The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. METHODS: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. RECOMMENDATIONS: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

Maternal Bonding Predicts Actigraphy-Measured Sleep Parameters in Depressed and Nondepressed Adults.

Associations between subjective maternal bonding recalled from the first 16 years of life and current sleep indices were investigated in a clinical sample of 34 adults with major depressive disorder and 36 normal controls (n = 70) using the self-report parental bonding instrument and wrist actigraphy. Results of multiple linear regression analyses indicated that reports of maternal bonding indices were associated with several sleep indices in adulthood independent of depression status. Higher levels of maternal care were associated with greater time in bed and total sleep time. Higher levels of maternal overprotection were associated with fewer awakenings. Findings indicate that reported maternal bonding characteristics in childhood are related to objectively measured sleep characteristics in adulthood, independent of mood state.

A Virtual Reality Intervention for the Treatment of Phantom Limb Pain: Development and Feasibility Results.

OBJECTIVE: To describe the development of a virtual reality (VR) treatment for phantom limb pain (PLP) and phantom sensations and provide feasibility data from testing the treatment in a population of veterans. DESIGN & SUBJECTS: Fourteen participants completed a baseline visit evaluating their amputation, PLP, and phantom sensations. Subsequently, participants completed a VR treatment modeled after mirror therapy for PLP, navigating in a VR environment with a bicycle pedaler and motion sensor to pair their cadence to a VR avatar. The VR avatar enabled visualization of the participant's intact phantom limb in motion, a hypothesized mechanism of mirror therapy. SETTING: Laboratory. METHODS: Participants completed pre- and post-treatment measures to evaluate changes in PLP, phantom sensations, and rate helpfulness, realism, immersion, adverse experiences, and treatment satisfaction. RESULTS: Eight of 14 participants (57.1%) reported PLP pre-VR treatment, and 93% (13/14) reported one or more unpleasant phantom sensations. After treatment, 28.6% (4/14) continued to report PLP symptoms (t[13] = 2.7, P = 0.02, d = 0.53) and 28.6% (4/14) reported phantom sensations (t[13] = 4.4, P = 0.001, d = 1.7). Ratings of helpfulness, realism, immersion, and satisfaction were uniformly high to very high. There were no adverse experiences. Four participants completed multiple VR treatments, showing stable improvements in PLP intensity and phantom sensations and high user ratings. CONCLUSIONS: This feasibility study of a novel VR intervention for PLP was practical and was associated with significant reductions in PLP intensity and phantom sensations. Our findings support continued research in VR-based treatments in PLP, with a need for direct comparisons between VR and more established PLP treatments.

Long-term effects of executive function training among veterans with chronic TBI.

Objective: To investigate long-term effects of GOALS executive function training in Veterans with chronic TBI. In a recently completed study Veterans with chronic TBI showed improvement immediately post-GOALS but not control training on measures of executive function, functional task performance, and emotion regulation. We now examine the long-term maintenance of post-GOALS training changes in the same sample. Setting: San Francisco VA Health Care System (SFVAHCS), and VA Northern California Health-Care System (VANCHS) in Martinez. Participants and Design: 24 Veterans with chronic TBI were assessed at baseline, post-GOALS training, and long-term follow-up 6+ months following completion of training with a structured telephone interview, neuropsychological and complex functional performance measures, and self-report measures of daily and emotional functioning. Results: Participants reported an increased likelihood of involvement in competitive employment/volunteering at follow-up (61%) compared to baseline (26%; χ2 = 5.66, p < .01, ѱ = .35). Repeated measures MANOVAS indicated improvement on attention/executive function (F = 13.85, p < .01, partial η2 = .42), complex functional task performance (GPS Total: F = 9.12, p < .01, partial η2 = .38) and daily functioning (MPAI Total: F = 3.23, p < .05, partial η2 = .21), and reduction in overall mood disturbance (POMS Total: F = 3.42, p < .05, partial η2 = .22) at follow-up relative to baseline. Discussion: Training in attention regulation applied to participant-defined goals is associated with meaningful long-term improvement in cognitive skills, emotion regulation, and daily functioning in Veterans with chronic TBI.

Psychologists aspiring to leadership positions in public sector health care.

