunodeficiency virus type 1-seropositive and -seronegative homosexual men.Archives of General Psychiatry, 56(1), 52–59.

Harding, R., Karus, D., Easterbrook, P., Raveis, V.H., Higginson, I.J., & Markoni, K. (2005).Does palliative care improve outcomes for patients with HIV/AIDS? A systematic reviewof the evidence. Sexually Transmitted Infections, 81, 5–14.

Herek, G.M., Capitanio, J.P., & Widaman, K.F. (2002). HIV-related stigma and knowledge inthe United States: Prevalence and trends, 1991–1999. American Journal of Public Health,92, 371–377.

Inouye, J., Flannelly, L., & Flannelly, K.J. (2001). The effectiveness of self-managementtraining for individuals with HIV/AIDS. Journal of the Association of Nurses in AIDS Care,12(5), 71–82.

Ireland, M. (1998). Therapeutic touch with HIV-infected children: A pilot study. Journal of theAssociation of Nurses in AIDS Care, 9(4), 68–77.

Kelly, J.A., Murphy, D.A., Bahr, G.R., Kalichman, S.C., Morgan, M.G., Stevenson,L.Y., . . . Bernstein, B.M. (1993). Outcome of cognitive-behavioral and support group brieftherapies for depressed, HIV-infected persons. American Journal of Psychiatry, 150(11),1679–1686.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman,S., . . . Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatricdisorders in the United States. Results from the National Comorbidity Survey. Archives ofGeneral Psychiatry, 51, 8–19.

Kessler, R.C., & Wang, P.S. (2008). The descriptive epidemiology of commonly occurringmental disorders in the United States. Annual Review of Public Health, 29, 115–129.

King, M. (1990). Psychological aspects of HIV infection and AIDS: What have we learned?British Journal of Psychiatry, 156, 151–156.

Leserman, J., Whetten, K., Lowe, K., Stangl, D., Swartz, M.S., & Thielman, N.M. (2005).How trauma, recent stressful events, and PTSD affect functional health status andhealth utilization in HIV-infected patients in the south. Psychosomatic Medicine, 67,500–507.

Lochet, P., Peyriere, H., Lotthe, A., Mauboussin, J.M., Delmas, B., & Reynes, J. (2003).Long-term assessment of neuropsychiatric adverse reactions associated with efavirenz.HIV Medicine, 4, 62–66.

Loutfy, M.R., Raboud, J.M., Antoniou, T., Kovacs, C., Shen, S., Halpenny, R., . . . Beninger,F. (2007). Immediate versus delayed polyalkylimide gel injections to correct faciallipoatrophy in HIV-positive patients. AIDS, 21(9), 1147–1155.

Lutgendorf, S.K., Antoni, M.H., Ironson, G., Klimas, N., Kumar, M., Starr, K., . . .Schneiderman, N. (1997). Cognitive-behavioral stress management decreases dysphoricmood and herpes simplex virus-Type 2 antibody titers in symptomatic HIV-seropositivegay men. Journal of Consulting and Clinical Psychology, 65(1), 31–43.

Lutgendorf, S.K., Antoni, M.H., Ironson, G., Starr, K., Costello, N., Zuckerman,M., . . . Schneiderman, N. (1998). Changes in cognitive coping skills and social supportduring cognitive behavioral stress management intervention and distress outcomes insymptomatic human immunodeficiency virus (HIV)-seropositive gay men. PsychosomaticMedicine, 60(2), 204–214.

Margolin, A., Avants, S.K., & Arnold, R. (2005). Acupuncture and spirituality-focused grouptherapy for the treatment of HIV-positive drug users: A preliminary study [References].Journal of Psychoactive Drugs, 37(4), 385–390.

McNair, D.M., & Lorr, M. (1964). An analysis of mood in neurotics. Journal of Abnormal andSocial Psychology, 69, 620–627.

Miles, M.S., Holditch-Davis, D., Eron, J., Black, B.P., Pedersen, C., & Harris, D.A. (2003).An HIV self-care symptom management intervention for African American mothers.Nursing Research, 52(6), 350–360.

