Nursing Psychotherapy Nurs 6650

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.

What type of group was discussed?

Himelhoch, Medoff and Oyenyi (2007) discusses the efficacy of addressing depression among HIV infected individuals. As such, the group discussed in the study is HIV infected individuals diagnosed with depression.

Who were the participants in the group? Why were they selected?

The study applies a secondary research approach that does not recruit any participants. Rather, it conducted as review collected from searching PubMed and Cochrane databases as well as bibliographies with controlled clinical trials. The participants in the evaluated studies were HIV infected individuals with depressive symptoms. These participants were selected because they were receiving treatment for depression using psychotherapy approaches to include cognitive behavioral therapy, supportive therapy and coping effectiveness training (Himelhoch, Medoff & Oyenyi, 2007).

What was the setting of the group?

All the studies that were reviewed were conducted in psychotherapy treatment settings where the participants were receiving treatment for their depressive symptoms. Nursing Psychotherapy Nurs 6650. The psychotherapy treatments occurred in group settings that included persons with similar symptoms (Himelhoch, Medoff & Oyenyi, 2007).

How often did the group meet?

Although how often the group met is not mentioned in the study as this is a systematic review, it can be assumed that the group met at least once every week. Ezhumalai et al. (2018) explains that group therapy is typically conducted once every week for up to 90 minutes in each session. Still, the group could also meet three to four times in a day depending on the clinical setting and needs of the individual group members. The daily meetings should take approximately 45 minutes for every session (Ezhumalai et al., 2018).

What was the duration of the group therapy?

The duration of the group therapy is not discussed in the study. However, Ezhumalai et al. (2018) mentions that group therapy conducted on a weekly basis should be for up to 90 minutes during each session, and the meetings should not exceed 25 sessions or six months. For group therapy conducted on a daily basis, each session should be for approximately 45 minutes (Ezhumalai et al., 2018).

What curative factors might be important for this group and why?

There are four curative factors that might be important for the group. The first curative factor is mirroring techniques since it allows for a two-way knowledge transfer to facilitate teaching and learning processes. The second curative factor is imitative behavior as the group members watch each group member responds to different issues. The third curative factor is development of socializing techniques as the group members have an opportunity to develop and maintain relationships within the group. They learn skills at handling social relationships with others. The fourth curative factor is imparting information as the group setting allows for information to be shared about experiences so that members are able to relate how they personally handled different situations. The fifth curative factor is universality as the group helps the members to know that they are not alone and isolated in their depression. The final curative factor is the presence of a therapy who mediates the group interactions and directs them to address the therapy objectives (Sochting, 2015). Nursing Psychotherapy Nurs 6650.

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What “exclusion criteria” did the authors mention?

The authors do not mention an exclusion criterion for the participants. Still, an exclusion and inclusion criteria is included for the studies that were reviewed. The criterion has three points. Firstly, the included studies must be prospective, double-blinded, controlled trials with random assignment. Secondly, they must report of outcomes of depressive symptoms. Thirdly, they must report on the use of a psychotherapeutic interventions (Himelhoch, Medoff & Oyenyi, 2007).

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?

The results of the study indicate that group psychotherapy is effective in reducing depressive symptoms among HIV-infected patients. It specifically notes that cognitive behavioral therapy, supportive therapy and coping effectiveness training are useful strategies for group therapy (Himelhoch, Medoff & Oyenyi, 2007).

Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article.

A major limitation in the study is that women were nearly absent from the study. This implies that the reported results were for male participants. As such, the results can be generalized for males with additional studies required for female participants (Himelhoch, Medoff & Oyenyi, 2007).

References

Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R., & Nikketha, B. S. (2018). Group Interventions. Indian Journal of Psychiatry, 60(Suppl. 4), S514-521. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_42_18

Himelhoch, S., Medoff, D. R., & Oyenyi, G. (2007).  Efficacy of Group Psychotherapy to Reduce Depressive Symptoms among HIV-Infected Individuals: A Systematic Review and Meta-Analysis. AIDS Patient Care and STDs, 21(10), 732-739. https://doi.org/10.1089/apc.2007.0012

Sochting, I. (2015). Cognitive Behavioral Group Therapy: Challenges and Opportunities. John Wiley & Sons, Ltd.

