Cognitive-behavioral stress management intervention effects on anxiety, 24-hr urinary norepinephrine output, and T-cytotoxic/suppressor cells over time among symptomatic HIV-infected gay men

The present study tested the effects of a multimodal cognitive-behavioral stress management (CBSM) intervention on anxious mood, perceived stress, 24-hr urinary catecholamine levels, and changes in T-lymphocyte subpopulations over time in symptomatic HIV+ gay men. Seventy-three men were randomized to either a group-based CBSM intervention (n = 47) or a wait-list control (WLC) condition (n = 26). Men assigned to CBSM showed significantly lower posttreatment levels of self-reported anxiety, anger, total mood disturbance, and perceived stress and less norepinephrine (NE) output as compared with men in the WLC group. At the individual level, anxiety decreases paralleled NE reductions. Significantly greater numbers of T-cytotoxic/suppressor (CD3+CD8+) lymphocytes were found 6 to 12 months later in those assigned to CBSM. Moreover, greater decreases in NE output and a greater frequency of relaxation home practice during the 10-week CBSM intervention period predicted higher CD3+CD8+ cell counts at follow-up.     

Reductions in herpes simplex virus type 2 antibody titers after cognitive behavioral stress management and relationships with neuroendocrine function, relaxation skills, and social support in HIV-positive men

OBJECTIVE: Coinfection with herpes simplex virus type 2 (HSV-2) is common in individuals infected with human immunodeficiency virus (HIV) and may have health implications. This study examined the effect of a 10-week cognitive behavioral stress management (CBSM) intervention on immunoglobulin G (IgG) antibody titers to HSV-2 in a group of mildly symptomatic HIV-infected gay men and the degree to which these effects were mediated by psychosocial and endocrine changes during the 10-week period. METHODS: Sixty-two HIV+ gay men were randomly assigned to either a 10-week CBSM intervention (N = 41) or a wait-list control condition (N = 21). Anxious mood, social support, cortisol/dehydroepiandrosterone sulfate (DHEA-S) ratio levels, and HSV-2 IgG antibody titers were assessed at baseline and after the 10-week period. CBSM participants also recorded their stress levels before and after at-home relaxation practice. RESULTS: HSV-2 IgG titers were significantly reduced in the CBSM participants but remained unchanged in the control group after the 10-week intervention period. Increases in one type of social support, perceived receipt of guidance, during the 10 weeks was associated with and partially mediated the effect of the intervention on HSV-2 IgG. Similarly, decreases in cortisol/DHEA-S ratio levels were associated with decreases in HSV-2 IgG, and lower mean stress levels achieved after home relaxation practice were associated with greater decreases in HSV-2 IgG among CBSM participants. CONCLUSIONS: These findings suggest that behavioral and psychosocial changes occurring during CBSM interventions, including relaxation, enhanced social support, and adrenal hormone reductions, may help to explain the effects of this form of stress management on immune indices such as HSV-2 antibody titers.     

Decreased depression up to one year following CBSM+ intervention in depressed women with AIDS: the smart/EST women's project

This prospective multisite Phase III clinical trial (Miami, New York, New Jersey) investigated the long-term (one year) effects of a 10-week group cognitive-behavioral stress management/expressive supportive therapy (CBSM+) intervention on disadvantaged minority women living with AIDS. The CBSM+ intervention consisted of 10-weekly group session of stress management, cognitive-behavioral skill training, relaxation techniques and expressive-supportive therapeutic strategies. The primary study outcome was self-reported depression scores as measured by the BDI. The CBSM+ Group intervention significantly decreased depression scores on the BDI for women following the intervention and maintained the decreased level at one-year follow-up.     

