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  Conference on Retroviruses
and Opportunistic Infections
Will be Virtual
Boston USA
March 6-10, 2021
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Online Mindfulness Lessons Ease
Depression, Anxiety in Older HIV+ During COVID
  CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021
Mark Mascolini
Twenty-minute online mindfulness lessons reduced depression, anxiety, and loneliness in a randomized US trial of 214 older HIV-positive people during the COVID-19 pandemic [1]. Researchers from Mazonson and Santas, with academic and ViiV Healthcare collaborators, suggested this online approach could "supplement strained existing mental health resources, without the need for face-to-face interaction and with minimal disruption to provider workflow." But interpretation of the results is not entirely clear.
Depression, anxiety, and loneliness affect high proportions of older people with HIV infection. The isolation and health threats during the COVID-19 pandemic may exacerbate these mental health problems in older HIV populations. The Mazonson research team conducted this randomized controlled trial to see whether a series of online mindfulness interventions could alleviate depression, anxiety, and loneliness in older people with HIV in the United States.
Conducted between May and August 2020, the ADHOC Mindfulness-Based Research (AMBR) study enrolled HIV-positive people 50 or older with any degree of self-reported loneliness. ADHOC is an ongoing observational study of people with HIV who are 50 or older and in care at a dozen clinics in California, Texas, Washington State, Washington, DC, and Chicago [2]. So ADHOC does not claim to represent the US HIV population. It is, as its name implies, an ad hoc or convenience sample.
The AMBR trial aimed to assess the impact of an online mindfulness intervention on three outcomes: depression (measured by the Center for Epidemiological Studies-Depression scale, CES-D-10), anxiety (measured by the Generalized Anxiety Disorder test, GAD-7), and loneliness (measured by the Three-Item Loneliness Scale, 3IL, and a daily diary that asked "How lonely did you feel today?"
mindful.org, a site that offers online courses, defines mindfulness as "the basic human ability to be fully present, aware of where we are and what we're doing, and not overly reactive or overwhelmed by what's going on around us" [3]. This group lists three techniques that promote mindfulness: (1) seated, walking, standing, and moving meditation, (2) short pauses inserted into everyday life, and (3) merging meditation practice with other activities, such as yoga or sports.
Previous randomized controlled trials found that a series of 20-minute online audio mindfulness lessons can help relieve depression, anxiety, and loneliness [4,5]. Participants randomized to the intervention arm in the AMBR trial could immediately listen to up to 14 lessons in 25 days. They could listen whenever they wanted on any internet-connected device.
Researchers randomized 107 people to the intervention arm and 107 to the control arm. In the first 25 days people in the intervention arm listened to at least one mindfulness lesson online, while people in the control group delayed listening to any online lessons. In the next 14 days, people in the intervention group and the control arm completed follow-up questionnaires and diaries. Ninety-nine people (92.5%) in the intervention arm and 103 (96%) in the control arm completed follow-up, and researchers analyzed results of these participants.
Participants averaged 60.4 years in age, 89% were men, 69% white, and 74% gay, with no significant differences in these factors between groups. During the 25-day intervention period, 92% of participants in the intervention arm completed at least 10 lessons.
At the end of follow-up, the average CES-D-10 depression score was significantly lower (better) in the intervention group than the control (10.2 vs 12.8, P < 0.01). Average GAD-7 anxiety score also proved significantly lower (better) in the mindfulness group than the control group at the end of follow-up (5.2 vs 6.7, P = 0.03). Loneliness at the end of follow-up did not differ significantly between groups when measured by 3IL (6.0 vs 6.3, P = 0.26). The mindfulness group had a lower (better) diary score for loneliness at the end of follow-up, though that difference stopped short of statistical significance (2.7 vs 3.1, P = 0.07).
These findings are difficult to interpret because the researchers give baseline scores for all four outcomes, but for only about two thirds to three quarters of participants for each outcome. Baseline scores were significantly better in the intervention group than the control group for CES-D-10 depression (P < 0.01), GAD-7 anxiety (P < 0.01), and diary-based loneliness (P < 0.01), and nearly significantly better in the intervention group for 3IL loneliness (P = 0.06). So the control group could have made greater gains than the intervention group for each measure but still have significantly worse scores in the end-of-study analysis.
At the end of follow-up, CES-D-10 depression score was lower (better) with the intervention for 59 Hispanics, blacks, and women analyzed (9.3 vs 12.7, P = 0.05), for 114 people with annual income at or below $50,000 (11.0 vs 13.5, P = 0.04), and for 89 people with obesity, diabetes, or chronic obstructive pulmonary disease (COPD) (11.2 vs 13.8, almost significant at P = 0.06). GAD-7 anxiety score was significantly lower (better) with the intervention in 59 Hispanics, blacks, or women (4.4 vs 6.9, almost significant at P = 0.06), in 114 people with an annual income at or below $50,000 (5.4 vs 7.4, P = 0.03), and in 89 people with obesity, diabetes, or COPD (5.2 vs 7.4, P = 0.03).
The Internet offers plentiful videos on mindfulness training, meditation, and courses, including many at www.mindful.org. But there is no simple way to tell whether free online mindfulness videos like these are as effective as those used in the AMBR trial.
1. Berko J, Mazonson P, Short D, et al. RCT of an online mental health intervention among older PLWH during COVID-19 pandemic. CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021. Abstract 110.
2. ClinicalTrials.gov. Aging With Dignity, Health, Optimism and Community (ADHOC). ClinicalTrials.gov identifier NCT04311554. https://clinicaltrials.gov/ct2/show/NCT04311554
3. www.mindful.org. What is mindfulness? https://www.mindful.org/what-is-mindfulness/
4. Lindsay EK, Young S, Brown KW, et al. Mindfulness training reduces loneliness and increases social contact in a randomized controlled trial. Proc Natl Acad Sci USA. 2019;116:3488-3493. https://doi.org/10.1073/pnas.1813588116
5. Lindsay EK, Chin B, Greco CM, et al. How mindfulness training promotes positive emotions: dismantling acceptance skills training in two randomized controlled trials. J Pers Soc Psychol. 2018;115:944-973. doi: 10.1037/pspa0000134. https://content.apa.org/record/2018-63189-003