Psychologists are well-positioned to take on leadership roles in health care systems as a result of the broad-based skills included in doctoral level, professional training programs. These include knowledge of evidence-based practice, extensive training in applied research and clinical practice, emphasis on critical thinking in scientific methods and hypothesis testing, teaching, supervision, team consultation, and continuous learning (APA Presidential Task Force on Evidence-Based Practice, 2006; Korman, 1974; McFall, 2007). Formal opportunities to learn how to apply these skills in leadership and organizational management roles are, however, limited during graduate training. There have been recent efforts within the American Psychological Association to foster interest and readiness for leadership roles among psychologists. These efforts have included a leadership development fellowship, on-demand webinars, and online learning for continuing education (American Psychological Association, 2023). The content of these training opportunities is typically general in nature so that it can be applied to all types of organizational settings. Psychologists interested in leadership positions within public sector health care organizations are likely to benefit from information that aligns more specifically with the mission and organizational structures of such systems. This article presents a conceptual framework to prepare psychologists aspiring to leadership positions in public sector health care. Leadership theories and models from organizational management science are outlined which capture the context and organizational goals of such programs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: defeatist performance attitudes and functional outcome.

OBJECTIVES: To determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST. DESIGN: An 18-month, single-blind, randomized controlled trial. SETTING: Outpatient clinic at a university-affiliated Veterans Affairs hospital. PARTICIPANTS: Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45-78. INTERVENTIONS: CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals. MEASUREMENTS: Blind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction. RESULTS: Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction. CONCLUSIONS: CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning. TRIAL REGISTRY: ClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796).

12-step affiliation and attendance following treatment for comorbid substance dependence and depression: a latent growth curve mediation model.

Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.

Alpha Event-Related Desynchronization During Reward Processing in Schizophrenia.

BACKGROUND: Alterations in the brain's reward system may underlie motivation and pleasure deficits in schizophrenia (SZ). Neuro-oscillatory desynchronization in the alpha band is thought to direct resource allocation away from the internal state, to prioritize processing salient environmental events, including reward feedback. We hypothesized reduced reward-related alpha event-related desynchronization (ERD) in SZ, consistent with less externally focused processing during reward feedback. METHODS: Electroencephalography was recorded while participants with SZ (n = 54) and healthy control participants (n = 54) played a simple slot machine task. Total alpha band power (8-14 Hz), a measure of neural oscillation magnitude, was extracted via principal component analysis and compared between groups and reward outcomes. The clinical relevance of hypothesized alpha power alterations was examined by testing associations with negative symptoms within the SZ group and with trait rumination, dimensionally, across groups. RESULTS: A group × reward outcome interaction (p = .018) was explained by healthy control participants showing significant posterior-occipital alpha power suppression to wins versus losses (p < .001), in contrast to participants with SZ (p > .1). Among participants with SZ, this alpha ERD was unrelated to negative symptoms (p > .1). Across all participants, less alpha ERD to reward outcomes covaried with greater trait rumination for both win (p = .005) and loss (p = .002) outcomes, with no group differences in slope. CONCLUSIONS: These findings demonstrate alpha ERD alterations in SZ during reward outcome processing. Additionally, higher trait rumination was associated with less alpha ERD during reward feedback, suggesting that individual differences in rumination covary with external attention to reward processing, regardless of reward outcome valence or group membership.

Improvement in executive functioning after Goal-Oriented Attentional Self-Regulation training is associated with reduction in PTSD hyperarousal symptoms among veterans with comorbid PTSD and mild TBI.

Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R2 = 0.26, F(1,15) = 5.01, ß = -.51, p < .05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans.

Psychological Dimensions Relevant to Motivation and Pleasure in Schizophrenia.

