Depressive Symptomatology in Relation to Emotional

Rehabilitation Psychology 2002, Vol. 47, No. 4, 402– 414

Copyright 2002 by the Educational Publishing Foundation 0090-5550/02/$5.00 DOI: 10.1037//0090-5550.47.4.402

Depressive Symptomatology in Relation to Emotional Control and Chronic Pain in Persons Who Are HIV Positive Luciana Lagana` California State University, Northridge Xin-Hua Chen, Cheryl Koopman, and Catherine Classen Stanford University School of Medicine Rachel Kimerling University of California, San Francisco David Spiegel Stanford University School of Medicine

ABSTRACT. Objective: To examine the relations of emotional control and chronic pain to depressive symptomatology in persons with positive human immunodeficiency virus (HIV) status. Study Design: Cross-sectional survey. Participants: One hundred twenty (51 women, 69 men) individuals with serologically documented HIV. Main Outcome Measures: Measures of depressive symptomatology (Center for Epidemiologic Studies—Depression Scale [CES–D]; L. S. Radloff, 1977), emotional control (i.e., inhibited expression of feelings of anger, anxiety, or depression; Courtauld Emotional Control Scale; M. Watson & S. Greer, 1983), and chronic pain. Results: Full multiple regression analysis showed that constant pain, emotional control, and antidepressant use were all significant predictors of (and positively associated with) CES–D total scores. Conclusions: Within comprehen-

Luciana Lagana`, Department of Psychology, California State University, Northridge; Xin-Hua Chen, Cheryl Koopman, Catherine Classen, and David Spiegel, Department of Psychiatry, Stanford University School of Medicine; Rachel Kimerling, Department of Psychiatry, University of California, San Francisco. This research was supported by National Institute of Mental Health Grants MH54930, David Spiegel, Principal Investigator, and MH19938-04, Alan Schatzberg, Principal Investigator. We appreciate the contributions of Dennis Israelski, David Lewis, Jose´ Maldonado, Michele Gill, Peea Kim, Kristen O’Shea, Luther Brock, Margaret Chesney, Susan Wheeler, Sue DiMiceli, and our research participants. Correspondence concerning this article should be addressed to Luciana Lagana`, Department of Psychology, California State University, Northridge, 18111 Nordhoff Street, Northridge, California 91330-8255. 402

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sive rehabilitation programs with these patients, pain management is a critical issue. Treatment should address patients’ comorbid depressive symptomatology and difficulties with expressing negative emotions.

Persons who have the human immunodeficiency virus (HIV) are living longer than ever before (McReynolds, 1998), and innovative medical treatments are offering increasing hope for reducing physical symptoms (Pequegnat & Stover, 1999). HIV, although experienced nowadays as a chronic long-term medical illness rather than as a terminal disease (McReynolds, 1998), affects patients in profound ways, both physically and psychologically (Brauhn, 1999). Unfortunately, comorbidity of physical and emotional disorders is prevalent among people with chronic illness (Strickler, 1998), and health-related stressors often affect depressive symptomatology in particular (Williamson, 1998). To explore this topic within the HIV-positive patient population, we examined the joint contribution to depressive symptomatology of two potential risk factors: emotional control and chronic pain. The following paragraphs provide the rationale for this choice of possible copredictors of levels of depressive symptomatology among HIV-positive patients. Depressive symptomatology constitutes a significant problem for persons with positive HIV status. Its prevalence is significantly higher in HIV-positive male intravenous drug users (33%) than in those who are HIV negative (16%). However, it does not differ significantly in HIV-positive women who are intravenous drug users (26%) compared with those who are HIV negative (30%; Lipsitz et al., 1994). Furthermore, depressive symptomatology may be related to health outcomes among HIV-positive individuals (Ostrow et al., 1989), predicting disease progression (Lyketsos et al., 1996) and contributing to immunosuppression (Gorman & Kertzner, 1990), as it is associated with decreased number of NK and CD8 lymphocytes in HIV-positive men (Leserman et al., 1997). Depressive symptoms predict shorter survival among symptomatic AIDS patients (Patterson et al., 1996) and particularly among gay and bisexual men with AIDS (Mayne, Vittinghoff, Chesney, Barret, & Coates, 1996). Unfortunately, depressive symptomatology may also undermine adherence to medical treatment, as depressive symptoms are more prominent among those living with HIV who fail to adhere to antiretroviral medications (Singh et al., 1996). A factor often associated with depressive symptomatology in chronically ill patient populations is the presence and intensity of pain (Rosenfeld et al., 1996). Patients with chronic pain conditions, such as those resulting from whiplash and other musculoskeletal injuries, often report elevations on depression scores (Peebles, McWilliams, & MacLennan, 2001). Chronic pain is a common healthrelated stressor among HIV-positive patients (Breitbart et al., 1996; Hewitt et al., 1997); therefore, we have included it in our investigation of possible predictors of depressive symptomatology. Prior studies have found that pain and depressive symptoms are positively related among persons who are HIV positive (Evans et al., 1998; Lagana` et al., 1997; Rosenfeld et al., 1999; Singer et al., 1993).

