Psychotherapy

In a 5- to 10-slide PowerPoint presentation, address the following:
Provide an overview of the article you selected, including answers to the following questions:
What type of group was discussed?
Who were the participants in the group? Why were they selected?
What was the setting of the group?
How often did the group meet?
What was the duration of the group therapy?
What curative factors might be important for this group and why?
What “exclusion criteria” did the authors mention?
Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own client groups. If so, how? If not, why?
Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article.
Note: The presentation should be 5–10 slides, not including the title and reference slides. Include presenter notes (no more than a half page per slide) and use tables and/or diagrams where appropriate. Be sure to support your work with specific citations from the article you selected. Support your presentation with evidence-based literature.
** 4 References required
** No plagiarism

Assignmentone
ATTACHED FILE(S)
732
AIDS PATIENT CARE and STDs
Volume 21, Number 10, 2007
© Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2007.0012
Efficacy of Group Psychotherapy to Reduce Depressive
Symptoms among HIV-Infected Individuals:
A Systematic Review and Meta-Analysis
SETH HIMELHOCH, M.D., M.P.H., DEBORAH R. MEDOFF, Ph.D.,
and GLORIA OYENIYI, B.A.
ABSTRACT
Depressed mood is highly prevalent among HIV-infected individuals. Some but not all stud-
ies have found group psychotherapy to be efficacious in this population. We performed a sys-
tematic review and meta-analysis of double-blinded, randomized controlled trials to exam-
ine efficacy of group psychotherapy treatment among HIV infected with depressive
symptoms. We used PubMed, the Cochrane database, and a search of bibliographies to find
controlled clinical trials with random assignment to group psychotherapy or control condi-
tion among HIV infected patients with depressive symptoms. The principal measure of ef-
fect size was the standard difference between means on validated depression inventories. We
identified 8 studies that included 665 subjects: 5 used cognitive behavioral therapy (CBT), 2
used supportive therapy, and 1 used coping effectiveness training. Three of the 8 studies re-
ported significant effects. The pooled effect size from the random effects model was 0.38 (95%
confidence interval [CI]: 0.23–0.53) representing a moderate effect. Heterogeneity of effect was
not found to be significant (p � 0.69; I2 � 0%). Studies reporting use of group CBT had a
pooled effect size from the random effects model of 0.37 (95% CI: 0.18–0.56) and was signif-
icant. Studies reporting the use of group supportive psychotherapy had a pooled effect size
from the random effects model 0.58 (95% CI: �0.05–1.22) and was nonsignificant. The results
of this study suggest that group psychotherapy is efficacious in reducing depressive symp-
toms among, HIV-infected individuals. Of note, women were nearly absent from all studies.
Future studies should be directed at addressing this disparity.
INTRODUCTION
DEPRESSED MOOD is highly prevalent amongindividuals receiving medical care for
HIV.1 Individuals with HIV and depressive
disorders, compared to those with HIV alone,
have increased HIV related morbidity,2,3 and
among women a higher mortality.4,5 Although
highly active antiretroviral therapy (HAART)
has led to substantial reductions in morbidity
and mortality associated with HIV, studies
have shown that individuals with HIV and de-
pressive disorders are more likely to encounter
greater delays in being prescribed antiretro-
viral therapy,6 and have worse adherence to
taking antiretroviral medication.7 This is in
keeping with research that has shown that de-
pression itself is associated with poor adher-
ence to medical treatment.8
Recent studies, however, suggest that men-
Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.
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GROUP PSYCHOTHERAPY TO REDUCE DEPRESSIVE SYMPTOMS 733
tal health interventions may lead to improved
depressive and HIV-related outcomes.9,10 A
recent systematic review and meta-analysis
found that antidepressants are efficacious tar-
geting depression among those with HIV.11
However, antidepressant treatment may be as-
sociated with high dropout rates11 and may not
be acceptable to all patients.
Psychotherapeutic interventions have also
been used to alleviate psychosocial and inter-
personal difficulties and distress associated
with HIV. Several randomized control trial
studies have investigated the efficacy of group
therapy techniques to decrease psychological
distress, decrease social isolation, and improve
coping among HIV-infected people.12–19 Most
of these studies used interventions based on
cognitive behavioral theory and nearly all these
studies were conducted among men. Because
some, but not all, studies have found group
therapy interventions to be efficacious in de-
creasing distress among HIV-infected people,
we undertook a meta-analysis of randomized
controlled trials to examine whether depressive
symptoms respond to group psychotherapy
treatment among HIV-infected people.
MATERIALS AND METHODS
Search strategy and study inclusion criteria
Because the term AIDS was introduced in
1981 we searched MEDLINE, PSYCHINFO,
and Cochrane databases from 1981–2006 using
the key words: psychotherapy and adaptation,
psychological with HIV or AIDS and limited to
randomized control trials. In an effort to locate
both published and unpublished studies the
bibliographies of key reviews were examined.