Motivation and pleasure deficits are common in schizophrenia, strongly linked with poorer functioning, and may reflect underlying alterations in brain functions governing reward processing and goal pursuit. While there is extensive research examining cognitive and reward mechanisms related to these deficits in schizophrenia, less attention has been paid to psychological characteristics that contribute to resilience against, or risk for, motivation and pleasure impairment. For example, psychological tendencies involving positive future expectancies (e.g., optimism) and effective affect management (e.g., reappraisal, mindfulness) are associated with aspects of reward anticipation and evaluation that optimally guide goal-directed behavior. Conversely, maladaptive thinking patterns (e.g., defeatist performance beliefs, asocial beliefs) and tendencies that amplify negative cognitions (e.g., rumination), may divert cognitive resources away from goal pursuit or reduce willingness to exert effort. Additionally, aspects of sociality, including the propensity to experience social connection as positive reinforcement may be particularly relevant for pursuing social goals. In the current review, we discuss the roles of several psychological characteristics with respect to motivation and pleasure in schizophrenia. We argue that individual variation in these psychological dimensions is relevant to the study of motivation and reward processing in schizophrenia, including interactions between these psychological dimensions and more well-characterized cognitive and reward processing contributors to motivation. We close by emphasizing the value of considering a broad set of modulating factors when studying motivation and pleasure functions in schizophrenia.

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Correlates of obsessive-compulsive disorder in a sample of HIV-positive, methamphetamine-using men who have sex with men.

Substance use has been identified as a risk factor for elevated levels of obsessive-compulsive disorder (OCD). This study examined methamphetamine use and sexual risk behaviors as correlates of OCD in a sample of 245 HIV-positive men having sex with men (MSM) in San Diego, CA. In a logistic regression analysis, OCD was associated with greater frequency of methamphetamine use, more depressive symptoms, seeking out risky venues and risky sexual partners when "high" on methamphetamine, and reporting fewer sex acts in the past 2 months. These data suggest the need for increased awareness and understanding of the role that OCD may play in the drug use behaviors and risky sexual practices of methamphetamine users.

Psychosocial and behavioral correlates of anxiety symptoms in a sample of HIV-positive, methamphetamine-using men who have sex with men.

Studies show high rates of psychiatric symptoms among methamphetamine users; however, little information exists regarding methamphetamine use and anxiety. This study investigated psychosocial and behavioral correlates of anxiety symptoms in a sample of 245 HIV-positive men having sex with men (MSM) who were enrolled in a sexual risk-reduction intervention. In a multiple regression analysis, anxiety symptoms were associated with homelessness, recent experience of HIV symptoms, injection drug use, lifetime sexual abuse, engaging in risky sexual behaviors, and seeking out partners at risky sexual venues when "high" on methamphetamine. These findings can be used to inform and refine sexual risk-reduction interventions and substance-use treatment programs for HIV-positive methamphetamine-using MSM.

Neuropsychological functioning and outcomes of treatment for co-occurring depression and substance use disorders.

BACKGROUND: We previously published findings from our clinical trial comparing treatment outcomes for substance-dependent veterans with co-occurring depression who received Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation (TSF) Therapy. OBJECTIVES: This study is a secondary analysis that examined whether neuropsychological functioning at baseline moderated substance use and depression outcomes in ICBT relative to TSF. METHODS: This study was a randomized clinical trial in which 164 veterans with major depressive disorder and comorbid alcohol, cannabinol, and/or stimulant dependence were randomly assigned to either ICBT or TSF group therapy. A comprehensive neuropsychological test battery was administered at baseline. RESULTS: Contrary to our hypothesis, participants with poor neuropsychological functioning had better substance use outcome in ICBT than in TSF, whereas participants with good neuropsychological functioning had comparable substance use outcomes in TSF and ICBT by 18-month follow-up. Depression outcomes, in contrast, were not moderated by neuropsychological functioning by 18-month follow-up. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The substance use outcomes may suggest that substance-dependent depressed adults with poorer neuropsychological functioning should be offered ICBT over TSF. These individuals may be less able to develop and use novel coping skills for managing substance use and depressive symptoms on their own without formal structured training in cognitive and behavioral skills provided in ICBT.

Psychiatric residents' interest in psychotherapy and training stage: a multi-site survey.

BACKGROUND: Most psychiatric residents enter training intent on learning both psychopharmacologic and psychotherapeutic interventions. After graduation, however, many emphasize pharmacotherapy over psychotherapy. METHODS: A multisite survey of psychiatry residents queried psychotherapy interests, attitudes, and practice intentions. Factors associated with self-reported decreased interest in psychotherapy since beginning residency were examined. RESULTS: Although 11.8% of the entire sample (n = 229 PGY1-PGY4 residents) reported decreased interest in psychotherapy during training, among PGY4s the corresponding figure was 16.4%. Positive attitudes towards psychotherapy, and self-perceived competence in cognitive-behavioral and psychodynamic psychotherapy were most highly correlated with maintained interest in psychotherapy. Dissatisfaction with the quality of psychotherapy faculty and curriculum, and viewing departmental leadership as unsupportive of psychotherapy training were correlated with decreased interest during training. CONCLUSIONS: Maintaining residents' interest in psychotherapy requires improvements in curriculum, teaching, and supervision throughout training. Our data underscore the crucial role that departmental leadership must play in supporting trainees' goals of becoming comprehensively trained psychiatrists.