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Although in great pain, many of these patients choose not to use pain medications because of concerns about their addiction potential, side effects (e.g., constipation and nausea), and the discomfort associated with injecting opioids (Breitbart et al., 1998). Unfortunately, as their HIV disease progresses, patients often experience increased physical and social difficulties, more pain, worse health, less energy, and increased psychological distress (Revicki, Wu, & Murray, 1995). Controlling negative emotion by withholding expression of depressive, anxious, or angry feelings is positively related to depressive symptomatology in chronically ill patient populations (Classen, Koopman, Angell, & Spiegel, 1996; Watson et al., 1991). However, because not all depressed patients suppress their emotions, these two constructs do not entirely overlap. Emotional control, i.e., the inhibited emotional expression of angry, anxious, or depressed mood states, appears to be related to worse physical health as well. Consistent with our theoretical approach, Berry and Pennebaker (1993) found that inhibition of emotional expression (e.g., nondisclosure of a childhood trauma) was associated with an increased risk for various health problems. According to Bungener, Kosmadakis, Jouvent, and Widlocher (1993), HIV-positive homosexual men exhibit significantly more emotional blunting, as defined by anhedonia and hypoexpressiveness, compared with HIV-negative homosexual and heterosexual men. On the basis of previous findings with cancer patients, Solomon and Temoshok (1987) suggested that nonexpression of negative emotion could predict more unfavorable disease progression among AIDS patients, making emotional control an important variable to consider. To our knowledge, no study has examined the relationship between emotional control and depressive symptomatology in persons with HIV. However, relative to other serious physical conditions, such as advanced breast cancer, emotional control has been linked to poor psychological adjustment (Classen et al., 1996). Another study targeting breast cancer patients found that anger control and anxiety control were positively related to greater depression and anxiety (Watson et al., 1991). Conversely, emotional expression may reduce psychological distress, including depressive symptoms, by discharging physiological arousal (Greer & Watson, 1985), facilitating better affect management, promoting cognitive restructuring, and improving intimacy (Spiegel, 1995, 1996). Therefore, emotional control may be positively related to depressive symptomatology because it can limit opportunities to use social support, as well as express affection and concerns, and may reduce intimacy in families and social networks (Bloom & Spiegel, 1984; Spiegel, Bloom, & Gottheil, 1983). Thus, the inhibition of negative emotional states is a potential risk factor for the development of psychopathology in seriously ill patient populations. Motivated by the lack of empirical evidence on the joint impact of pain and emotional control on depressive symptomatology, we tested whether the simultaneous presence of elevations in pain and emotional control scores predicts higher levels of depressive symptomatology among HIV-positive patients.

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METHOD Research Participants We initially recruited 143 HIV-positive individuals (66 women and 77 men) as part of a larger randomized clinical trial that examined the effects of group psychotherapy on health behavior and quality of life. Our data were collected between 1996 and 1998. Research participants were recruited through Northern California newspaper ads, physician referrals, and self-referrals, as well as from four metropolitan medical centers of the greater San Francisco Bay Area. Informed consent was obtained for each participant prior to medical and psychiatric screens. After providing informed consent, each participant underwent a screening interview, the Structured Clinical Interview for DSM–IV Axis I Disorders—Nonpatient Edition (SCID-I/NP; Version 2.0; First, Spitzer, Gibbon, & Williams, 1996). Inclusion criteria for selecting research participants were as follows: (a) able to provide written confirmation from the primary physician that he or she had serologically tested positive for HIV-1 antibodies by standard methods, (b) 18 years of age or older and English speaking, and (c) able to attend a weekly group if randomly assigned to that treatment condition. Exclusion criteria included (a) unwilling to be randomized to either research condition, (b) having active tuberculosis, (c) having attended 3 or more months of an HIV/AIDS-related support group within the previous year or currently participating in an ongoing HIV/AIDS-related support group, (d) actively psychotic, (e) acutely intoxicated, and (f) at risk of harm to self or to others. We also excluded individuals who had been diagnosed with dissociative identity disorder, schizophrenia, or any other psychotic disorder, as well as those who had been diagnosed with (but were not in treatment for) obsessive compulsive disorder, major depressive disorder, or bipolar disorder, because of the fact that the support group intervention was not likely to address their specific needs. The results of this study are based on 120 individuals (51 women and 69 men); we eliminated from the data analyses the cases with incomplete data on the variables of primary interest in this study. Demographic and health status characteristics of the sample are summarized in Table 1.