Studies were included if they met the follow-
ing criteria: (1) prospective, double-blinded,
controlled trials with random assignment; (2)
report of outcomes of depressive symptoms;
(3) report of use of a psychotherapeutic inter-
ventions. The three authors independently
screened the titles and abstracts of each citation.
Data extraction
Data were independently extracted from the
studies by the three authors. Discrepancies
were resolved by formal review and then by
consensus. Our outcome of interest was de-
pressive symptoms. Depression inventories
that were specific for depressive symptoms
were abstracted. These inventories included
the Hamilton Depression Inventory (Ham-D),
Center for Epidemiogic Studies-Depression
(CES-D), and Beck Depression Inventory (BDI).
The standardized difference in means (Co-
hen d), the effect size, was calculated from
means and standard deviations from these
scales. When data on means or standard devi-
ations were lacking we contacted the authors
of the manuscripts. The one author contacted
did not respond to our inquiry for requested
information. We also compiled information re-
garding demographics, study characteristics,
and type of psychotherapy intervention re-
ported.
Quality of clinical trials
As variation in quality of clinical trials can
result in biased estimates of reported interven-
tion effectiveness, we evaluated the quality of
the clinical trials using a 15-item scale devel-
oped by Detsky et al.20 Each author indepen-
dently rated the quality of the clinical studies.
Discrepancies were resolved by formal review
and then by consensus.
Statistical analysis
We calculated effect sizes and pooled esti-
mates of effect across studies (Stat 8.0: metan
command) using analysis of variance models
for standardized mean differences (Cohen d).
A random effects model was used. We chose
to use a random effects model because it takes
into account both within and between-study
variation leading to a more conservative
weighting estimates. Heterogeneity, or the be-
tween study variation in outcomes, was mea-
sured using the Q statistic.21 The Q statistic is
considered to have a low power as a test of het-
erogeneity; therefore, heterogeneity was con-
sidered present with a p � 0.10. If heterogene-
ity was found to be present the I2 statistic was
used to describe the percentage of variation
due to heterogeneity across studies. In the ab-
sence of heterogeneity (i.e., Q statistic, p �
0.10), pooled results were reported. Publication
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bias was evaluated using a funnel plot as well
as Eggers and Beggs tests.21
RESULTS
Search findings
We identified 18 randomized clinical tri-
als.12–19,22–31 Of these, 8 trials12–19 met inclusion
criteria (Fig. 1). These 8 trials included 665 pa-
tients randomly assigned to psychotherapy or
a parallel control arm (Table 1). Depression was
required at baseline for only one study14 and
two studies excluded those with major depres-
sion.15,17 With respect to the type of psycho-
therapeutic treatment all of the studies used a
group format. One study had two intervention
arms—a CBT group intervention and a sup-
portive therapy group intervention.14 Five of
the treatment interventions were described as
cognitive behavioral therapy (CBT),12–16 one
was described as coping effectiveness training
(CET),17 and two were described as supportive
psychotherapy.14,18 Finally one study reported
results that combined two treatment arms
(emotional expressive and CBT therapy) to-
gether.19 Length of treatment ranged between
7–15 sessions. The length of the intervention
ranged between 90 and 150 minutes. All inter-
ventions were directed at improving psycho-
logical distress and improving mood. Two
interventions were also directed at reducing
grief.16,18 Six trials occurred in the United
States, one trial occurred in Amsterdam19 and
one occurred in Hong Kong.13 With respect to
demographics all but one16 study was con-
ducted on men (Table 1). All studies were rated
as reflecting good quality.
Depressive symptom outcome
Three of the 8 studies reported significant ef-
fects. Of the 3 studies that found significant ef-
fects, one used cognitive behavioral treatment
intervention,16 one used supportive psycho-
therapy,14 and one reported the results of a
combination of emotional expressive and CBT
therapy.19 The pooled effect size from the ran-
dom effects model was 0.38 (95% CI: 0.23–0.53;
HIMELHOCH ET AL.734
FIG. 1. Flow diagram of randomized control trials included and excluded in meta-analysis.
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GROUP PSYCHOTHERAPY TO REDUCE DEPRESSIVE SYMPTOMS 735
Fig. 2) representing a small-moderate effect
size. Heterogeneity of effect was not found to
be significant (p � 0.69; I2 � 0% of variability
in effect sizes due to heterogeneity).
We were interested in investigating whether
intervention type (i.e., CBT versus non-CBT
group therapy interventions) moderated the ef-
fect between psychotherapy and depressive
symptoms. Studies reporting use of group CBT
had a pooled effect size from the random ef-
fects model of 0.37 (95% CI: 0.18–0.56]) and was
significant representing a moderate effect size.
