Intervening for exhaustion

"The search for psychosocial factors that contribute to the aetiology and course of coronary heart disease (CHD) has been an energetic, although not always fruitful, pursuit for more than half a century. Around 20 years ago, Appels [1] identified a prodromal constellation of symptoms, including physical exhaustion and feelings of hopelessness, that preceded major CHD events. It was hypothesized that this syndrome of “vital exhaustion” (VE) was a causal risk factor for CHD events, and several observational studies demonstrating prospective associations between VE and subsequent events have been adduced as supporting the hypothesis [2], [3], [4] and [5]. In a recent commentary, however, we discussed the difficulties inherent in drawing causal conclusions from observational evidence [6]. Applying general arguments that are by now very well rehearsed [7] and [8], we suggested that considerations such as confounding by common antecedents of both VE and CHD and reverse causation could not be readily dismissed and resolution was likely only following experimental studies. For example, an explanation of these prospective associations that regards CHD events as the result of inflammatory processes involved in the progress of atherosclerosis and VE as a consequence of such processes is just as parsimonious as one that regards VE as a causal risk. It is also equally, if not more, plausible biologically; there is now substantial evidence that inflammatory cytokines communicate with the central nervous system contributing to illness behaviour and experience and fostering feelings of depression and fatigue [9]. We also posed the question of what implications do the results of observational studies of VE hold for treatment [6]. Again, we would argue that in the absence of experimental evidence, the implications are extremely limited."\ud \u

Invited Commentary: Stress and Mortality

In this issue of the Journal, Nielsen et al. (Am J Epidemiol 2008;168:481−91) use data from a large Danish study to provide evidence that self-reported stress is associated with increased all-cause mortality over the next 20 years. The finding is remarkable. In this commentary, the authors explore what is really meant by stress; they argue that it would be naïve to view stress as reported in this way, with some external exposure. It has to be seen through the lens of the participant's personal experience, and this lens is likely to be clouded by personality, coping styles, and the common mental disorders—depression and anxiety. The authors discuss a wider literature concerning similar findings associating depression with mortality, suggesting three broad reasons for the association. First, the findings might be explained by the impact of stress or distress on well-established risk factors for cardiovascular disease and cancer. Second, there might be direct, underlying psychosomatic pathways by which stress or distress can affect immune or autonomic function. Third, there might be common causal pathways—shared genes or early adversities that predict both stress and mortality from other causes independently. The authors suggest that life course epidemiologic research is required to test these competing hypotheses

Post-traumatic stress symptoms in cancer survivors: relationship to the impact of cancer scale and other associated risk factors

PURPOSE: The purpose of this study was to determine the prevalence of post-traumatic stress symptoms in a sample of cancer survivors and to investigate their association with the impact of cancer, depressive symptoms, and social support. METHODS: We administered a survey to participants in a cancer survivor registry. It included: Post-Traumatic Stress Disorder Checklist-Civilian version (PCL-C), Impact of Cancer Scale (IOC) v.2, and measures of social support, income, and long-term effects of cancer. We performed multivariate analyses to estimate associations between PCL-C and other variables. PCL-C score was examined as a continuous dependent variable and categorically. RESULTS: Responses were available from 162 cancer survivors. Mean age was 51 years (standard deviation (SD) 16); mean time since diagnosis was 11 years (SD 10). Mean PCL-C score was 27 (SD 9, range 17–64); 29% of the sample scored 30 and above, 13% scored 38 and above, 7% scored 44 and above. Linear regression indicated that PCL-C scores were significantly associated with the IOC negative impact summary scale (NIS) (p <0.001), depressive symptoms (p = 0.003), less social support (p = 0.02), and lower income (p = 0.03). NIS subscale analyses showed that two subscales, life interference (LI) and worry (W), were significantly correlated with PCL-C score (LI: p <0.001; W: p = 0.02). CONCLUSIONS: In this study, the IOC NIS was associated with endorsement of PTSD symptoms. Assessing survivors for PTSD symptoms with the PCL-C could detect those individuals in need of psychosocial support. The IOC may be useful for identifying target areas for interventions to reduce these symptoms among cancer survivors

Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis

Introduction: Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods: We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results: Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ 2=7.7; p=0.005). Conclusions: We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence

Psychosocial Factors Associated with Subclinical Atherosclerosis in South Asians: The MASALA Study

South Asians have the highest rates of premature atherosclerotic cardiovascular disease (ASCVD) amongst all ethnic groups in the world; however this risk cannot be fully explained by traditional risk factors. Participants from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study were included in this cross-sectional analysis. The purpose of this study was to investigate the association of psychosocial factors (including anger, anxiety, depressive symptoms, current and chronic stress, social support, and everyday hassles) with carotid intima-media thickness (CIMT). Three multivariate models were examined to evaluate the association between the psychosocial factors and cIMT. Findings suggest that the impact of psychosocial factors on subclinical atherosclerosis is differential for South Asian men and women. For men, anxiety and depression were associated; while for women, stress was associated with common carotid intima media thickness, independent of traditional CVD risk factors, diet and physical activity

Psychological interventions for coronary heart disease

A meta-analysis was conducted on 35 trials involving 10,703 individuals who had experienced a myocardial infarction and were randomised to an intervention involving some form of psychological therapy. Ten of these studies involved individuals with confirmed psychiatric diagnoses. Moderate quality evidence found no reduction of risk for total mortality or revascularisation procedures in comparison to usual care. Low quality evidence found no risk reduction for non-fatal MI although there was a 21% reduction in cardiac mortality. There was also some evidence of benefit on measures of psychological morbidity including anxiety, depression, and stress. It is concluded that psychological interventions may reduce cardiac mortality, although stronger evidence is required before this can be definitively concluded. It is also not clear who benefits most from psychological interventions