Optimizing the effects of stress management interventions in HIV.

Scott-Sheldon, Kalichman, Carey, and Fiedler (2008) present a thoughtful, important, and timely meta-analysis of randomized controlled trials of stress management interventions in HIV. They differentiate controlled effect sizes across classes of acute outcomes including psychological distress, psychosocial processes, biological processes (immune status, viral, and hormonal) and fatigue. The authors join Scott-Sheldon et al., in considering future directions for this type of clinical psychosocial intervention research in HIV. Recommendations for addressing the high prevalence of psychosocial problems including diagnosable mental health disorders comorbid with HIV are presented. Suggestions for addressing medication adherence and accommodating interventions with concomitant substance use treatment are also considered. These recommendations are presented with an emphasis on expanding both the efficacy and effectiveness of psychosocial interventions in HIV. These recommendations are presented as realistic strategies for improving the modest treatment effect sizes for psychosocial outcomes and identifying meaningful effects on distal physiological outcomes associated with traditional stress management interventions in HIV. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: A randomized efficacy trial.

In this depression prevention trial, 341 high-risk adolescents (mean age = 15.6 years, SD = 1.2) with elevated depressive symptoms were randomized to a brief group cognitive-behavioral (CB) intervention, group supportive-expressive intervention, bibliotherapy, or assessment-only control condition. CB participants showed significantly greater reductions in depressive symptoms than did supportive-expressive, bibliotherapy, and assessment-only participants at posttest, though only the difference compared with assessment controls was significant at 6-month follow-up. CB participants showed significantly greater improvements in social adjustment and reductions in substance use at posttest and 6-month follow-up than did participants in all 3 other conditions. Supportive-expressive and bibliotherapy participants showed greater reductions in depressive symptoms than did assessment-only controls at certain follow-up assessments but produced no effects for social adjustment and substance use. CB, supportive-expressive, and bibliotherapy participants showed a significantly lower risk for major depression onset over the 6-month follow-up than did assessment-only controls. The evidence that this brief CB intervention reduced risk for future depression onset and outperformed alternative interventions for certain ecologically important outcomes suggests that this intervention may have clinical utility. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Individual and group cognitive-behavioral treatment for work-related stress complaints and sickness absence: A randomized controlled trial.

Work-related stress is widespread and can lead to long-term absenteeism and work disability. Cognitive-behavioral treatment (CBT) has demonstrated effectiveness in treating psychopathology but has only rarely been tested in clinical samples with work-related stress. A randomized controlled trial was conducted to investigate the efficacy of CBT-based stress management training (SMT). Eighty-two patients on sickness leave with work-related stress were randomly assigned to (a) individual SMT, (b) group SMT, or (c) care as usual (CAU). The SMT comprised 12 sessions conducted by a psychologist. Complaints of burnout and distress were measured at baseline, and at 4, 7, and 10 months. Absenteeism was measured during the whole research period. Across treatment conditions, complaints and sickness absence reduced considerably between baseline and 4 months. Thereafter, complaints remained approximately stable, whereas sickness absence further reduced. Hardly any significant group difference emerged, and no consistent pattern could be discerned in favor of any treatment condition. In subgroups with low depressive complaints, though, individual SMT resulted in larger reductions of some complaints than CAU. In conclusion, this study adds to the evidence that CBT-based interventions as currently practiced are not successful in treating patients with clinical levels of work-related stress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of a coping group intervention for adults with HIV who are AIDS bereaved: Longitudinal effects on grief.

The authors sought to study the longitudinal effects of a cognitive-behavioral group intervention for coping with AIDS bereavement among a diverse sample of adults who were HIV positive. Participants (N = 267) were randomly assigned to receive the 12-week intervention or individual therapy upon request. Measures were administered at baseline, postintervention, and 4-, 8-, and 12-month follow-ups. Longitudinal data were analyzed with linear mixed models to examine change in grief by condition across the study period and the effect of the intervention on grief through its interaction with psychiatric distress. The authors used the Grief Reaction Index to assess grief and the Symptom Checklist-90-Revised to assess global psychiatric distress. Participants in both conditions reported decreases in grief severity. However, among those with higher levels of psychiatric distress, participants in the group intervention had significantly lower grief severity scores compared with participants in the individual therapy condition. The long-term effectiveness of this AIDS-bereavement intervention for psychiatrically distressed people with HIV/AIDS supports the need for tailored interventions among those at risk for complicated grief responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stress management interventions for HIV+ adults: A meta-analysis of randomized controlled trials, 1989 to 2006.