Measures Demographic questionnaire. Research participants completed a brief questionnaire assessing demographic characteristics that included age, gender, ethnicity, employment status, and household income. Medical status. The medical status of each participant was assessed through self-report on the following variables: (a) use of antidepressants, pain medications, antiretroviral therapy for HIV, and anti-anxiety medications; (b) number of months since HIV diagnosis; (c) persistent sore throat; (d) persistent nasal headache; and (e) bruising lasting over 2 weeks.

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Table 1. Characteristics of the Sample Variable Age (years) Gender (% male) Ethnicitya Caucasian African American Latino–Hispanic Native American Asian American–Pacific Islander Other Household income Less than $20,000 $20,000–$39,999 $40,000 or above Employed Months since HIV diagnosis Medications Antiretroviral medication Pain medication Antidepressants a

M

%

SD

40.0

7.5 57.5 57.5 31.7 10.8 7.5 5.0 5.0 54.2 17.8 27.9 37.5

74.7

42.5 75.0 25.8 18.3

Ethnicities exceed 100% because of multiple ethnic backgrounds of many of the participants.

Center for Epidemiologic Studies—Depression Scale (CES–D; Radloff, 1977). The CES–D assesses the number and frequency of depressive symptoms that are not confounded with physical illness through a 20-item self-report measure (cutoff score ⫽ 16). This measure has been shown to have high internal consistency across diverse psychiatric and nonpsychiatric populations (Cronbach’s ␣s ⫽ .85 to .90) and adequate test–retest reliability (Radloff, 1977; Roberts, 1980; Ross & Mirowsky, 1984). In addition, self-report and clinician ratings of depression correlate highly with the CES–D (Radloff, 1977; Weissman, Sholomskas, Pottenger, Prusoff, & Locke, 1977). In our sample, Cronbach’s alpha was .71. Rating of chronic pain (adapted from Spiegel & Bloom, 1983). We assessed chronic pain using the following question: “If you have had pain in the last six months, it typically lasted: a) constant pain for entire six months, b) if one day or more: Days , and c) if less than one day: Hours (up to 24) .” We considered the participants who chose the first option to be experiencing chronic pain. Self-report measures of pain such as this have been shown to be more accurate than those assessing autonomic physiological responses (Hilgard & Hilgard, 1975). Concurrent validity of this measure was supported by three Spearman correlation coefficients between scores on chronic pain and persistent

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sore throat, persistent nasal headache, and bruising lasting over 2 weeks, rs(118) ⫽ .22–.27, p ⬍ .05. Courtauld Emotional Control Scale (CECS; Watson & Greer, 1983). The CECS is a 21-item measure that evaluates the extent to which individuals report controlling their feelings of anger, anxiety, or depression. Participants respond to phrases such as “When I am angry . . . ” by indicating the degree to which statements such as “I bottle it up” describe their experience. Emotional control was measured using a combined score based on the three subscales of the CECS. Cronbach’s alphas for the CECS show a high internal consistency, ranging from .86 for anger to .88 for both anxious and depressed mood. Test–retest reliability has also been demonstrated, with r ⫽ .95 for the total CECS over a period of 3– 4weeks (Watson & Greer, 1983). Cronbach’s alpha for our study participants was .82. This measure has been found to be negatively related to psychological adjustment in HIV-positive patients (Grassi, Righi, Sighinolfi, Makoui, & Ghinelli, 1998), recently diagnosed cancer patients (Watson et al., 1991), and advanced cancer patients (Classen et al., 1996).