Studies reporting the use of group supportive
psychotherapy had a pooled effect size from
the random effects model 0.58 (95% CI:
�0.05–1.22]) and was nonsignificant. In the one
study that used CET, the effect size from the
random effects model was 0.16 (95% CI:
�0.27–0.59]) and was not significant.
We were also interested in investigating
whether the focus of treatment (i.e., grief and
depressive symptoms versus depressive symp-
toms) moderated the effect between psy-
chotherapy and depressive symptoms. Studies
focusing on grief and depressive symptoms
had a pooled effect size from the random ef-
fects model of 0.34 (95% CI: 0.12–0.56]) and was
significant, representing a small to moderate ef-
fect size. Studies focusing on depressive symp-
toms had a pooled effect size from the random
effects model 0.42 (95% CI: 0.21–0.63) and was
significant representing a moderate effect size.
Finally we were interested in investigating
whether the exclusion of depression moderated
the effect between psychotherapy and depres-
sive symptoms. The two studies that excluded
participants with major depression were found
to have a pooled effect size from the random
effects model of 0.26 (95% CI: �0.10–0.61) and
was not significant. In contrast, those studies
that included participants with major depres-
sion had a pooled effect size from the random
effects model of 0.41 (95% CI: 0.24–0.48) and
was significant, representing a moderate effect
size.
Assessment of publication bias
The funnel plot was roughly symmetric. Eg-
ger’s test and Begg’s test were both nonsignif-
icant. Taken together these findings suggest the
relative absence of publication bias.
DISCUSSION
Our meta-analysis of randomized double-
blinded controlled trials of group psychother-
TABLE 1. CHARACTERISTICS OF THE GROUP THERAPY STUDIES
Baseline Number Group Depression
Number Age Male Caucasian depression group meetings: outcome Type of control
Study randomized (mean) (%) (%) required meetings min/wk measurea group
Goodkin 97 36.5 100 52.6 No 10 90 Hamilton Usual care
Sikkema 235 40.3 64 28.0 No 12 90 Hamilton Usual care
Kellyb 68 34.0 100 62.0 Yes 8 90 CES-D Usual care
Chanc 13 38.1 100 — No 7 120 CES-D Wait list
Chesney 84 39.0 100 82.0 Noe 10 90 CES-D HIV info/wait list
Mulderc,d 27 40.4 100 — No 15 150 BDI Wait list
Lutgendorf 40 36.7 100 62.5 Noe 10 135 BDI Wait list
Antoni 101 41.6 100 52.0 No 10 135 BDI Med adherence
aThe Ham-D is a 17-item scale clinician-rated depression scale with a response range from 0–54. The CES-D is a
20-item subject-rated depression scale with a response range from 0–60. The BDI is a 21-item subject-rated depres-
sion scale with a response range from 5–63.
bThis study had a CBT arm and a supportive therapy arm.
cThe Chan study was from Hong Kong and did not report on race. The Mulder sample was from Amsterdam and
did not report on race.
dThe Mulder study had a CBT and an emotional expressive therapy arm. However, the intervention results were
presented as a combination of both CBT and emotional expressive therapy.
eThe Chesney study excluded participants with major depression. The Lutgendorf study excluded participants with
Hamilton Depression Rating Scale for Depression in the “moderate or greater severity level.”
CBT, cognitive behavioral therapy.
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apy targeting depressive symptoms among
HIV-infected individuals found that group
psychotherapy is efficacious. The combined ef-
fect size was 0.38 (95% CI: 0.23–0.53) repre-
senting a small to moderate effect size. We did
not find any heterogeneity among the studies
and there did not appear to be publication bias.
A meta-analysis of group psychotherapy for
unipolar depression found that among 15 stud-
ies in which participants in the group psy-
chotherapy intervention were compared to un-
treated controls the pooled effect size was
1.03.32 The greater effect size found in the meta-
analysis among those treated for unipolar de-
pression may not be surprising. Those with
unipolar depression, in contrast to those with
depressive symptoms, are, on average more
likely to have a greater burden of depressive
symptoms and therefore have a greater proba-
bility of depressive symptom reduction which
would be reflected in a larger effect size.
In our meta-analysis, most studies used a
cognitive behavior group therapy intervention
to target depressive symptoms. The combined
effect size for cognitive behavior was 0.37 (95%
CI: 0.18–0.56) representing a moderate effect
size. Thus, cognitive behavioral therapy ap-
pears to be efficacious in targeting depressive
symptoms among HIV-infected individuals.