Objective: Numerous studies document that stress accelerates disease processes in a variety of diseases including HIV. As a result, investigators have developed and evaluated interventions to reduce stress as a means to improve health among persons living with HIV. Therefore, the current meta-analysis examines the impact of stress-management interventions at improving psychological, immunological, hormonal, and other behavioral health outcomes among HIV= adults. Design: This meta-analytic review integrated the results of 35 randomized controlled trials examining the efficacy of 46 separate stress management interventions for HIV+ adults (N = 3,077). Main Outcome Measures: Effect sizes were calculated for stress processes (coping and social support), psychological/psychosocial (anxiety, depression, distress, and quality of life), immunological (CD4+ counts and viral load), hormonal (cortisol, dehydroepiandrosterone sulfate [DHEA-S], cortisol/DHEA-S ratio, and testosterone) and other behavioral health outcomes (fatigue). Results: Compared to controls, stress-management interventions reduce anxiety, depression, distress, and fatigue and improve quality of life (d+s + 0.16 to 0.38). Stress-management interventions do not appear to improve CD4+ counts, viral load, or hormonal outcomes compared with controls. Conclusion: Overall, stress-management interventions for HIV+ adults significantly improve mental health and quality of life but do not alter immunological or hormonal processes. The absence of immunological or hormonal benefits may reflect the studies' limited assessment period (measured typically within 1-week postintervention), participants' advanced stage of HIV (HIV+ status known for an average of 5 years), and/or sample characteristics (predominately male and White participants). Future research might test these hypotheses and refine our understanding of stress processes and their amelioration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention.

Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of brief interventions for problem and pathological gamblers.

Limited research exists regarding methods for reducing problem gambling. Problem gamblers (N = 180) were randomly assigned to assessment only control, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy evidenced significantly reduced gambling on 1 index compared with the control condition. These results suggest the efficacy of a very brief intervention for reduction of gambling among problem and pathological gamblers who are not actively seeking gambling treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Passage meditation reduces perceived stress in health professionals: A randomized, controlled trial.

The authors evaluated an 8-week, 2-hr per week training for physicians, nurses, chaplains, and other health professionals using nonsectarian, spiritually based self-management tools based on passage meditation (E. Easwaran, 1978/1991). Participants were randomized to intervention (n = 27) or waiting list (n = 31). Pretest, posttest, and 8- and 19-week follow-up data were gathered on 8 measures, including perceived stress, burnout, mental health, and psychological well-being. Aggregated across examinations, beneficial treatment effects were observed on stress (p = .0013) and mental health (p = .03). Treatment effects on stress were mediated by adherence to practices (p = .05). Stress reductions remained large at 19 weeks (84% of the pretest standard deviation, p = .006). Evidence suggests this program reduces stress and may enhance mental health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can group interventions facilitate forgiveness of an ex-spouse? A randomized clinical trial.

This study evaluated the effectiveness of 2 versions of an 8-session forgiveness group intervention for divorced individuals. Participants (randomized, n = 192; analyzed, n = 149) were randomly assigned to a secular forgiveness condition, a religious forgiveness condition, or a no-intervention comparison condition. Measures of forgiveness and mental health were obtained at pretest, posttest, and 6-week follow-up. Participants in both intervention conditions increased significantly more than comparison participants on self-reported forgiveness of an ex-spouse and understanding of forgiveness. Participants in the secular condition showed a greater decrease in depressive symptoms than comparison participants. Intrinsic religiousness did not moderate intervention effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral intervention for stress management in sports.

This article covers stress management for athletes beginning with a brief behavioral conceptualization of athletic performance and analysis of stress. Examples of external and internal stressors are offered, as well as of stress responses from autonomic, somatic, and cognitive domains. Further discussed are specific types of stress management approaches used with athletes, and associated with external vs. internal sources of stress, and with the 3 stress response domains. Although the article focuses on the author's own conceptualization and experiences with sport interventions, relevant research results from the current literature are cited to provide a broader context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of occupational stress management intervention programs: A meta-analysis.