Data Analysis We utilized a full regression model using the simultaneous entry of variables to test the relations of the rating of chronic pain and CECS total score with CES–D total score. In addition, we wanted to examine these relations within a regression model that also included demographic and health status variables that accounted for variance in depressive symptomatology. Therefore, we calculated Spearman rank order correlations of CES–D total scores with each of the demographic and health status variables to identify which of these variables should be included in this analysis. To analyze ethnicity in relation to CES–D scores, we created a dummy variable for each ethnic category. For example, if participants identified themselves as African American, they were coded as a “1” for that ethnicity, but if they did not, they were coded as a “0” for that ethnic category. Using this method for categorizing research participants’ ethnicities, we found that CES–D scores were significantly and positively correlated with being African American, rs(118) ⫽ .19, p ⬍ .05. Furthermore, CES–D scores were significantly and negatively correlated with employment status, rs(118) ⫽ –26, p ⬍ .01, and positively correlated with use of antidepressant medications, rs(118) ⫽ .24, p ⬍ .01, indicating that more severely depressed individuals were less likely to be employed and more likely to report taking antidepressant medication. African American ethnicity, employment status, and use of antidepressants were not significantly correlated with each other or with the two independent variables of interest (rating of constant pain and emotional control). Therefore, we included African American ethnicity (coded as “0” and “1”), employment status, and use of antidepressant medications in further analysis of CES–D scores.

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RESULTS This study was based on the data collected from 120 (of 142) respondents who provided complete data. When comparing these 120 respondents on medical status and demographic characteristics with those 22 whose data were too incomplete for inclusion, we found that the only significant difference was that men were significantly more likely to provide complete data than were women (91% and 77%, respectively), ␹2(1, N ⫽ 142) ⫽ 4.93, p ⬍ .05. Demographic and health status characteristics of the sample are illustrated in Table 1. Total scores on the CES–D ranged from 0 to 48 (M ⫽ 16.25, SD ⫽ 11.71), with 45.0% scoring at or above the cutoff score of 16 (indicating likely depression). Scores on the CECS ranged from 22 to 73 (M ⫽ 47.96, SD ⫽ 10.81). Almost half the sample (48.3%) reported experiencing constant pain during the past 6 months on the rating of chronic pain. In the multiple regression analysis, shown in Table 2, the overall model was statistically significant, F(5, 114) ⫽ 6.19, p ⬍ .001. CES–D total scores were significantly greater among persons who reported use of antidepressants (p ⬍ .05), rated themselves as being in constant pain (p ⬍ .01), and had higher emotional control scores on the CECS (p ⬍ .05). African American ethnic background and employment status were not significantly related to CES–D scores in the context of the full regression model. The bivariate correlations between the CES–D scores and the other variables included in the regression model have already been reported (see the Data Analysis section). We also examined the bivariate relations between the CES–D scores and the two independent variables of primary interest. CES–D scores were correlated with rating of constant pain, rs(118) ⫽ .33, p ⬍ .01, and with CECS scores, rs(118) ⫽ .21, p ⬍ .01. Figure 1 shows a bar graph to assist the reader in understanding the relations of the rating of constant pain and CECS emotional control scores with CES–D scores. This bar graph illustrates the results of using a procedure in which we first split the CECS scores at the median to analyze low versus high CECS

Table 2. Full Multiple Regression Predicting Depressive Symptoms in HIV-Positive Men and Women (N ⫽ 120) Variable African American Employment status Antidepressant use Chronic pain CECS total score

B

SE B

2.88 ⫺1.68 6.23 6.11 0.22

2.17 1.22 2.54 1.97 0.09

␤ .12 ⫺.12 .21* .26** .20*

Note. R2 ⫽ .22 for the full regression model. CECS ⫽ Courtauld Emotional Control Scale (Watson & Greer, 1983). * p ⬍ .05. ** p ⬍ .01.

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Figure 1. Depressive symptomatology by emotional control and chronic pain. CES–D ⫽ Center for Epidemiologic Studies—Depression Scale (Radloff, 1977); CECS ⫽ Courtauld Emotional Control Scale (Watson & Greer, 1983).

scores and then analyzed within each of those categories the mean CES–D scores of individuals rating themselves as being in or not being in constant pain.

