Interpersonal Therapy for Depression
with HIV-Positive Clients
Infection with the human immunodeficiency virus (HIV) seems to be associated with increased prevalence of depression. A meta-analysis by Ciesla and Roberts (2001) found the prevalence of depression in persons living with HIV/AIDS (PLWHA) two to four times greater than in the general population.
Markowitz, Klerman and Perry (1992) described the use of interpersonal therapy (IPT) for treatment of depressed PLWHA (IPT-HIV). As with the standard model of IPT first articulated by Klerman, Weissman, Rounsaville and Chevron (1984), Markowitz and colleagues focused IPT-HIV around the problem areas of grief, role transitions, interpersonal disputes, and interpersonal deficits. One distinguishing feature between IPT-HIV and standard IPT is that standard IPT typically only involves a single problem area, or at most two. PLWHA often present with all four problem areas simultaneously. PLWHA experience grief from multiple losses of friends, loved ones and partners to the disease. PLWHA also engage in anticipatory grief as they contemplate the potential of their own mortality. Becoming infected with HIV marks the beginning of a series of role transitions, starting with acceptance of one's disease status, initiating medications, developing symptoms, and eventually progressing to the most advanced stage of HIV disease, AIDS. Role disputes emerge in relationships where one partner is infected and the other is not. Role disputes also can occur from PLWHA in the workplace. Interpersonal deficits are not uncommon as PLWHA withdraw from all social contacts. However, because the problem area of interpersonal deficits is the least developed aspect of IPT, case formulation focuses on the other three problem areas, most commonly role transitions (Markowitz et al., 1992)
One essential task in standard IPT as described by Klerman and colleagues (1984) is assignment of the sick role to the person in treatment in which the patient is relieved of some social obligations, but, at the same time, is obligated to cooperate with treatment. In IPT-HIV, the client is given a dual sick role, that of depression as well as HIV disease. The obligations are doubled as well: the patient must cooperate with both the treatment of depression by the psychotherapist, and the treatment of HIV disease by the physician. As Swartz and Markowitz (1998) point out, psychoeducation about depression is an important component of standard IPT. Because of the dual sick role of the PLWHA, IPT-HIV calls for the client to become knowledgeable about HIV as well. Therapists practicing IPT-HIV must themselves be familiar with HIV in order that they may dispel clients' misconceptions about HIV, fill in gaps about the nature and course of HIV disease, and provide information about advances in treatment. Therapists should encourage clients to develop their own resources outside of therapy (Swartz & Markowitz, 1998).
As Swartz and Markowitz (1998) note, "HIV-positive patients may drift to either the past or the future, longing for their preinfection lifestyles and friends, or prematurely dwelling on anticipated suffering and death" (p. 138). They urge therapists not to dismiss these concerns, but, rather, to help clients mourn losses and address fears about an uncertain future. They point out that the here-and-now focus of IPT helps clients make progress on problems in the present (Swartz & Markowitz, 1998).
HIV infection tends to raise existential issues such as the meaning and purpose of one's life (Farber, 2002), and these issues may not fit well into the framework of IPT-HIV. With this exception, the problem areas of grief, role transition, and interpersonal dispute as modified for HIV-positive clients seem to be a good fit for the kinds of issues presented by this population. An additional modification that might be worth considering is adding the problem area of grief for the loss of the healthy self which was proposed by Frank (2005) in the context of treating bipolar disorder, although this might be considered within the realm of role transitions.
Cognitive-behavioral therapy (CBT) is another therapeutic modality used successfully for treating depression in PLWHA. As Crepaz and colleagues (2008) explain, cognitive-behavioral therapy focuses on recognizing and altering irrational cognitions related to depression, "correctly appraising internal and external stressors, gaining stress management skills, and developing adaptive coping strategies" (p. 5). Troublesome thoughts are intercepted and replaced with more positive ones until the process becomes automatic. A CBT therapist working with an HIV-positive client who blames himself for becoming infected would help the client become aware of these cognitions and how they contribute to that person's depression, and urge the client to develop more affirming cognitions less likely to contribute to depressed mood. Thus, CBT would be an effective therapeutic approach for a client who is or can become aware of his or her thinking. IPT, because of its focus on the association of affect and life events, would be a more effective approach for a client with insight into his or her emotions. CBT might be preferable for clients who are unable to develop such insight.
Markowitz and colleagues (1998) directly compared the use of IPT, CBT, supportive therapy alone, and supportive therapy with antidepressant medication. Markowitz and his colleagues found IPT superior to CBT and supportive therapy alone, and comparable to supportive therapy in conjunction with antidepressant medication. The outcomes for CBT did not differ significantly from supportive therapy. Because of the small sample sizes in the experimental cells, the differences could not be deemed significant, but the rate of remission of depressive symptomatology was 46% for IPT, 30% for CBT, 21% for supportive therapy, and 50% for supportive therapy combined with an antidepressant. Markowitz and colleagues noted that because IPT connects life events to mood episodes, IPT helps clients "mourn life upheavals while pragmatically and optimistically encouraging them to find new life goals and adjustments" (p. 455). IPT therapists encourage clients to "change their lives and seek whatever they desired for however much time remained to them" (p. 455). CBT, on the other hand, focuses on "patients' exaggerations and distorted thoughts, a relatively disadvantageous approach in treating patients with objectively negative life events" (p. 456). His team also observed that those clients where interpersonal deficits predominated as the problem area might be better candidates for CBT.
Markowitz and colleagues' 1998 study, although conducted on a small sample, still stands as the most compelling evidence supporting IPT-HIV as a psychosocial intervention for depressed HIV-positive clients. This finding is particularly important for clients who may be unwilling to take psychoactive medications, or may be unable to tolerate their side effects. IPT-HIV may be particularly helpful for depressed HIV-positive women who wish to become pregnant or breastfeed, and therefore unable to take antidepressants. IPT-HIV is an important, evidence-based tool for treating depression associated with HIV.
Ciesla, J. & Roberts, J. (2001). Meta-analysis of the relationship between HIV infection and risk for depressive disorders. American Journal of Psychiatry, 158(5), 725-730
Crepaz, N., et al. (2008). Meta-analysis of cognitive behavioral interventions on HIV-positive persons' mental health and immune functioning. Health Psychology, 27(1), 4-14
Farber, E.W. (2002). Existential treatment with HIV/AIDS clients. In Comprehensive Handbook of Psychotherapy, Vol. 3. Kaslow, F.W. et al. Eds. New York: Wiley.
Frank, E. (2005) Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy. New York: Guilford.
Klerman, G.L., Weissman, M.M., Rounsaville, B.J. & Chevron, E.S. (1984). Interpersonal Psychotherapy of Depression. New York: Basic Books.
Markowitz, J.C., Klerman, G.L. & Perry, S.W. (1992). Interpersonal psychotherapy of depressed HIV-positive outpatients. Hospital and Community Psychiatry, 43(9), 885-890.
Markowitz, J.C., et al. (1998). Treatment of depressive symptoms in human immunodeficiency virus-positive patients. Archives of General Psychiatry, 55, 454-457.
Swartz, H.A. & Markowitz, J.C (1998). Interpersonal psychotherapy for the treatment of depression in HIV-positive men and women. In Interpersonal Psychotherapy. Markowitz, J.C., Ed. Washington, DC: American Psychiatric Press.
Written for Interpersonal Therapy at Washington University in St. Louis, Spring 2012. Grade: 15/15.
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Last revised: May 15, 2015.