A meta-analysis was conducted to determine the effectiveness of stress management interventions in occupational settings. Thirty-six experimental studies were included, representing 55 interventions. Total sample size was 2,847. Of the participants, 59% were female, mean age was 35.4, and average length of intervention was 7.4 weeks. The overall weighted effect size (Cohen's d) for all studies was 0.526 (95% confidence interval = 0.364, 0.687), a significant medium to large effect. Interventions were coded as cognitive-behavioral, relaxation, organizational, multimodal, or alternative. Analyses based on these subgroups suggested that intervention type played a moderating role. Cognitive-behavioral programs consistently produced larger effects than other types of interventions, but if additional treatment components were added the effect was reduced. Within the sample of studies, relaxation interventions were most frequently used, and organizational interventions continued to be scarce. Effects were based mainly on psychological outcome variables, as opposed to physiological or organizational measures. The examination of additional moderators such as treatment length, outcome variable, and occupation did not reveal significant variations in effect size by intervention type. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypnotic taper with or without self-help treatment of insomnia: A randomized clinical trial.

This study aimed to assess the efficacy of a minimal intervention focusing on hypnotic discontinuation and cognitive-behavioral treatment (CBT) for insomnia. Fifty-three adult chronic users of hypnotics were randomly assigned to an 8-week hypnotic taper program, used alone or combined with a self-help CBT. Weekly hypnotic use decreased in both conditions, from a nearly nightly use at baseline to less than once a week at posttreatment. Nightly dosage (in lorazepam equivalent) decreased from 1.67 mg to 0.12 mg. Participants who received CBT improved their sleep efficiency by 8%, whereas those who did not remained stable. Total wake time decreased by 52 min among CBT participants and increased by 13 min among those receiving the taper schedule alone. Total sleep time remained stable throughout withdrawal in both CBT and taper conditions. The present findings suggest that a systematic withdrawal schedule might be sufficient in helping chronic users stop their hypnotic medication. The addition of a self-help treatment focusing on insomnia, a readily available and cost-effective alternative to individual psychotherapy, produced greater sleep improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of brief interventions for body dissatisfaction.

The authors examined the relative effectiveness of 3 different approaches to the experience of body dissatisfaction compared to a control and ruminative attention control condition, with respect to increasing weight and appearance satisfaction. One hundred female undergraduates (mean age = 24.38, SD = 9.39) underwent a body dissatisfaction induction procedure, which significantly decreased levels of weight and appearance satisfaction. Participants were then randomized, 20 to each of 5 groups: control, ruminative attention control, acceptance, distraction, and cognitive dissonance. With the exception of the control group, participants were briefly trained in their assigned technique and were asked to practice this over the next 5 min while repeated measures of weight and appearance satisfaction were recorded. Acceptance, cognitive dissonance, and distraction were superior to both control conditions in increasing weight satisfaction and were superior to a control condition in improving appearance satisfaction. Only acceptance was superior in improving appearance satisfaction compared to a ruminative attention control. The evidence suggests that acceptance is a promising approach to investigate further with respect to its efficacy for reducing body dissatisfaction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing perinatal depression in low-income home visiting clients: A randomized controlled trial.

Objective: To assess the efficacy of a 6-week cognitive-behavioral intervention in preventing the onset of perinatal depression and reducing depressive symptoms among low-income women in home visitation programs. Method: Sixty-one women who were pregnant or who had a child less than 6 months of age and who were assessed as at risk for perinatal depression were randomized to a 6-week, group-based cognitive-behavioral intervention or usual home visiting services. Study participants were predominately African American, unmarried, and unemployed. Intervention sessions were led by a licensed clinical social worker or clinical psychologist. Home visitors provided 1-on-1 reinforcement of key intervention messages between group sessions. Depressive symptoms were measured with the Beck Depression Inventory–II (Beck, Steer, & Brown, 1996), and major depressive episodes were measured with the Maternal Mood Screener (MMS; Le & Mu?oz, 1998). Outcomes were assessed at baseline and at 1 week and 3 months postintervention. Results: Repeated measures analysis of variance indicated that there was a significant Time × Condition interaction, F(2, 112) = 4.1, p = .02. At 3 months postintervention, 9 of 27 (33%) women receiving usual care reported levels of depressive symptoms that met clinical cutoff for depression on the MMS compared with 3 of 32 (9%) women in the intervention condition, χ2(1, N = 59) = 5.18, p     

Prevention of depressive symptoms in adolescents: A randomized trial of cognitive-behavioral and interpersonal prevention programs.