DISCUSSION We examined relations between emotional control and chronic pain with depressive symptomatology among a diverse group of HIV-positive patients. As predicted, emotional control and chronic pain were found to be associated with amplified depressive symptomatology in HIV-positive individuals. Antidepressant use was also predictive of higher CES–D total scores; this is not surprising, as it is similar to the finding that HIV-positive patients with higher pain scores report greater use of pain medications (Lagana` et al., 1997). Depressive symptoms were higher among those who were either African American or unemployed. However, these relationships lost significance in the context of the other variables examined in this study, suggesting that using antidepressants, being in constant pain, and exerting greater emotional control may be more salient than demographic characteristics in predicting depressive symptoms in this population. Given that this is a cross-sectional study, it is not possible to determine the direction of causality among these variables. Differences in the severity of depressive symptomatology among patients who differed on measures of emotional control and chronic pain might have existed before the diagnosis of HIV. Longitudinal research is needed on this topic to clarify these relations. Another limitation of this study is that by excluding individuals who had been or were

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participating in support groups, we may have obtained a somewhat biased sample. Furthermore, the finding that fewer women than men provided complete data for this study could raise questions about generalizing these results to HIV-positive women. However, even among the women, 77% of them provided complete data, which seems reasonable for drawing interpretations from the results. Our findings that emotional control and chronic pain are significant predictors of depressive symptomatology replicate research conducted with breast cancer patients regarding an association between higher emotional control and poorer psychological adjustment (Classen et al., 1996; Watson et al., 1991) and between pain and depression (Spiegel, Sands, & Koopman, 1994). They provide evidence of the relation among these three constructs that generalizes across different types of chronic illness. It is possible that by not expressing their negative emotions, people are deprived of opportunities to receive social support and/or resolve upsetting problems, thereby allowing these emotions to persist (Bloom & Spiegel, 1984; Spiegel et al., 1983). When individuals do not express their negative emotions, members of their families and social networks may be less likely to express their affection and concern to them, reducing the likelihood of enhancing intimacy in these relationships. In turn, this could lead to diminished enjoyment of everyday life, as well as contribute to a lack of interest or pleasure in activities. Alternatively, depressive symptoms may lead to increased emotional control in that, as depressed individuals experience a decrease in energy, a lack of interest in activities, and feelings of worthlessness, they may lack the energy required to express negative emotions and may feel that there is little point to doing so. The relation of chronic pain to depressive symptoms also requires further investigation. Previous research on cancer and depressive symptomatology suggests that pain induces depression (Spiegel et al., 1994). Again, our crosssectional data do not permit us to conclude that the experience of chronic pain led to depressed mood in our sample. It is also possible that depressed mood amplifies the experience of pain. Future research should assess the extent to which our results could generalize to patient populations living with other types of chronic illness. This would provide empirical support for the development of multidisciplinary rehabilitation interventions for HIV-positive patients that would focus on pain reduction and facilitating expression of negative feelings as important components of treatment for depressive symptomatology and diseaserelated coping. In this regard, rehabilitation psychologists interested in the relation between depressive symptoms and pain in chronic illnesses, such as fibromyalgia, have identified as the optimal intervention a combination of sleep and pain medications, together with exercise and cognitive– behavioral therapy (Rossy et al., 1999). In conclusion, our work has contributed to an innovative area of research, namely how living with HIV as a chronic illness can intrude on patients’ lives, by examining the complex relations among depressive symptomatology, chronic pain, and, for the first time in this context, emotional control. These findings

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underscore the need to treat the pain of HIV-positive individuals and to help them express their negative emotions, as both factors are associated with depressive symptomatology. If emotional control and depressive symptoms are in fact interrelated, then psychosocial treatment encouraging emotional expression of negative mood states may be an effective rehabilitation effort aimed at enhancing the psychological adjustment of HIV-positive individuals. In particular, anger is a prominent affect among these patients (Rabkin, Remien, Katoff, & Williams, 1993). Many individuals who are taking protease inhibitors report notable frustration because their medication regimens have assumed a central role in their lives (Stone et al., 1998). High levels of depressive symptoms are likely to make it even harder for HIV-positive patients to adhere to their medication regimens; these individuals might start missing doses, taking partial doses, or be tempted to give up treatment altogether, at least temporarily. This could result in the fast emergence of drug-resistant HIV isolates (Katzenstein, 1997). Learning to appropriately express negative emotions and acquiring pain management skills through rehabilitation programs may improve treatment adherence by reducing depressive symptomatology. It is important to examine whether such adherence problems can be successfully addressed by sound psychotherapeutic interventions aimed at facilitating the expression of affect and the management of chronic pain.

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