AIDS Treatment News #161, October 16, 1992
Jason Heyman

At this year's International Conference on AIDS, a presentation by Jeffrey Burack, M. D. and others, reported that T-helper counts of depressed patients dropped 38 percent faster than those patients who were not depressed. His work, entitled "Depression predicts accelerated CD4 decline among gay men in San Francisco," studied 330 HIV-positive patients between 1985 and 1991.

Dr. Burack explained the different mechanisms through which the treatment of depression might actually slow disease progression. "Depression has been shown to impair immune response in the laboratory, so there might be a direct effect of depression on the immune system. Also, depressed persons may be less likely to seek out or stick to appropriate medical care for HIV and may be more likely to engage in risky or unhealthy behaviors."

Currently, Dr. Burack is collaborating with the Center for AIDS Prevention Studies (CAPS) in San Francisco on a study of interventions for HIV-related depression in gay men, called the Positive Education Project. The interventions include two types of group discussion sessions. One is informational, offering patients direct access to information about AIDS and the treatments they are taking. The other is a psychological/emotional support group. (For more information or to enroll call Derek Aspacher at CAPS, 415/597-9141).

This program is just one of many studies looking at psychoneuroimmunology, a new field of science examining the interrelationship of psychology, neurology and immunology. Because of the large amount of research in the field, this article only addresses the psychological and social factors such as stress, depression, and social support.

Basic Research On Psychological Factors and Disease

Much of the most compelling research in this field has not focused on AIDS, but on other diseases such as cancer. While not directly applicable to AIDS, the results do give support to claims that psychosocial factors play a major role in the progression of disease. But their precise role in the pathogenesis of AIDS has not been determined.

The most scientifically sound evidence of a relationship between stress and illness was detailed in "Psychological Stress and Susceptibility to the Common Cold," published in 1991 in the New England Journal of Medicine. In a carefully designed trial, research subjects were exposed to cold viruses and then quarantined and monitored for the development of symptoms. The researchers found that the rate of infection was directly related to psychological stress.

Similar evidence was found in a Stanford University study on the survival of 86 women with metastatic breast cancer.(1) For one year, the women took part in group therapy sessions where they were encouraged to share their experiences and form bonds with the other women; they were also taught self-hypnosis to control pain. In a follow-up study ten years later, the researchers found that the women who participated in the psychosocial interventions lived an average of two years longer than those who did not.

An intriguing fact about the study is that the researchers did not expect to see an effect. "We intended, in particular, to examine the often overstated claims made by those who teach cancer patients that the right mental attitude will help to conquer the disease." The study was mentioned October 4 in the New York Times Magazine in an article about the mainstreaming of alternative medicine.

Current AIDS-Related Research

The success of the Stanford study may soon be replicated with a group of HIV-positive people. A UCLA study led by Margaret Kemeny, Ph.D., is now offering free, intensive group therapy that will focus on quality of life and stress management. The project is the outgrowth of previous research by Kemeny, who found that chronically depressed people with HIV had a much steeper decline in their immune system over a five-year period.(2,3) The UCLA Group Therapy Project is now enrolling symptomatic, HIV-positive, gay and bisexual men between ages 25 and 45. (To enroll, call 310/206-7870.)

In a comprehensive review of current research into the relationship between psychological health and AIDS,(4) Michael Antoni and Cornelis Mulder found that the stress of being HIV positive or having AIDS could influence the course of infection. In their review of about 40 studies, they examined the contradictory results, and found that many questions have yet to be answered. The majority of the studies, however, seemed to show a positive correlation. The authors were cautious about interpreting the positive results, but argued that they demonstrate the need for further research.

Understanding the relationship between immune function and psychological state is very difficult, according to Leon McKusick, a psychiatrist with the CAPS program in San Francisco. For example, it is almost impossible to figure out if someone's depression is causing an immune dysfunction or that the reverse is true, that is, the immune dysfunction is causing depression. McKusick said that although it is generally accepted that some correlation exists, it has not been proven that a behavioral intervention has a direct effect on immune status. In the case of AIDS, he explained, it is very hard to determine causality. "Although we may all agree that one's psychology affects one's immune parameters, interfering might not help." Lydia Temoshok(5) has addressed these issues in her research, stressing that it is especially important to be precise in the measurements used to decipher data from clinical trials. Some of the confusion lies in the translation of research data into meaningful concepts because of the nature of HIV disease in which "...psychologic, neurologic, and immunologic changes occur as central, rather than as resultant or adjunctive, aspects of the disease process."

