Background Depression and anxiety are common in patients with coronary artery disease (CAD). While depression clearly has been associated with mortality in this population, the relationship between anxiety and mortality is less clear. Accordingly, we performed a series of meta-analyses to (1) examine the relationship between anxiety and mortality in patients with established CAD and (2) determine if this relationship differs in patients with stable CAD compared to those who have just suffered an acute coronary syndrome (ACS). Methods and Results Systematic literature searches identified 44 articles (total N=30,527) evaluating the prospective relationship between anxiety and mortality in individuals with established CAD. A series of eight adjusted and unadjusted meta-analyses were performed to examine this relationship across all patients, with sensitivity analyses completed in post-ACS and stable CAD cohorts. In unadjusted analyses, anxiety was associated with a moderate increase in mortality risk (odds ratio=1.21 per standard deviation increase in anxiety). However, when adjusting for covariates, nearly all associations became non-significant. In sensitivity analyses, anxiety was associated with an increased risk of poor outcomes in the stable CAD—but not post-ACS—cohort. Conclusions These analyses confirm that anxiety is associated with increased risk of mortality in patients with CAD; however, this relationship is not as strong as that of depression and may be explained partly by other clinical factors. If anxiety screening is performed, it should be performed during a period of clinical stability and should target anxiety disorders rather than anxiety symptoms alone.

Summary Background Depression, highly prevalent in HIV, is consistently associated with worse ART adherence. Integrating CBT for depression with adherence counseling using the “Life-Steps” approach (CBT-AD) has an emerging evidence base. The aim of the current study was to test the efficacy of CBT-AD. Methods We conducted a three-arm RCT (N=240 HIV-positive adults with depression), comparing CBT-AD to Life-Steps integrated with information and supportive psychotherapy (ISP-AD) (both 12 sessions), and to ETAU (1 session Life-Steps). Participants were recruited from three sites in New England area, two being hospital settings, and one being a community health center. Randomization was done via a 2:2:1 ratio, using random allocation software by the data manager, in pairs, stratified by three variables: site, whether or not the participant was prescribed antidepressant medications, and history of injection drug use. The primary outcome was adherence assessed via electronic pill caps (MEMs) with correction for “pocketed” doses. Secondary outcomes included depression, plasma HIV RNA and CD4. Follow-ups occurred at 4, 8 and 12 months. We used intent-to treat analyses with ANCOVA for independent-assessor pre-post assessments of depression and mixed effects modeling for longitudinal assessments. Clinical Trial Registration: NCT00951028, https://clinicaltrials.gov/ct2/show/NCT00951028), closed to new participants. Findings The period of recruitment was February 26, 2009 to June 21, 2012, with the 12-month follow-up period extending until April 29, 2013. There were no study-related adverse events. CBT-AD (n=94 randomized, 83 retained) had greater improvements in adherence (Est.=1·00, CI=0·34, 1·66, p=0·003) and depression (CES-D Est.=−0·41, CI=−0·66, −0·16, p=0·001; MADRS Est.=−4·69, CI=−8·09, −1·28, p=0·007; CGI Est.=−0·66, CI=−1·11,-0·21, p=0·005) than ETAU (49 randomized, 46 retained) at post-treatment (4-month). Over follow-ups, CBT-AD (84 retained) maintained higher adherence (Est.=8·93, CI=1·90, 15·97, p=0·013) and lower depression on the CES-D (Est=−3·56, CI=−6·08, −1·05, p=·005) and CGI (Est.=−0·39, CI=−0·77, −0·18, p=·04) than ETAU (86 retained); however, not for the MADRS. There were no significant differences between CBT-AD and ISP-AD (97 randomized, 87 retained) for the post-treatment or follow-up (86 retained) analyses. There were no intervention effects on HIV RNA or CD4, though a higher percentage (91·4%) than expected was virally suppressed at baseline. Interpretation Integrating evidenced-based treatment for depression with evidenced-based adherence counseling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate of effective psychosocial depression treatments such as CBT-AD to individuals living with HIV/AIDS, as well as examine the cost-effectiveness of such approaches. Funding National Institute of Mental Health (R01MH084757) and some author time from NIAID 5P30AI060354, and P30AI042853.

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46–.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47–.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Adherence to antiretroviral therapy (ART) among HIV-infected individuals is necessary to both individual and public health, and psychosocial problems have independently been associated with poor adherence. To date, studies have not systematically examined the effect of multiple, co-occurring psychosocial problems (i.e., “syndemics”) on ART adherence. Participants included 333 HIV-infected individuals who completed a comprehensive baseline evaluation, as part of a clinical trial to evaluate an intervention to treat depression and optimize medication adherence. Participants completed self-report questionnaires, and trained clinicians completed semi-structured diagnostic interviews. ART non-adherence was objectively measured via an electronic pill cap (i.e., MEMS). As individuals reported a greater number of syndemic indicators, their odds of non-adherence increased. Co-occurring psychosocial problems have an additive effect on the risk for poor ART adherence. Future behavioral medicine interventions are needed that address these problems comprehensively, and/or the core mechanisms that they share.