Less can be said about the other forms of
therapy used. For example, although support-
ive therapy seems to have a positive effect on
reducing distress and depression among HIV-
infected individuals, the limited number of
studies and the large variability in the results
of these studies makes it difficult to draw a
clear conclusion. Whether the focus of the in-
tervention was on grief and depressive symp-
toms or depressive symptoms alone, did not
appear to moderate the effect of the interven-
tion with respect to depressive symptoms.
Finally, the pooled results of the studies that
included participants with major depression
appeared to have a significant effect while
those that excluded participants with major de-
pression did not. As those with major depres-
sion, on average, are likely to have a greater
probability of depressive symptom reduction
than those without major depression, the dif-
ference we found may in fact reflect a floor ef-
fect.
Although the theoretical underpinnings of
the group therapy interventions included in the
meta-analysis were diverse they did share sev-
HIMELHOCH ET AL.736
FIG. 2. Forrest plot: Effect of group psychotherapy on depressive symptom outcome stratified by type of group
intervention.
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GROUP PSYCHOTHERAPY TO REDUCE DEPRESSIVE SYMPTOMS 737
eral features in common. First, all used a group
therapy format. Second, all sessions were at
least 90 minutes and occurred on average for
10 sessions. Third, each study used techniques
specifically tailored to improve coping strate-
gies and improve social support. Most, but not
all, also provided some form of relaxation train-
ing. These elements may represent common
components of successful group psychother-
apy for HIV-infected individuals with distress.
With respect to demographics it is interest-
ing to note that all but one of the studies was
conducted among men. These findings may in
part be result of the demographic nature of the
epidemic over time. In the late 1980s and early
1990s HIV was considered primarily a disease
of men.33 However, the emerging population
at risk for HV are now non-white and Hispanic
women. Providing effective interventions that
target depressive symptoms among women is
especially important as two prospective stud-
ies demonstrate that compared to nonde-
pressed women with HIV, women with depres-
sive symptoms are significantly at increased
risk of mortality.4,5 Furthermore, being a
woman is considered an independent risk fac-
tor for depression.34,35 Because some studies
suggest that mental health interventions may
in fact be protective 9 it is important to ensure
that women are accessing appropriate mental
health treatment. As the results of the meta-
analysis may not generalize to women, future
studies may be needed to address this dis-
parity.
Minorities appeared to be well represented
in most of the studies evaluated. Among the 5
studies that occurred in the United States, mi-
norities represented, on average, about half of
the participant sample.
There are several limitations to this study.
First, many of the studies occurred prior to the
HAART era and as such we were unable to ad-
dress whether or not adherence to HAART was
an important moderator of response. Studies
have shown that individuals with HIV and de-
pressive disorders, compared to those with
HIV alone, have worse adherence to taking an-
tiretroviral medication.6,36,37 However, studies
have also found that mental health treatment
increases the probability that individuals with
depression receive and utilize HAART.9,38,39
Thus, it is possible that interventions that re-
duce depressive symptoms may in fact im-
prove access to and adherence with HAART.
Future meta-analyses may be able to better ad-
dress this outcome.
Second, only a couple of studies provided in-
formation of CD4 counts or HIV disease sever-
ity and therefore we were unable to determine
the impact this may have had on treatment re-
sponse. As there did not appear to be any sig-
nificant heterogeneity in the studies investi-
gated, it is unclear whether severity of illness
would be important moderators to consider in
a meta-regression. Third, we acknowledge that
individuals enrolled in clinical trials may be
more adherent to interventions and may be dif-
ferent then patients seen in actual clinical prac-
tice. This may then limit the generalizability of
the findings of this meta-analysis.
Finally, we used a unit-free, standardized
score, the effect size, in order to combine the
results from several depression instruments. By
combining the results of the depression instru-
ments in this way we avoided the possibility of
selection bias (i.e., not including results in the
meta-analysis because they contained different
depression outcome measures) and increased
the overall power of our analysis. This method,
though, assumes that the different instruments
used in the meta-analysis, in fact, measure the
same construct (i.e., depression) and are simi-
larly responsive to symptom change. If these
assumptions are not met, there is a potential for
increased heterogeneity in the study results. As
our study used instruments that are frequently
used to measure depression and as we did not
find any heterogeneity in our study results we
believe that combing results from different de-
pression instruments did not violate the above
assumptions.
CONCLUSION
This study suggests that group therapy, and
particularly group cognitive behavioral ther-
apy may be efficacious in treating depressive
symptoms among those infected with HIV.
However, the underrepresentation of women
limits the generalizability of these findings. Be-
cause women may be at risk for depression and
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are an emerging population at risk for HIV fu-
ture studies should be directed to remedy this
disparity.
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Address reprint requests to:
Seth Himelhoch, M.D., M.P.H.
Department of Psychiatry
Division of Services Research
737 Lombard Street, Room 516
Baltimore, MD 21201
E-mail: shimelho@psych.umaryland.edu
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