Psychological Health and the Immune System

Throughout the history of the AIDS epidemic there has been
ongoing debate about the effects of psychological well-being and
stress on the immune system. Current research is beginning to
show scientific evidence of an effect, but controversy continues.

At this year's International Conference on AIDS, a
presentation by Jeffrey Burack, M. D. and others, reported that
T-helper counts of depressed patients dropped 38 percent faster
than those patients who were not depressed. His work, entitled
"Depression predicts accelerated CD4 decline among gay men in San
Francisco," studied 330 HIV-positive patients between 1985 and
1991.

Dr. Burack explained the different mechanisms through which
the treatment of depression might actually slow disease
progression. "Depression has been shown to impair immune
response in the laboratory, so there might be a direct effect of
depression on the immune system. Also, depressed persons may be
less likely to seek out or stick to appropriate medical care for
HIV and may be more likely to engage in risky or unhealthy
behaviors."

Currently, Dr. Burack is collaborating with the Center for
AIDS Prevention Studies (CAPS) in San Francisco on a study of
interventions for HIV-related depression in gay men, called the
Positive Education Project. The interventions include two types
of group discussion sessions. One is informational, offering
patients direct access to information about AIDS and the
treatments they are taking. The other is a
psychological/emotional support group. (For more information or
to enroll call Derek Aspacher at CAPS, 415/597-9141).

This program is just one of many studies looking at
psychoneuroimmunology, a new field of science examining the
interrelationship of psychology, neurology and immunology.
Because of the large amount of research in the field, this
article only addresses the psychological and social factors such
as stress, depression, and social support.

Basic Research On Psychological Factors and Disease

Much of the most compelling research in this field has not
focused on AIDS, but on other diseases such as cancer. While not
directly applicable to AIDS, the results do give support to
claims that psychosocial factors play a major role in the
progression of disease. But their precise role in the
pathogenesis of AIDS has not been determined.

The most scientifically sound evidence of a relationship
between stress and illness was detailed in "Psychological Stress
and Susceptibility to the Common Cold," published in 1991 in the
New England Journal of Medicine. In a carefully designed trial,
research subjects were exposed to cold viruses and then
quarantined and monitored for the development of symptoms. The
researchers found that the rate of infection was directly related
to psychological stress.

Similar evidence was found in a Stanford University study on
the survival of 86 women with metastatic breast cancer.(1) For
one year, the women took part in group therapy sessions where
they were encouraged to share their experiences and form bonds
with the other women; they were also taught self-hypnosis to
control pain. In a follow-up study ten years later, the
researchers found that the women who participated in the
psychosocial interventions lived an average of two years longer
than those who did not.

An intriguing fact about the study is that the researchers
did not expect to see an effect. "We intended, in particular, to
examine the often overstated claims made by those who teach
cancer patients that the right mental attitude will help to
conquer the disease." The study was mentioned October 4 in the
New York Times Magazine in an article about the mainstreaming of
alternative medicine.

Current AIDS-Related Research

The success of the Stanford study may soon be replicated
with a group of HIV-positive people. A UCLA study led by
Margaret Kemeny, Ph.D., is now offering free, intensive group
therapy that will focus on quality of life and stress management.
The project is the outgrowth of previous research by Kemeny, who
found that chronically depressed people with HIV had a much
steeper decline in their immune system over a five-year
period.(2,3) The UCLA Group Therapy Project is now enrolling
symptomatic, HIV-positive, gay and bisexual men between ages 25
and 45. (To enroll, call 310/206-7870.)

In a comprehensive review of current research into the
relationship between psychological health and AIDS,(4) Michael
Antoni and Cornelis Mulder found that the stress of being HIV
positive or having AIDS could influence the course of infection.
In their review of about 40 studies, they examined the
contradictory results, and found that many questions have yet to
be answered. The majority of the studies, however, seemed to
show a positive correlation. The authors were cautious about
interpreting the positive results, but argued that they
demonstrate the need for further research.

Understanding the relationship between immune function and
psychological state is very difficult, according to Leon
McKusick, a psychiatrist with the CAPS program in San Francisco.
For example, it is almost impossible to figure out if someone's
depression is causing an immune dysfunction or that the reverse
is true, that is, the immune dysfunction is causing depression.
McKusick said that although it is generally accepted that some
correlation exists, it has not been proven that a behavioral
intervention has a direct effect on immune status. In the case
of AIDS, he explained, it is very hard to determine causality.
"Although we may all agree that one's psychology affects one's
immune parameters, interfering might not help."

Lydia Temoshok(5) has addressed these issues in her
research, stressing that it is especially important to be precise
in the measurements used to decipher data from clinical trials.
Some of the confusion lies in the translation of research data
into meaningful concepts because of the nature of HIV disease in
which "...psychologic, neurologic, and immunologic changes occur
as central, rather than as resultant or adjunctive, aspects of
the disease process."