Behavioral medicine and the management of HIV/AIDS

Psychosocial treatment studies provide a method for conducting causal investigations within a clinical environment. They can also inform about relations between psychosocial or biobehavioral processes on the one hand, and disease on the other. Our studies conducted on HIV-positive (HIV+) homosexual men indicate that a group-based cognitive behavioral stress management (CBSM) intervention can decrease distress, buffer the psychological and immunological sequelae of HIV+ serostatus notification, and improve surveillance of herpes viruses. Decreased dysphoria induced by CBSM appears to be a significant mediator of control over cellular immunity. Poor HIV+ African American women, as well as more affluent gay men, benefit from group-based CBSM, but important gender and sociocultural differences must be taken into account in developing protocols. Adherence to highly active antiretroviral therapy (HAART), coupled with good health behavior, can contain HIV/AIDS in most instances. In contrast, poor HAART adherence coupled with poor health behavior (e.g., unprotected sex) can lead to drug resistance and infection of partners with virulent mutated strains. Thus, now more than ever, behavioral medicine approaches to management and secondary prevention of HIV/AIDS are needed.     

Cognitive behavioral stress management effects on mood,social support,and a marker of antiviral immunity are maintained up to 1 year in HIV-infected gay men

Numerous herpesvirus infections are associated with clinically relevant outcomes as well as an accelerated HIV replication rate and subsequent disease progression. Stress managementinterventionsmayimprovemarkersofcellularimmunecontroloverlatent herpesvirus infections and these changes appear to be mediated by perceptions of increased social support availability. We examined the effects ofagroup-based cognitive behavioral stress management (CBSM) intervention on distress, dysphoria, perceived socialsupport,andherpesvirus immunoglobulin G (IgG) antibody titers during the 6to 12 months following the intervention. Of those who were initially randomized, 49 HIV-infected men were followed during the 6-to 12-month period after randomization to either a 10-week CBSM intervention (n=31) or amodified wait-list control condition (n = 18). Measures of distress, dysphoria, social support, and blood samples for herpesvirus Ig Gtiters were taken at baseline,immediately following CBSM and at-6-to 12-month follow-up. Men in CBSM displayed maintenance of previously observed intervention effects on dysphoria, reliable alliance support, and herpesvirus IgG antibody titers (i.e., Epstein-Barr virus capsid antigen; EBV-VCA). Intervention-related changes in EBV-VCA were unrelated to changes in lymphocyte subsets (i.e., CD4+, CD8+, and CD4+:CD8+) or changes in measures of dysphoria and social support during the investigation period. Data indicate that HIV-infected men participating in a CBS Mintervention maintain better psychosocial status and immunologic control of latent EBV infection up to 1 year after its conclusion. This research was supported by National Institute of Mental Health Grants P50 MH4355 and T32 MH18917.     

Effects of stress management on testosterone levels in women with early-stage breast cancer

We examined the effects of a10-week, group-based cognitive-behavioral stressman-agement (CBSM) intervention on serum testosterone levels in women with Stage 1or 2 breast cancer. At 4 to 8 weeks postsurgery, participants were randomized to CBSM (n = 24) or to a wait-list control group (n = 10). Free and total testosterone was assessed via radioimmunoassay before and after the study period. The participants also completed a questionnaire assessing the degree to which living with breast cancer had led to social and emotional benefits in their life. We observed significant decreases in testosterone levels in the CBSM group and no change in the controls. Decreasesintes-tosterone were related to increases in positive contributions. These findings suggest that a short-term psychological intervention can help modulate androgen functioning, and these changes are related to enhanced benefit finding observed among women with breast cancer participating in CBSM.     

Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer

OBJECTIVE: This study examined the effects of a cognitive-behavioral stress management (CBSM) group intervention on serum cortisol levels in women being treated for stage I or II breast cancer. METHODS: Participants were randomly assigned to undergo a 10-week intervention (N = 24) within 8 weeks after surgery or were placed on a waiting list (N = 10). Cortisol was assessed by means of a radioimmunoassay of blood samples collected at the same time of day just before the start of the intervention and immediately after its completion. The women also reported the degree to which breast cancer had made positive contributions to their lives. RESULTS: Intervention participants showed increased benefit finding and reduced serum cortisol levels, whereas control subjects experienced neither change. Path analysis suggested that the effect of CBSM on cortisol was mediated by increases in benefit finding. CONCLUSIONS: These findings suggest that positive growth enhanced during a time-limited intervention can influence physiological parameters such as cortisol among women with early stage breast cancer.     

