|Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006
|Scott-Sheldon L A, Kalichman S C, Carey M P, Fielder R L
This review concluded that stress-management interventions for HIV-positive participants significantly improved mental health and quality of life, but did not alter immunological or hormonal processes. This conclusion clearly reflected the results of the review, but it was difficult to be sure of the reliability of the conclusions due to the lack of a validity assessment of the primary studies.
To assess the impact of stress-management interventions on psychological, immunological, hormonal and other behavioural health outcomes in HIV-positive adults.
PubMed, PsycINFO, AIDSearch, Dissertation Abstracts, ERIC, CRISP and The Cochrane Library databases were searched up to February 2007. Search terms were reported. References of identified studies and reviews were checked. Authors and professional listserve mailing lists were contacted. Both published and unpublished studies were eligible for inclusion.
Randomised controlled trials (RCTs) that assessed a psychological, behavioural or stress-management intervention in adults who were HIV-seropositive and reported at least one psychological or psychosocial outcomes were eligible for inclusion. Studies were required to report sufficient data for the calculation of a between-groups estimate of effect size and to specify the stress-management intervention adopted. Studies in mixed populations were included if results were reported separately for HIV-positive individuals. Outcomes assessed were coping and social support, anxiety, depression, distress, quality of life, CD4 counts and viral load, cortisol, DHEA-S, the cortisol DHEA-S ratio, testosterone and other behavioural outcomes including fatigue.
Most of the selected studies were conducted in the United States. Participants in the studies were recruited through clinical contacts or a combination of clinical and community contacts. Participants had known their HIV status for an average of five years. Most were male (82 per cent) and Caucasian (56 per cent). Most were men who have sex with men (MSM) (67 per cent). The mean age was 37 years. Participants in the great majority of studies were using anti-retroviral medication. Levels of distress in enrolled participants varied. Group and individual interventions were used and a range of methods and approaches used. Most studies used a control condition of no intervention or waiting list. Outcome measures at the first post-intervention assessment were assessed (mean 1.16 weeks, range 0 to 26 weeks).
Study authors were contacted if additional information was required to determine eligibility. No further details of the selection process were given.
Assessment of study quality
The authors did not state that they assessed validity.
Data were extracted on outcomes reported. Effect sizes were calculated for each outcome. Where multiple measures of the same outcome were reported, the effect sizes were averaged. Where outcomes were reported separately for subgroups, effect sizes were calculated separately for each subgroup. Where multiple control conditions were employed, the condition with the least patient contact was used for the calculation of effect sizes. Two reviewers independently performed the data extraction; disagreements were resolved through discussion.
Methods of synthesis
Weighted mean effect sizes with 95% confidence intervals (CIs) were calculated using both fixed- and random-effects models. Statistical heterogeneity was calculated using the Q statistic and the I2 statistic. Outliers were excluded if statistically significant heterogeneity was detected. If significant heterogeneity remained, regression analyses were used to assess the relationship between study characteristics and effect size.
Results of the review
Thirty-five RCTs evaluating 46 interventions were included (n=2,498).
Stress-management interventions significantly reduced anxiety (0.31, 95% CI: 0.14, 0.48), depression (0.29, 95% CI: 0.18, 0.41), fatigue (0.38, 95% CI: 0.16, 0.59) and distress (0.19, 95% CI: 0.06, 0.33), and improved quality of life (0.16, 95% CI: 0.05, 0.27) compared to control groups (all pooled effects sizes from random-effects meta-analyses).
There were no statistically significant differences between the groups for coping, social support, CD4 count, viral load and hormonal outcomes. Statistically significant heterogeneity was found for the analyses of anxiety, depression and hormonal outcomes.
Results of the regression analyses were also reported.
Stress-management interventions improved mental health and quality of life significantly, but did not alter immunological or hormonal processes. The effects may reflect the limited assessment periods of most studies and reflect participant characteristics.
The review question and the inclusion criteria were clear. The authors searched a number of relevant databases and other sources, thereby reducing the chance that relevant studies were excluded and the risk of publication bias. The authors reported using methods designed to minimise reviewer bias and error in the data extraction, but it was not clear if this was the case for the selection of studies. No assessment of study validity was reported, which made it difficult to assess the reliability of the evidence. The decision to employ meta-analysis appeared appropriate. Heterogeneity was assessed and explored. The authors' conclusions clearly reflected the results of the review, but in the absence of a validity assessment it was difficult to be sure of the reliability of the conclusions.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that further research should investigate the effectiveness of stress-management interventions in more diverse patient groups, explore patient characteristics that might moderate efficacy and use longer assessment periods. They also stated that research was required to assess the effectiveness and cost-effectiveness of stress-management interventions for HIV-positive patients in developing countries.
National Institutes of Health Grant R01-MH71164 and R01-MH068171.
Scott-Sheldon L A, Kalichman S C, Carey M P, Fielder R L. Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006. Health Psychology 2008; 27(2): 129-139
Subject indexing assigned by NLM
Adaptation, Psychological /physiology; Arousal /physiology; Behavior Therapy /methods; CD4 Lymphocyte Count; Dehydroepiandrosterone Sulfate /blood; HIV Seropositivity /immunology /psychology; Hydrocortisone /blood; Pyridines; Randomized Controlled Trials as Topic; Stress, Psychological /complications /psychology /therapy; Testosterone /blood; Viral Load
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.