World Journal of AIDS, 2011, 1, 15-22
doi:10.4236/wja.2011.12003 Published Online June 2011 (http://www.SciRP.org/journal/wja)
15
The Effect of Cognitive Behavioral Therapy and
Changes of Depressive Symptoms among Thai
Adult HIV-Infected Patients
Isareethika Jayasvasti1, Narin Hiransuthikul1, Nuttorn Pityaratstian2, Vitool Lohsoonthorn1,
Buranee Kanchanatawan2, Boonruang Triruangworawat3
1Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 2Department of
Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 3Department of Health Service Support, Ministry of
Public Health, Bangkok, Thailand.
Received March 17th, 2011; Revised April 12th, 2011; Accepted April 25th, 2011.
ABSTRACT
Background: In Thailand, the therapeutic effect of cognitive behavioral therapy (CBT) for depression among adult
HIV-infected patients has been limitedly studied. Objectives: To determine the association of CBT and changes of de-
pression both immediately post treatment and at 3-month post-treatment. Materials and Methods: A prospective cohort
study was conducted at the University Hospital in Thailand. Forty and eighty HIV-infected adults who voluntarily re-
ceived and did not receive CBT were recruited from the immunology clinic and sexually transmitted diseases clinic be-
tween September 2010 and February 2011. Sociodemographic characteristics and medical histories of the participants
were collected. A standard Thai Depression Inventory (TDI) was used for evaluation of depressive symptoms. TDI
score of 21 or above was interpreted as depression. Other questionnaires included a Montreal Cognitive Assessment
questionnaire, standard questionnaire for evaluating life stress event and questionnaire for HIV social support. Results:
The mean ages of participants were 44.8 and 43.4 years in the CBT and non-CBT groups respectively. In both group,
about half of the subjects were females. Life stress event score in CBT group was significantly higher than the non-CBT
group (p < 0.01). At baseline, the mean TDI scores of the CBT group and non-CBT group were 26.7 and 25.3 respec-
tively. After adjustment for age, gender, social support, life stress event and current opportunistic infection; the mean
changes of TDI scores in the CBT group were significantly higher than the non-CBT group both immediately [12.13
(95% CI, 10.00 - 14.26)] (p < 0.001) and at 3-month post-treatment [15.94 (95% CI, 13.69 - 18.18)] (p < 0.001).
Conclusions: CBT is beneficial for treatment of depression among adult HIV-infected patients in Thailand. Th e benefi-
cial effect of CBT was not only immediate but also sustained at 3-month post-treatment.
Keywords: Cognitive Behavioral Therapy (CBT), HIV/AIDS, Depression
1. Introduction
By the year 2020, World Health Organization has pre-
dicted that depression will be the leading cause of
worldwide disability [1]. Globally, several studies have
shown that the prevalence of depression among human
immunodeficiency virus (HIV)-infected patients and
AIDS was higher than normal population with a preva-
lence of about 15 - 30 percent [2-5]. HIV infection af-
fects all aspects of a patient’s life and results in physical,
psychological, social, and spiritual adaptation. Mental
health problems among individuals with HIV infection
include grief, stigmatization, fear of reaction from others,
uncertainly about the future, and changes in identity as
well as psychological disorders, especially depression
[6,7]. HIV disease is also influenced by one’s coping
style, social support, and other life stress [6,8,9]. Several
studies have shown that depression was significantly
associated with poor adherence to highly active antiret-
roviral therapy (HAART) [3,10-14]. This resulted in drug
resistance mutation and treatment failure [8] which in-
creased patients’ health care costs [3,15] and affected
their quality of life as well as health outcomes[16,17].
Similarly, depression has been related to faster increase
in plasma HIV viral load, more rapid decline in CD4+T
lymphocyte cells count [18] and progression to AIDS,

The Effect of Cognitive Behavioral Therapy and Changes of Depressive Symptoms among Thai Adult
HIV-Infected Patients
16
Figure 1. The process of study.
and increased mortality [19].