Stress Management,Depression, and Immune Status in Lower‐Income Racial/Ethnic Minority Women Co‐infected with HIV and HPV

The stress of co‐infection with human immunodeficiency virus (HIV) and human papillomavirus (HPV), in race/ethnic minority women, may increase depression and immune decrements. Compromised immunity in HIV+ HPV+ women may increase the odds of cervical dysplasia. Thus, we tested the efficacy of a 10‐week cognitive behavioral stress management (CBSM) group intervention and hypothesized that CBSM would decrease depression and improve immune status (CD4+ T‐cells, natural killer [NK] cells). HIV+ HPV+ women (n = 71) completed the Beck Depression Inventory and provided blood samples, were randomized to CBSM or a control condition, and were re‐assessed post‐intervention. Women in CBSM revealed less depression, greater NK cells, and marginally greater CD4+ T‐cells post‐intervention vs. controls. Stress management may improve mood and immunity in HIV+ HPV+ lower‐income minority women.     

Reductions in Salivary Cortisol Are Associated with Mood Improvement During Relaxation Training Among HIV-Seropositive Men

This study examined salivary cortisol and mood during relaxation training in 30 symptomatic, HIV+ gay men participating in a 10-week, group-based cognitive-behavioral stress management intervention. Cortisol levels and mood were assessed within these sessions just before and after 45-min relaxation exercises given as part of each session. Participants also recorded their stress level and compliance with daily home relaxation practice. Presession cortisol levels decreased across the 10-week period and were related to decreases in global measures of total mood disturbance and anxious mood. Reductions in presession cortisol levels were also associated with decreases in self-reported stress level during home practice. Greater reductions in cortisol during the first three sessions were associated with more frequent relaxation practice at home. These findings suggest that salivary cortisol represents an objective neuroendocrine marker for changes in anxiety and distress observed during relaxation training in symptomatic, HIV-seropositive men.     

Yoga and Cognitive‐behavioral Interventions to Reduce Stress in Incoming College Students: A Pilot Study

We examined the feasibility and differential efficacy of cognitive‐behavioral stress management (CBSM ) and yoga for first‐year college students to reduce stress and improve mental and physical health. Thirty‐four incoming first‐year female students were assigned to 8 weeks of yoga, CBSM , or a wait‐list control. Assessments were made at baseline, end of intervention, and 4 months after intervention end. Both CBSM and yoga produced salutary changes in psychosocial and behavioral health as well as health‐related measures of physical function and activity relative to the control group. Stress‐management interventions are feasible and highly regarded by first‐year women and demonstrate promising effects.     

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity.

Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.     

Sacred moments: implications on well-being and stress

This research provides a theoretical, empirical, and qualitative examination of the role of cultivating sacred moments in daily life on subjective well-being (SWB), psychological well-being (PWB), and stress. Seventy-three participants were randomly assigned to two groups: (a) a 3-week intervention group where members were instructed in cultivating sacred moments, or (b) a 3-week control group where members were instructed in writing about daily activities. Findings indicate that the intervention was equally as effective as an adapted therapeutic writing intervention. There were significant effects over time across multiple assessments related to SWB, PWB, stress, and daily spiritual experiences after the 3-week intervention and again 6 weeks later. Qualitative analysis complemented and enriched the findings of these results. This study introduces a new intervention into the field of clinical psychology and extends the findings of prior research.     

How stress management improves quality of life after treatment for breast cancer

The range of effects of psychosocial interventions on quality of life among women with breast cancer remains uncertain. Furthermore, it is unclear which components of multimodal interventions account for such effects. To address these issues, the authors tested a 10-week group cognitive-behavioral stress management intervention among 199 women newly treated for nonmetastatic breast cancer, following them for 1 year after recruitment. The intervention reduced reports of social disruption and increased emotional well-being, positive states of mind, benefit finding, positive lifestyle change, and positive affect for up to 12 months (indeed, some effects strengthened over time). With respect to mechanisms tested, the intervention increased confidence in being able to relax at will. There was also evidence that effects of the intervention on the various outcomes examined were mediated by change in confidence about being able to relax. Thus, this intervention had beneficial effects on diverse aspects of quality of life after treatment for breast cancer, which appear linked to a specific stress management skill taught in the intervention.     

Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being

BACKGROUND: Mindfulness-based stress reduction (MBSR) proposes a systematic program for reduction of suffering associated with a wide range of medical conditions. Studies suggest improvements in general aspects of well-being, including quality of life (QoL), coping and positive affect, as well as decreased anxiety and depression. METHODS: A quasi-experimental study examined effects of an 8-week MBSR intervention among 58 female patients with fibromyalgia (mean, 52 +/- 8 years) who underwent MBSR or an active social support procedure. Participants were assigned to groups by date of entry, and 6 subjects dropped out during the study. Self-report measures were validated German inventories and included the following scales: visual analog pain, pain perception, coping with pain, a symptom checklist and QoL. Pre- and postintervention measurements were made. Additionally, a 3-year follow-up was carried out on a subgroup of 26 participants. RESULTS: Pre- to postintervention analyses indicated MBSR to provide significantly greater benefits than the control intervention on most dimensions, including visual analog pain, QoL subscales, coping with pain, anxiety, depression and somatic complaints (Cohen d effect size, 0.40-1.10). Three-year follow-up analyses of MBSR participants indicated sustained benefits for these same measures (effect size, 0.50-0.65). CONCLUSIONS: Based upon a quasi-randomized trial and long-term observational follow-up, results indicate mindfulness intervention to be of potential long-term benefit for female fibromyalgia patients.     

Psychological and quality-of-life outcomes from a comprehensive stress reduction and lifestyle program in patients with coronary artery disease: results of a randomized trial

BACKGROUND: Stress reduction and comprehensive lifestyle modification programs have improved atherosclerosis and cardiac risk factors in earlier trials. Little is known about the impact of such programs on quality-of-life (QoL) and psychological outcomes. Given recent significant improvements in cardiac care, we evaluated the current benefit of stress reduction/lifestyle modification on QoL and emotional distress in patients with coronary artery disease (CAD). METHODS: 101 patients (59.4 +/- 8.6 years, 23 female) with CAD were randomized to a 1-year lifestyle/stress management program (n = 48) or written advice (n = 53). QoL and psychological outcomes were assessed with the SF-36, Beck Depression, Spielberger State/Trait Anxiety, Spielberger State/Trait Anger and Perceived Stress Inventories. Group repeated-measures analyses of variance were performed for all measures. RESULTS: Adherence to the program was excellent (daily relaxation practice 39 +/- 5 vs. 5 +/- 8 min, respectively; p < 0.001). Both groups improved comparably in most dimensions of QoL, and significantly greater improvements for the lifestyle group were found for physical function and physical sum score (p = 0.046 and p = 0.045). Depression, anxiety, anger and perceived stress were reduced similarly in both groups. However, intervention x gender interaction effects revealed greater benefits among women in the lifestyle intervention vs. advice group for depression and anger (p = 0.025 and p = 0.040), but no effects for men. CONCLUSIONS: A comprehensive lifestyle modification and stress management program did not improve psychological outcomes in medically stable CAD patients. The program did appear to confer psychological benefits for women but not men. Further trials should investigate gender-related differences in coronary patient responses to behavioral interventions.     

Measuring asthma-specific quality of life: structured review

Measuring quality of life (QoL) has become an increasingly important dimension of assessing patient well-being and drug efficacy. As there are now several asthma QoL questionnaires to choose from, it is important to appreciate their strengths and weaknesses. To assist in this choice, we have reviewed the existing questionnaires in a structured way. Information relating to the conceptual and measurement model, reliability, validity, interpretability, burden, administration format and translations was extracted from the published literature. The instruments differ in almost all criteria considered, and therefore it cannot be assumed that they measure the same thing. We recommend the selection of questionnaires that are designed only for asthma and that do not assess symptoms as part of QoL. Only two of the questionnaires reviewed fulfill these requirements: the Sydney Asthma QoL Questionnaire (AQLQ-S) and the Living with Asthma Questionnaire (LWAQ). However, for multinational studies, it may be convenient or practical to use questionnaires that have been linguistically validated in many languages (AQLQ-J, SGRQ). It remains unclear which of these questionnaires best reflects patient perceptions of QoL. Our review did not involve patients, so for the time being choosing from existing questionnaires requires a compromise based on the rigor of the development process and the target patient group.     