Depressed mood is highly prevalent among HIV-infected individuals. Some but not all studies have found group psychotherapy to be efficacious in this population. We performed a systematic review and meta-analysis of double-blinded, randomized controlled trials to examine 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 condition among HIV infected patients with depressive symptoms. The principal measure of effect 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 reported 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 significant. 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. Nursing Psychotherapy Nurs 6650.The results
of this study suggest that group psychotherapy is efficacious in reducing depressive symptoms 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 among
individuals 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 depressive disorders are more likely to encounter
greater delays in being prescribed antiretroviral therapy,6 and have worse adherence to
taking antiretroviral medication.7 This is in
keeping with research that has shown that depression itself is associated with poor adherence to medical treatment.8
Recent studies, however, suggest that menDepartment 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 targeting depression among those with HIV.11
However, antidepressant treatment may be associated with high dropout rates11 and may not
be acceptable to all patients.
Psychotherapeutic interventions have also
been used to alleviate psychosocial and interpersonal 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 decreasing 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 following criteria: (1) prospective, double-blinded,
controlled trials with random assignment; (2)
report of outcomes of depressive symptoms;
(3) report of use of a psychotherapeutic interventions. 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 depressive 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 (Cohen d), the effect size, was calculated from
means and standard deviations from these
scales. When data on means or standard deviations were lacking we contacted the authors
of the manuscripts.Nursing Psychotherapy Nurs 6650.  The one author contacted
did not respond to our inquiry for requested
information. We also compiled information regarding demographics, study characteristics,
and type of psychotherapy intervention reported.
Quality of clinical trials
As variation in quality of clinical trials can
result in biased estimates of reported intervention effectiveness, we evaluated the quality of
the clinical trials using a 15-item scale developed by Detsky et al.20 Each author independently 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 estimates 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 between study variation in outcomes, was measured using the Q statistic.21 The Q statistic is
considered to have a low power as a test of heterogeneity; therefore, heterogeneity was considered present with a p 0.10. If heterogeneity was found to be present the I2 statistic was
used to describe the percentage of variation
due to heterogeneity across studies. In the absence 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 trials.12–19,22–31 Of these, 8 trials12–19 met inclusion
criteria (Fig. 1). These 8 trials included 665 patients 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 depression.15,17 With respect to the type of psychotherapeutic treatment all of the studies used a
group format. One study had two intervention
arms—a CBT group intervention and a supportive 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) together.19 Length of treatment ranged between
7–15 sessions. The length of the intervention
ranged between 90 and 150 minutes. All interventions were directed at improving psychological 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 conducted on men (Table 1). All studies were rated
as reflecting good quality.
Depressive symptom outcome
Three of the 8 studies reported significant effects. Of the 3 studies that found significant effects, one used cognitive behavioral treatment
intervention,16 one used supportive psychotherapy,14 and one reported the results of a
combination of emotional expressive and CBT
therapy.19 The pooled effect size from the random effects model was 0.38 (95% CI: 0.23–0.53;
734 HIMELHOCH ET AL.
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 effect between psychotherapy and depressive
symptoms. 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
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 symptoms) moderated the effect between psychotherapy and depressive symptoms. Studies
focusing on grief and depressive symptoms
had a pooled effect size from the random effects model of 0.34 (95% CI: 0.12–0.56]) and was
significant, representing a small to moderate effect size. Studies focusing on depressive symptoms 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 depressive 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.Nursing Psychotherapy Nurs 6650.  In contrast, those studies
that included participants with major depression 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. Egger’s test and Begg’s test were both nonsignificant. Taken together these findings suggest the
relative absence of publication bias.
DISCUSSION
Our meta-analysis of randomized doubleblinded controlled trials of group psychotherTABLE 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 depression scale with a response range from 5–63. bThis study had a CBT arm and a supportive therapy arm.
c
The 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 effect size was 0.38 (95% CI: 0.23–0.53) representing 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 studies in which participants in the group psychotherapy intervention were compared to untreated controls the pooled effect size was
1.03.32 The greater effect size found in the metaanalysis among those treated for unipolar depression 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 probability 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 appears 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 supportive therapy seems to have a positive effect on
reducing distress and depression among HIVinfected 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 intervention was on grief and depressive symptoms or depressive symptoms alone, did not
appear to moderate the effect of the intervention 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 depression did not. As those with major depression, on average, are likely to have a greater
probability of depressive symptom reduction
than those without major depression, the difference we found may in fact reflect a floor effect.
Although the theoretical underpinnings of
the group therapy interventions included in the
meta-analysis were diverse they did share sev736 HIMELHOCH ET AL.
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 strategies and improve social support. Most, but not
all, also provided some form of relaxation training. These elements may represent common
components of successful group psychotherapy for HIV-infected individuals with distress.
With respect to demographics it is interesting 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 studies demonstrate that compared to nondepressed women with HIV, women with depressive symptoms are significantly at increased
risk of mortality.4,5 Furthermore, being a
woman is considered an independent risk factor 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 metaanalysis may not generalize to women, future
studies may be needed to address this disparity.
Minorities appeared to be well represented
in most of the studies evaluated. Among the 5
studies that occurred in the United States, minorities 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 address whether or not adherence to HAART was
an important moderator of response. Studies
have shown that individuals with HIV and depressive disorders, compared to those with
HIV alone, have worse adherence to taking antiretroviral 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 reduce depressive symptoms may in fact improve access to and adherence with HAART.
Future meta-analyses may be able to better address this outcome.
Second, only a couple of studies provided information of CD4 counts or HIV disease severity and therefore we were unable to determine
the impact this may have had on treatment response. As there did not appear to be any significant heterogeneity in the studies investigated, it is unclear whether severity of illness
would be important moderators to consider in
a meta-regression. Nursing Psychotherapy Nurs 6650. Third, we acknowledge that
individuals enrolled in clinical trials may be
more adherent to interventions and may be different then patients seen in actual clinical practice. 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 instruments 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 similarly 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 depression instruments did not violate the above
assumptions.
CONCLUSION
This study suggests that group therapy, and
particularly group cognitive behavioral therapy may be efficacious in treating depressive
symptoms among those infected with HIV.
However, the underrepresentation of women
limits the generalizability of these findings. Because women may be at risk for depression and
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are an emerging population at risk for HIV future studies should be directed to remedy this
disparity.
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