Psychotherapy has been shown to promote adaptation
to neuropsychiatric and psychosocial problem in
HIV-infected patients [6]. Specific individual and group
psychotherapy are both effective for reducing depressive
symptoms in people with HIV [20,21]. Cognitive behav-
ioral therapy (CBT) is a psychotherapeutic method that
has been shown to be effective for treatment of depres-
sion [3,22-25] and also useful for HIV-infected patients
[26]. It is a structured, goal-oriented therapy and based
on two way collaboration between therapist and client.
CBT is designed to be as short term as possible [27] and
focus on identifying automatic thoughts, modifying the
dysfunctional thoughts and promoting more realistic
adaptive patterns of thinking and behavior that may con-
tribute to or prolong an episode of depression [28,29].
In Thailand, there were few studies addressing CBT for
treatment of HIV-infected patients with depression.
However, they did not control for confounding effects
and were not designed to examine the sustainability of
CBT on treatment of depression. The objectives of this
study were to determine the association of CBT and
change of depression among Thai adult HIV-infected
patients both immediately and at 3-month post-treatment
as well as to examine whether improvement of depres-
sion in those who completed CBT was sustained during
follow-up.
2. Materials and Methods
This cohort study was conducted at King Chulalongkorn
Memorial Hospital (KCMH), Bangkok, Thailand.
KCMH is a 2000-bed public medical school hospital
which provides medical services mainly for lower and
middle income population. Participants were recruited
from the immunology clinic and sexual transmitted dis-
eases clinic between September 2010 and February 2011.
At both clinics, CBT has been a routine service for
treatment of HIV-infected clients with depression. HIV-
infected clients were informed about the detail of the
study by professional nurses of each clinic. Those who
agreed to participate in the study were initially screened
for depression using the self-reported depression inven-
tory (Thai Depression Inventory; TDI) [30]. Individuals
with depression were asked whether they would like to
receive CBT by the expert or not. Those who agreed
were sent to CBT expert. For CBT, there were eight
therapeutic sessions (two sessions per week) in one
month period. The process of conducting the study was
summarized in Figure 1. Inclusion criteria were
HIV-infected individual with age above 18 years, educa-
tional level at least primary school and having TDI score
of at least 21. Exclusion criteria were previous diagnosis
of other major mental health illness including psychotic
disorder, bipolar disorder, organic brain syndrome, active
use of substance or other, axis I psychiatric conditions
that would interfere with the ability to participate in
group psychotherapy and subjects whose treatment with
psychotropic agents were not stable. Data were collected
by a set of questionnaires that consisted of 5 parts. The
first part was a Case Record Form (CRF) used for col-
lecting sociodemographic characteristics and medical
history of participants. The second part was a TDI, a
culturally appropriate instrument for measuring the se-
verity of depression with good reliability (Cronbach’s
alpha = 0.86) and for th e validity o f this tool, it was com-
pared with The Hamilton Rating Scale for concurrent
validity. The result showed that the TDI well reflected
the severity of depression (The Pearson product moment
correlation was 0.72). This questionnaire has 20 items.
TDI score was a subjective oriented rating scale with
range of score 0 to 60. TDI score of 21 or above was
interpreted as depression, higher scores reflecting greater
depression [30]. Assessment of depression by TDI was
repeated both among participants who did and did not

The Effect of Cognitive Behavioral Therapy and Changes of Depressive Symptoms among Thai Adult
HIV-Infected Patients
17
receive CBT immediately and at 3-month post-treatment.
The third part was the Montreal Cognitive Assessment
(MOCA) questionnaire with aim to detect mild cogn itive
impairment (MCI) of the subjects. Scores below 26 indi-
cated MCI. The sensitivity and specificity of MOCA for
MCI is 0.90 and 0.87 respectively [31]. The fourth part
was the 43 item-questionn aire, adapted from Holmes and
Rahe stress scale, to assess life stress event within the
past 1 year of an individual’s life according to life stress
event. It had very good reliability (Cronbach’s alpha =
0.99) [32]. The final part was the HIV social support
questionnaire adapted from patients’ report assessment of
living with HIV/AIDS in resource-constrained setting s. It
had good reliability (Cronbach’s alpha = 0.85). The
higher score indicated higher social support [13].