A few studies have shown that interventions can have a
direct impact on the immune system of HIV-positive people by
enhancing psychological health. Researchers at the University of
Miami studied the impact of an aerobic exercise training program
on 39 gay men, 16 of whom were HIV positive and asymptomatic; the
others were HIV negative.(6) After a five-week training period,
the HIV-negative volunteers had average T-helper increases of
220, while the HIV-positive volunteers, who began with an average
of 905 T-helper cells, only increased by 50. The researchers
point to the sometimes minimal positive effects seen in anti-
retroviral therapy and conclude that further research into the
role of exercise for stress management should be pursued.

The mental health of HIV-positive women was studied at the
Beth Israel Medical Center in New York(7) and St. Mary's Hospital
in London.(8) Both studies found high incidence of depression and
stress. In light of current knowledge about the faster rate of
disease progression in women, these researchers predicted that
psychosocial factors are at the heart of the problem. Further
research will be needed to prove or disprove this relationship.

Other treatments that were reported at the conference to
have some beneficial effect on psychological well-being are: art
therapy, an attention training program, a 12-step recovery
program, psychospiritual counseling, and social support.

Comment

A basic approach in traditional medical systems is the
connection between mind, body and spirit, known as holism. In,
for example, traditional Chinese medicine, this connection forms
the basis for most medical practices. Psychoneuroimmunology seems
to be Western science's attempt to understand and integrate these
views. The word psychoneuroimmunology can itself be understood
in its three parts; psyche (spirit), neuro (mind) and immunology
(body). Both psychoneuroimmunology and holism are concerned with
the interaction of these various parts, and the effect one might
have on the others.

Some of the controversy that surrounds holism also applies
to psychoneuroimmunology. Critics argue that they both lead to a
"blame the victim" mentality, by making a patient responsible for
his or her own illness. On the other hand, the possibility of
increased compliance with other therapies and improvement in the
quality of life are positive aspects of this approach.

Also, because psychological treatments and exercise do not
have counter-indications with drug treatments, or any noticeable
toxicities, they can be an effective complement to an HIV
treatment strategy. But only when we have scientifically sound
research on the importance of psychological health in a person
with HIV will many more people take advantage of what seem to be
very useful and safe treatments.

Resources and References

The Center for Attitudinal Healing offers free group therapy
sessions for people with HIV or AIDS. An introduction to their
services is offered every Thursday at 12:30 at their office, 19
Main Street, Tiburon, CA, 94920. For more information call,
415/435-5022.

An organization has formed in Paris for PWA's interested in
Psychoneuroimmunology. For information contact: Parsifal, B. P:
305, 75525 Paris, Cedex 11, France.

1. Spiegel D, Kraemer HC, Bloom JR, Gottheil E. Effect of
psychosocial treatment on survival of patients with metastatic
breast cancer. THE LANCET. October 14, 1989; pages 888-891.

2. Kemeny ME, Duran R, Weiner H, Taylor SE, Visscher B, Fahey
JL. Chronic Depression Predicts Immune Decline over a five year
period. Presented at 99th Annual Convention of the American
Psychological Association, San Francisco, August 1991.

3. Solomon, GF, Kemeny ME, Temoshok L. Psychoneuroimmunologic
aspects of human immunodeficiency virus infection. In: Ader R,
Felton DL, Cohen N (editors) PSYCHOIMMUNOLOGY II. Orlando FL:
Academic Press; 1991: pages 1081-1113.

4. Muldur CL, Antoni MH. Psychosocial correlates of immune
status and disease progression in HIV-1 infected homosexual men:
review of preliminary findings, and commentary. PSYCHOLOGY AND
HEALTH. 1992: volume 6, pages 175-192.

5. Temoshok L. On methods and models of research on
Psychoneuroimmunology and HIV/AIDS. In Schmidt LR and others
(editors)THEORETICAL & APPLIED ASPECTS OF HEALTH PSYCHOLOGY.
London: Harwood Academic Publishers; 1990: pages 77-83.

6. La Perriere A, Fletcher MA, Antoni MH, Klimas NG, Ironson G,
Schneiderman N. Aerobic exercise training in an AIDS risk group.
International Journal of Sports Medicine. 1991; volume 12, pages
S53-S57.

7. Bailer PA, Prenzlauer SL, Getter EV, Wallack JW.
Psychological distress in HIV-infected women. VIII International
Conference on AIDS, Amsterdam, June 19-24, 1992 [abstract
#PoB3764].

8. Sherr L, Melvin D, Petrak J, Davey T, Glover L, Hedge B.
Women, AIDS and HIV infection -- psychological barriers and
trauma. VIII International Conference on AIDS, Amsterdam, June
19-24, 1992 [abstract #PoB3426].