This study evaluated the efficacy of 2 programs for preventing depressive symptoms in adolescents. Participants were 380 high school students randomly assigned to a cognitive-behavioral program (CB), an interpersonal psychotherapy-adolescent skills training program (IPT-AST), or a no-intervention control. The interventions involved eight 90-min weekly sessions run in small groups during wellness classes. At postintervention, students in both the CB and IPT-AST groups reported significantly lower levels of depressive symptoms than did those in the no-intervention group, controlling for baseline depression scores; the 2 intervention groups did not differ significantly from each other. The effect sizes, using Cohen's d, for the CB intervention and the IPT-AST intervention were 0.37 and 0.26, respectively. Differences between control and intervention groups were largest for adolescents with high levels of depressive symptoms at baseline. For a high-risk subgroup, defined as having scored in the top 25th percentile on the baseline depression measure, the effect sizes for the CB and the IPT-AST interventions were 0.89 and 0.84, respectively. For the whole sample, sociotropy and achievement orientation moderated the effect of the interventions. Intervention effects were short term and were not maintained at 6-month follow-up. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group-based randomized trial of contingencies for health and abstinence in HIV patients.

Objective: Contingency management (CM) treatments are usually applied individually for drug abstinence, but CM can also be targeted toward health behaviors and implemented in groups. This study evaluated effects of a group-based CM intervention that focused on reinforcing health behaviors. Method: HIV-positive patients with cocaine or opioid use disorders (n = 170) were randomized to weekly CM or 12-step (TS) groups for 24 weeks (mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 session for TS participants). During the treatment period, both groups received compensation for attendance ($10 per session) and submission of urine samples (about $2 per sample). In addition, participants received $25 for submitting samples and completing evaluations at Months 1, 3, 6, 9, and 12; 65–75 of the 81 participants assigned to TS and 71–80 of the 89 participants assigned to CM completed these evaluations. During the treatment period, patients in the CM group received chances to win prizes contingent upon completing health activities and submitting substance-free specimens (M = $260, SD = $267). Results: Mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 sessions for TS participants. CM participants submitted a significantly greater number of consecutive drug-free specimens than did TS participants (5.2 ± 6.0 vs. 3.7 ± 5.6), but proportions of negative samples did not differ between groups during treatment or at follow-up evaluations. From pre- to posttreatment, CM participants showed greater reductions in viral loads and HIV-risk behaviors than did TS participants, but these effects were not maintained throughout the follow-up period. Conclusions: These data suggest the efficacy of group-based CM for HIV-positive substance abusers, but more research is needed to extend the long-term benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reducing STD and HIV risk behavior of substance-dependent adolescents: A randomized controlled trial.

A randomized controlled trial assessed 3 interventions designed to increase safer sex behaviors of substance-dependent adolescents. Participants (N = 161) received 12 sessions of either a health information intervention (I only), information plus skills-based safer sex training (I + B), or the same experimental condition plus a risk-sensitization manipulation (I + M + B). The I + B and I + M + B conditions, as compared with the I only condition, (a) produced more favorable attitudes toward condoms; (b) reduced the frequency of unprotected vaginal sex; and (c) increased behavioral skill performance, frequency of condom-protected sex, percentage of intercourse occasions that were condom protected, and number of adolescents who abstained from sex. The intervention that included the risk-sensitization procedures was more resistant to decay. An unexpected finding was that the I + B and I + M + B conditions produced substantial increased in sexual abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment effectiveness of parent management training in Norway: A randomized controlled trial of children with conduct problems.

This study was a randomized control trial (RCT) of Parent Management Training--The Oregon Model (PMTO) in Norway. A sample representing all health regions of Norway and consisting of 112 children with conduct problems and their families participated in the study. Families were randomly assigned to either PMTO or a regular services comparison group. PMTO was delivered via existing children's services, and families were recruited using the agencies' regular referral procedures, making this the first effectiveness study of PMTO and the first RCT of PMTO conducted outside of the United States. Using a multiagent-multimethod approach, results showed that PMTO was effective in reducing parent-reported child externalizing problems, improving teacher-reported social competence, and enhancing parental discipline. Age level and gender modified the effects of PMTO treatment on other outcomes. In a path model, participation in PMTO was associated with improved parental discipline, and effective discipline predicted greater child compliance, fewer child-initiated negative chains, and lower levels of child externalizing problems. Findings are presented along with a discussion of the implications for practice and research and the challenges accompanying effectiveness trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)