Four months of cognitive behavioral therapy for depression and antiretroviral adherence significantly improved adherence and depression scores when compared with treatment as usual in a three-way randomized trial involving adults with HIV infection. Relative improvements in adherence and depression held up in the eight months after the interventions ended.
Researchers from the University of Miami and collaborators at other sites noted that depression remains highly prevalent in HIV populations and consistently imperils adherence to antiretroviral therapy. Building on evidence that cognitive behavioral therapy for depression and adherence (CBT-AD) improves both depression and adherence, the investigators conducted a larger trial randomizing HIV-positive adults to CBT-AD or two other interventions.
Cognitive behavioral therapy “takes a hands-on, practical approach to problem-solving” and aims “to change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel.” This trial randomized participants in a 2:2:1 ratio to four months (12 visits) of CBT-AD with the Life-Steps adherence approach, to 12 visits of supportive psychotherapy plus Life-Steps for adherence (ISP-AD) or to enhanced treatment as usual plus Life-Steps adherence counseling (ETAU). Life-Steps involves problem-solving for adherence plus adherence-reminding devices.
Participants recruited at three New England HIV clinics were 18 years old or older, had taken antiretroviral therapy for at least two months and had a current diagnosis of depression. The trial excluded people with active major mental illness that would interfere with study participation as well as patients with recent CBT or intensive adherence intervention. Recruitment occurred from February 2009 to April 2012, and follow-up extended to April 2013. The researchers used electronic pill caps (MEMS) to measure adherence and three tools to measure depression: Center for Epidemiological Studies depression (CESD) score, Montgomery-Asberg depression rating scale (MADRS) score and clinical global impression (CGI) score.
The study involved 94 people (77% men) randomized to CBT-AD, 97 (59% men) randomized to ISP-AD and 49 (73% men) randomized to ETAU. Age averaged about 47 years across study groups, about two-thirds were white and about one-quarter black. Approximately 15% across study groups had a detectable viral load. Attrition was lower than anticipated in all study arms. Of the 12 planned study sessions with CBT-AD and ISP-AD, participants averaged about 11.4 sessions.
Compared with ETAU, CBT-AD yielded an estimated 1% increase in adherence from one visit to the next over 16 weeks of treatment (P = .003). CBT-AD resulted in significantly improved depression scores from visit to visit compared with ETAU when measured by CESD (estimated 0.41-point greater reduction, P = .001), CGI (estimated 0.66 units lower, P = .005) and MADRS (estimated 4.69 points lower, P = .007). After treatment completion, the CBT-AD group did not differ significantly from the ETAU group in viral load or CD4 count.
Although adherence declined by an average 4.5% per visit in the CTB-AD group after the intervention ended, that group maintained almost 9% higher adherence than the ETAU group through 12 months of follow-up. The CTB-AD group generally maintained depression results through 12 months.
During treatment, adherence improved at the same rate in the CBT-AD group and the ISP-AD group. Depression scores, viral load and CD4 count did not differ significantly between these groups.
The researchers concluded that “[i]ntegrating a cognitive behavioural treatment to promote adherence with treatment for depression (CBT-AD) can be a useful strategy to improve both adherence and depression in people living with HIV who are diagnosed with depression.” Because CBT-AD did no better in promoting adherence or relieving depression than the other psychotherapy approach, ISP-AD, the researchers proposed that “integrating Life-Steps, a cognitive behavioural intervention for adherence, with whatever psychotherapy a patient is receiving for depression, could result in improvements in adherence that are parallel with depression improvements.”
The inability of CBT-AD to improve HIV suppression or CD4 counts, the investigators suggested, could reflect the high proportion of participants (91%) who already had an undetectable viral load when the study began.
By Mark Mascolini