VA Academic Affiliations Matter in the Era of Community Care: A Model From California.

BACKGROUND: The Veterans Health Administration (VHA), 1 of 3 administrative branches in the US Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. The VHA has 4 missions: providing health care to eligible veterans; supporting research to benefit veterans and the larger society; providing education for health care trainees; and supporting emergency response. OBSERVATIONS: In service of these goals, the VA has academic affiliations with training institutions throughout the country, offering unique and extensive training and research opportunities. These affiliations are a 2-way street where both the VA and the affiliate provide and gain from their partnership. For example, VA affiliations with University of California (UC) medical schools benefit veteran care and are a major contributor to the UC academic mission. This article explores the history of the VA, current veteran demographics and needs, academic affiliations, and the integrated care model of training in all VHA facilities. The VA and UC academic affiliation system is described further with regard to shared research and educational functions. CONCLUSIONS: We identify risks to academic affiliations if a shift occurs from VHA care to VA-managed community-based care following the implementation of recent legislation. We also provide suggestions for VA academic affiliates to help assess and guide the potential impact of increased VA-managed community care.

Goal-Oriented Attention Self-Regulation Training Improves Executive Functioning in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury.

Difficulties in executive-control functions are common sequelae of both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The goal of this study was to assess whether a cognitive rehabilitation training that was applied successfully in civilian and military TBI would be effective for military Veterans with comorbid PTSD and mild TBI (mTBI). In the previous study, Veterans with a history of mild to severe TBI improved significantly after goal-oriented attentional self-regulation (GOALS) training on measures of attention/executive function, functional task performance, and emotional regulation. The objective of this study was to assess effects of GOALS training in Veterans with comorbid PTSD and mTBI. Forty Veterans with a current PTSD diagnosis and history of mTBI (6+ months post) were randomized to either five weeks of GOALS or Brain-Health Education (BHE) training matched in time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance, and self-report measures of emotional functioning/regulation. After GOALS but not BHE training, participants significantly improved from baseline on primary outcome measures of: overall complex attention/executive function neuropsychological performance composite (F = 12.35, p = 0.001; Cohen d = 0.48), and overall mood disturbance -POMS emotional regulation self-report (F = 4.29, p = 0.05, Cohen d = 0.41). In addition, GOALS but not BHE participants indicated a significant decrease in PTSD symptoms (PCL-M Total Score) (F = 4.80, p = 0.05, Cohen d = 0.60), and demonstrated improvement on complex functional task performance-GPS Learning and Memory (F = 5.06, p = 0.05, Cohen d = 0.56]. Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in Veterans with comorbid PTSD and mTBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance, potentially making it particularly relevant for Veterans with a history of mTBI and comorbid psychiatric symptoms.

A longitudinal investigation of the impact of life stress on HIV treatment adherence.

Suboptimal antiretroviral adherence is associated with poorer HIV outcomes. Psychosocial factors, including life stress, depression and coping, may influence adherence behavior. This prospective investigation sought to examine the impact of life stress (acute life events, chronic stress, and perceived stress), depression, and coping style on adherence to HIV treatment regimes over time. Participants were 87 treatment-seeking HIV-infected individuals recruited from an urban HIV clinic. They completed clinician-administered interviews and self-report questionnaires at baseline and 3-month follow-up. Acute life events and chronic stress prospectively predicted decreases in treatment adherence more strongly among individuals in a major depressive episode (n = 21) compared to non-depressed individuals (n = 66). Coping style did not appear to be the mechanism by which life stress influenced adherence among depressed HIV-infected individuals. These findings demonstrate that life stress has toxic effects for depressed individuals and suggest that treatment adherence interventions with depressed individuals could be enhanced via development of stress management skills.