Molassiotis, A., Callaghan, P., Twinn, S.F., Lam, S.W., Chung, W.Y., & Li, C.K. (2002).A pilot study of the effects of cognitive-behavioral group therapy and peer support/counseling in decreasing psychologic distress and improving quality of life in Chinesepatients with symptomatic HIV disease. AIDS Patient Care & STDs, 16(2), 83–96.

Psychology, Health & Medicine 545

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Mulder, C.L., Emmelkamp, P.M., Antoni, M.H., Mulder, J.W., Sandfort, T.G., & de Vries,M.J. (1994). Cognitive-behavioral and experiential group psychotherapy for HIV-infected homosexual men: A comparative study. Psychosomatic Medicine, 56(5), 423–431.

Murphy, R., & Barbaro, G. (2003). Clinical and biological insights in HIV-associatedcardiovascular disease in the era of highly active antiretroviral therapy. AIDS,17(Suppl. 1), S1–S3.

Murphy, D.A., Lu, M.C., Martin, D., Hoffman, D., & Marelich, W.D. (2002). Results of apilot intervention trial to improve antiretroviral adherence among HIV-positive patients.Journal of the Association of Nurses in AIDS Care, 13(6), 57–69.

Moyle, G.J., Lysakova, L., Brown, S., Sibtain, N., Healy, J., Priest, C., . . . Barton, S.E. (2004).A randomized open-label study of immediate versus delayed polylactic acid injections forthe cosmetic management of facial lipoatrophy in persons with HIV infection. HIVMedicine, 5(2), 82–87.

O’Cleirigh, C., Hart, T.A., & James, C.A. (2007). HIV and anxiety. In M.J. Zvolensky & J.A.Smits (Eds.), Anxiety in health behaviors and physical illness (pp. 317–339). New York:Springer.

O’Leary, A., Hoff, C.C., Purcell, D.W., Gomez, C.A., Parsons, J.T., Hardnett, F., & Lyles,C.M. (2005). What happened in the SUMIT trial? Mediation and behavior change. AIDS,supplement 1:S111–S121.

Pence, B.W. (2009). The impact of mental health and traumatic life experiences onantiretroviral treatment outcomes for people living with HIV/AIDS. Journal ofAntimicrobial Chemotherapy, 63(4), 636–640.

Power, R., Tate, H.L., McGill, S.M., & Taylor, C. (2003). A qualitative study of thepsychosocial implications of lipodystrophy syndrome on HIV positive individuals.Sexually Transmitted Infections, 79, 137–141.

Quereda, C., Corral, I., Moreno, A., Perez-Elias, M.J., Casado, J.L., Dronda, F., . . .Moreno,S. (2008). Effect of treatment with efavirenz on neuropsychiatric adverse events ofinterferon in HIV/HCV-coinfected patients. Journal of Acquired Immune DeficiencySyndromes, 49(1), 61–63.

Rao, D., Nainis, N., Williams, L., Langner, D., Eisin, A., & Paice, J. (2009). Art therapy forrelief of symptoms associated with HIV/AIDS. AIDS Care, 21(1), 64–69.

Reyes, J.C., Robles, R.R., Colon, H.M., Marrero, C.A., Matos, T.D., Calderon, J.M., &Sheppard, E.W. (2007). Severe anxiety symptomatology and HIV risk behavior amongHispanic injection drug users in Puerto Rico. AIDS and Behavior, 11, 145–150.

Robiner, W.N., Melroe, N.H., Campbell, S., Rhame, F.S., Colon, E., Chung, J., &Reaney, S. (1993). Psychological effects of participation and nonparticipation in aplacebo-controlled zidovudine clinical trial with asymptomatic human immunodefi-ciency virus-infected individuals. Journal of Acquired Immune Deficiency Syndromes,6(7), 795–808.