A few studies have shown that interventions can have a direct impact on the immune system of HIV-positive people by enhancing psychological health. Researchers at the University of Miami studied the impact of an aerobic exercise training program on 39 gay men, 16 of whom were HIV positive and asymptomatic; the others were HIV negative.(6) After a five-week training period, the HIV-negative volunteers had average T-helper increases of 220, while the HIV-positive volunteers, who began with an average of 905 T-helper cells, only increased by 50. The researchers point to the sometimes minimal positive effects seen in anti- retroviral therapy and conclude that further research into the role of exercise for stress management should be pursued.

The mental health of HIV-positive women was studied at the Beth Israel Medical Center in New York(7) and St. Mary's Hospital in London.(8) Both studies found high incidence of depression and stress. In light of current knowledge about the faster rate of disease progression in women, these researchers predicted that psychosocial factors are at the heart of the problem. Further research will be needed to prove or disprove this relationship.

Other treatments that were reported at the conference to have some beneficial effect on psychological well-being are: art therapy, an attention training program, a 12-step recovery program, psychospiritual counseling, and social support.

Comment

A basic approach in traditional medical systems is the connection between mind, body and spirit, known as holism. In, for example, traditional Chinese medicine, this connection forms the basis for most medical practices. Psychoneuroimmunology seems to be Western science's attempt to understand and integrate these views. The word psychoneuroimmunology can itself be understood in its three parts; psyche (spirit), neuro (mind) and immunology (body). Both psychoneuroimmunology and holism are concerned with the interaction of these various parts, and the effect one might have on the others.

Some of the controversy that surrounds holism also applies to psychoneuroimmunology. Critics argue that they both lead to a "blame the victim" mentality, by making a patient responsible for his or her own illness. On the other hand, the possibility of increased compliance with other therapies and improvement in the quality of life are positive aspects of this approach.

Also, because psychological treatments and exercise do not have counter-indications with drug treatments, or any noticeable toxicities, they can be an effective complement to an HIV treatment strategy. But only when we have scientifically sound research on the importance of psychological health in a person with HIV will many more people take advantage of what seem to be very useful and safe treatments.

Resources and References

The Center for Attitudinal Healing offers free group therapy sessions for people with HIV or AIDS. An introduction to their services is offered every Thursday at 12:30 at their office, 19 Main Street, Tiburon, CA, 94920. For more information call, 415/435-5022.

An organization has formed in Paris for PWA's interested in Psychoneuroimmunology. For information contact: Parsifal, B. P: 305, 75525 Paris, Cedex 11, France.

1. Spiegel D, Kraemer HC, Bloom JR, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. THE LANCET. October 14, 1989; pages 888-891.

2. Kemeny ME, Duran R, Weiner H, Taylor SE, Visscher B, Fahey JL. Chronic Depression Predicts Immune Decline over a five year period. Presented at 99th Annual Convention of the American Psychological Association, San Francisco, August 1991.

3. Solomon, GF, Kemeny ME, Temoshok L. Psychoneuroimmunologic aspects of human immunodeficiency virus infection. In: Ader R, Felton DL, Cohen N (editors) PSYCHOIMMUNOLOGY II. Orlando FL: Academic Press; 1991: pages 1081-1113.

4. Muldur CL, Antoni MH. Psychosocial correlates of immune status and disease progression in HIV-1 infected homosexual men: review of preliminary findings, and commentary. PSYCHOLOGY AND HEALTH. 1992: volume 6, pages 175-192.

5. Temoshok L. On methods and models of research on Psychoneuroimmunology and HIV/AIDS. In Schmidt LR and others (editors)THEORETICAL & APPLIED ASPECTS OF HEALTH PSYCHOLOGY. London: Harwood Academic Publishers; 1990: pages 77-83.

6. La Perriere A, Fletcher MA, Antoni MH, Klimas NG, Ironson G, Schneiderman N. Aerobic exercise training in an AIDS risk group. International Journal of Sports Medicine. 1991; volume 12, pages S53-S57.

7. Bailer PA, Prenzlauer SL, Getter EV, Wallack JW. Psychological distress in HIV-infected women. VIII International Conference on AIDS, Amsterdam, June 19-24, 1992 [abstract #PoB3764].

8. Sherr L, Melvin D, Petrak J, Davey T, Glover L, Hedge B. Women, AIDS and HIV infection -- psychological barriers and trauma. VIII International Conference on AIDS, Amsterdam, June 19-24, 1992 [abstract #PoB3426].

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