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Cognitive behavioural therapy for adherence and depression in patients with HIV: a three-arm randomised controlled
Steven A Safren1, C Andres Bedoya2, Conall O'Cleirigh3
1Department of Psychology, University of Miami, Miami, FL, USA; Behavioral Medicine, Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA; The Fenway Institute at Fenway Health, Boston, MA, USA.
Insights
Cognitive behavioural therapy for depression integrated with adherence counselling (CBT-AD) improved antiretroviral therapy (ART) adherence and depression symptoms in people with HIV. This integrated approach offers a promising intervention for managing co-occurring conditions in HIV care.
Area of Science:
- Clinical Psychology
- Infectious Diseases
- Public Health
Background:
- Depression is common in people with HIV, impacting antiretroviral therapy (ART) adherence.
- Cognitive behavioural therapy for depression integrated with adherence counselling (CBT-AD) shows potential.
- This study aimed to evaluate the efficacy of CBT-AD in this population.
Purpose of the Study:
- To test the efficacy of CBT-AD compared to other interventions.
- To assess the impact of CBT-AD on ART adherence and depression symptoms.
Main Methods:
- A three-arm randomized controlled trial involving HIV-positive adults with depression.
- Participants were assigned to CBT-AD, information and supportive psychotherapy plus adherence counselling (ISP-AD), or enhanced treatment as usual (ETAU).
- ART adherence was the primary outcome, measured by electronic pill caps (MEMS).
Main Results:
- CBT-AD significantly improved ART adherence and depression symptoms compared to ETAU.
- No significant differences in adherence were found between CBT-AD and ISP-AD.
- No study-related adverse events were reported.
Conclusions:
- Integrating evidence-based depression treatment with adherence counselling is beneficial for individuals with HIV and depression.
- Further research should focus on disseminating CBT-AD and evaluating its cost-effectiveness.
Background:
Depression is highly prevalent in people with HIV and has consistently been associated with poor antiretroviral therapy (ART) adherence. Integrating cognitive behavioural therapy (CBT) for depression with adherence counselling using the Life-Steps approach (CBT-AD) has an emerging evidence base. The aim of this study was to test the efficacy of CBT-AD.
Methods:
In this three-arm randomised controlled trial in HIV-positive adults with depression, we compared CBT-AD with information and supportive psychotherapy plus adherence counselling using the Life-Steps approach (ISP-AD), and with enhanced treatment as usual (ETAU) including Life-Steps adherence counselling only. Participants were recruited from three sites in New England, USA (two hospital settings and one community health centre). Patients were randomly assigned (2:2:1) to receive CBT-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), ISP-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), or ETAU (one Life-Steps session and five assessment visits roughly every 2 weeks), randomisation was done with allocation software, in pairs, and stratified by three variables: study site, whether or not participants had been prescribed antidepressant medication, and whether or not participants had a history of injection drug use. The primary outcome was ART adherence at the end of treatment (4 month assessment) assessed via electronic pill caps (Medication Event Monitoring System [MEMS]) with correction for pocketed doses, analysed by intention to treat.
Findings:
Patients were recruited from Feb 26, 2009, to June 21, 2012. Patients who were assigned to CBT-AD (94 randomly assigned, 83 completed assessment) had greater improvements in adherence (estimated difference 1·00 percentage point per visit, 95% CI 0·34 to 1·66, p=0·003) and depression (Center for Epidemiological Studies depression [CESD] score estimated difference -0·41, -0·66 to -0·16, p=0·001; Montgomery-Asberg depression rating scale [MADRS] score -4·69, -8·09 to -1·28, p=0·007; clinical global impression [CGI] score -0·66, -1·11 to -0·21, p=0·005) than did patients who had ETAU (49 assigned, 46 completed assessment) after treatment (4 months). No significant differences in adherence were noted between CBT-AD and ISP-AD (97 assigned, 87 completed assessment). No study-related adverse events were reported.
Interpretation:
Integrating evidenced-based treatment for depression with evidenced-based adherence counselling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate effective psychosocial depression treatments such as CBT-AD to people living with HIV/AIDS and examine the cost-effectiveness of such approaches.
Funding:
National Institute of Mental Health, National Institute of Allergy and Infectious Diseases.
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