Roemer, E. (2001). Measures for anxiety and related constructs. In M.M. Antoni, S.M.Orsillo, & E. Roemer (Eds.), Practitioner’s guide to empirically based measures of anxiety(pp. 49–84). New York: Kluwer Academic/Plenum Publishers.

Roy-Byrne, P.P., Davidson, K.W., Kessler, R.C., Asmundson, G.J.G., Goodwin, R.D.,Kubzansky, L., . . . Stein, M.B. (2008). Anxiety disorders and comorbid medical illness.General Hospital Psychiatry, 30, 208–225.

Sareen, J., Jacobi, F., Cox, B.J., Belik, S.-L., Clara, I., & Stein, M.B. (2006). Disability andpoor quality of life associated with comorbid anxiety disorders and physical conditions.Archives of Internal Medicine, 166, 2109–2116.

Scott-Sheldon, L.A., Kalichman, S.C., Carey, M.P., & Fielder, R.L. (2008). Stress manage-ment interventions for HIVþ adults: A meta-analysis of randomized controlled trials,1989 to 2006. Health Psychology, 27(2), 129–139.

Shear, M.K., Vander Bilt, J., Rucci, P., Endicott, J., Lydiard, B., Otto, M.W., . . . Frank, D.M.(2001). Reliability and validity of a structured interview guide for the Hamilton AnxietyRating Scale (SIGH-A). Depression and Anxiety, 13, 166–178.

Shor-Posner, G., Lecusay, R., Miguez, M.J., Moreno-Black, G., Zhang, G., Rodriguez,N., . . .Wilkie, F. (2003). Psychological burden in the era of HAART: Impact of seleniumtherapy. International Journal of Psychiatry in Medicine, 33(1), 55–69.

546 C. Clucas et al.

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3

Sikkema, K.J., Hansen, N.B., Tarakeshwar, N., Kochman, A., Tate, D.C., & Lee, R.S. (2004).The clinical significance of change in trauma-related symptoms following a pilot groupintervention for coping with HIV-AIDS and childhood sexual trauma. AIDS & Behavior,8(3), 277–291.

Smith, M.Y., Egert, J., Winkel, G., & Jacobson, J. (2002). The impact of PTSD on painexperience in persons with HIV/AIDS. Pain, 98(1–2), 9–17.

Thein, H.H., Maruff, P., Krahn, M.D., Kaldor, J.M., Koorey, D.J., Brew, B.J., & Dore, G.J.(2007). Improved cognitive function as a consequence of hepatitis C virus treatment.HIV Medicine, 8(8), 520–528.

Vidrine, D.J., Arduino, R.C., & Gritz, E.R. (2006). Impact of a cell phone intervention onmediating mechanisms of smoking cessation in individuals living with HIV/AIDS[References]. Nicotine & Tobacco Research, 8(Suppl 1), S103–S108.

Vitiello, B., Burnam, M.A., Bing, E.G., Beckman, R., & Shapiro, M.F. (2003). Use ofpsychotropic medications among HIV-infected patients in the United States. AmericanJournal of Psychiatry, 160, 547–554.

Weber, R., Christen, L., Loy, M., Schaller, S., Christen, S., Joyce, C.R., . . . Cohen, M.R.(1999). Randomized, placebo-controlled trial of Chinese herb therapy for HIV-1-infectedindividuals. Journal of Acquired Immune Deficiency Syndromes, 22(1), 56–64.

Weiser, E.B. (2007). The prevalence of anxiety disorders among adults with asthma: A meta-analytic review. Journal of Clinical Psychology in Medical Settings, 14, 297–307.

Whetten, K., Reif, S., Whetten, R., & Murphy-McMillan, L.K. (2008). Trauma, mentalhealth, distrust, and stigma among HIV-positive persons: Implications for effective care.Psychosomatic Medicine, 70(5), 531–538.

Psychology, Health & Medicine 547

Dow

nloa

ded

by [

Kin

g's

Col

lege

Lon

don]

at 0

2:32

10

Oct

ober

201

3