Addressing obesity and diabetes among African American men: examination of a community-based model of prevention

The Save Our Sons study is a community-based, culturally responsive, and gender-specific intervention aimed at reducing obesity and diabetes among a small sample (n = 42) of African American men. The goals of the study were to: (1) test the feasibility of implementing a group health education and intervention model to reduce the incidence of diabetes and obesity among African American men; (2) improve regular access to and utilization of health care services and community supportive resources to promote healthy lifestyles among African American men; and (3) build community networks and capacity for advocacy and addressing some of the health needs of African American men residing in Lorain County, Ohio. Trained community health workers facilitated activities to achieve program aims. Following the 6-week intervention, results indicated that participant's had greater knowledge about strategies for prevention and management of obesity and diabetes; increased engagement in exercise and fitness activities; decreased blood pressure, weight, and body mass index levels; and visited a primary care doctor more frequently. Also, local residents elevated African American men's health and identified it as a priority in their community. This model of prevention appears to be a substantial, robust, and replicable approach for improving the health and wellbeing of African American men.     

Increases in Positive Reappraisal Coping During a Group-Based Mantram Intervention Mediate Sustained Reductions in Anger in HIV-Positive Persons

Background  There is evidence that various meditation practices reduce distress, but little is known about the mechanisms of frequently repeating a mantram—a spiritual word or phrase—on distress reduction. Mantram repetition is the portable practice of focusing attention frequently on a mantram throughout the day without a specific time, place, or posture. Purpose  We examined the hypothesis of whether increases in positive reappraisal coping or distancing coping mediated the sustained decreases in anger found following a group-based mantram intervention that was designed to train attention and promote awareness of internal experiences. Method  A secondary analysis was performed on data collected from a randomized controlled trial that compared a group-based mantram intervention (n = 46) to an attention-matched control (n = 47) in a community sample of human immunodeficiency virus-positive adults. Positive reappraisal and distancing coping were explored as potential mediators of anger reduction. Results  Participants in the mantram intervention reported significant increases in positive reappraisal coping over the 5-week intervention period, whereas the control group reported decreases. Increases in positive reappraisal coping during the 5-week intervention period appear to mediate the effect of mantram on decreased anger at 22-week follow-up. Conclusions  Findings suggest that a group-based mantram intervention may reduce anger by enhancing positive reappraisal coping. This work was supported by a grant from the NIH/NCCAM (R21AT01159-01A) with additional support from the UCSD General Clinical Research Center (#1637), NIH/National Center for Research Resources (M01RR008), Ruth L. Kirschstein National Research Service Award (T32-MH019391), the San Diego Veterans Medical Research Foundation, and the Department of Veterans Affairs, VA San Diego Healthcare System, San Diego, CA.     

Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention

ObjectiveTo examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes.MethodsThe sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c.ResultsThe group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress.ConclusionsPath analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os.Practice Implications: Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.     

Legal status, emotional well-being and subjective health status of Latino immigrants

Among the many stresses that undocumented Latino immigrants experience, worries about their legal status and preoccupation with disclosure and deportation can heighten the risk for emotional distress and impaired quality of health. To better document these effects, this study examined the relationship between deportation concern and emotional and physical well-being among a group of Latino immigrants in a midwestern city. One-hundred-forty-three persons were recruited through community sources. Fifty-six participants (39%) expressed concern with seeking services for fear of deportation, while 87 did not endorse this concern. Measures of emotional distress, Hispanic immigrant stress and subjective health status were administered. Results indicate that Latino immigrants with concerns about deportation are at heightened risk of experiencing negative emotional and health states (particularly anger), Hispanic immigrant stress associated with extrafamilial factors and substandard health status. Findings inform policymakers of culturally relevant stressors of undocumented Latino immigrants that help to create and perpetuate the health and mental health disparities of this group.