3. Statistical Analysis
Sample size calculation for cohort study was done. We
used the parameter from the study of the effective of
CBT and depression among HIV-infected patients by
Safren et al. [33], which found that a mean difference of
depression score between CBT and non CBT group was
7 and the variance of the mean difference was 9.9. We
used the alpha of 0.05, power of 0.80, the ratio of the
CBT versus non-CBT group was 1:2 to obtain the ade-
quate sample size in both CBT and non-CBT group [34].
The calculated sample size of CBT and non-CBT groups
were 40 and 80 respectively. Sociodemographic charac-
teristics and clinical parameter were described using de-
scriptive statistics. The univariate analysis for asso ciation
between CBT and depression were done by student’s
t-test. To compare baseline characteristics between CBT
versus non-CBT group, we used student’s t-test for con-
tinuous variables and chi-square test or Fisher exact test
for categorical variables. The variables between CBT
versus non-CBT group that were not comparable at base-
line and the variables associated with depression from
literature review were selected for multiple linear reg res-
sion to look for adjusted association between CBT and
depression. A p-value of less than 0.05 was considered
statistically significant.
4. Results
The calculated number of participants in CBT and
non-CBT groups was 40 an d 80 respectively. At baselin e,
no statistically significant differences were observed be-
tween CBT and non-CBT groups regarding to sociode-
mographic and clinical characteristics (Table 1). The
psychological factors in each group were shown in Table
2. We found that there were statistically significant
higher score of life stress event in the CBT group (p <
0.05).
TDI scores in each group at baseline, immediately and
3-month post-treatment were demonstrated in Table 3
and Figure 2. The retention rate in CBT group at final
evaluation was 95%. Two subjects in the CBT group and
ten in the non-CBT group lost to follow-up at 3-month
follow-up. At baseline, no statistically significant differ-
ence in mean TDI score was observed between CBT and
non-CBT group. By univariate analysis, the CBT group
had statistically significant higher mean changes of TDI
score both immediately and at 3-month post-treatment (p
Table 1. Demographic and clinical characteristics of study population (N = 120).
Characteristics CBT group
(n = 40) Non-CBT group (n = 80) p-value†
Mean age (SD) 44.8 (12.01) 43.4 (8.84) 0.46
Female (%) 23 (57.5) 40 (50.0) 0.44
Heterosexual HIV transmission (%) 32 (80.0) 68 (85.0) 0.54
Education (%) 0.40
Primary school 17 (42.5) 25 (31.3)
Secondary school 13 (32.5) 24 (30.0)
Diploma 6 (15.0) 11 (13.8)
Bachelor’s degree or higher 4 (10.0) 20 (25.0)
Couple marital status (%) 17 (42.5) 35 (43.8) 0.96
Others have known HIV status (%) 29 (72.5) 61 (76.3) 0.65
Having opportunistic infection (%) 15 (37.5) 27 (33.8) 0.69
Having others physical illness (%) 20 (50.0) 48 (60.0) 0.30
Using hypnotic drug (%) 13 (32.5) 21 (26.3) 0.47
On current HAART (%) 35 (87.5) 72 (90.0) 0.68
Taking efavirenz (%) 14 (35.0) 29 (36.3) 0.89
Mean time(year)since HIV diagnosis (SD) 7.6 (5.13) 8.7 (5.72) 0.27
Mean time(year)since start HAART (SD) 5.1 (4.33) 5.9 (4.84) 0.37
Median current CD4 cell counts (IQR) cells/mm3 406.5 (293, 600) 448 (299, 620) 0.83
Proportion of subjects with undetectable
plasma HIV-RNA (%) (N = 76) 19 (82.6) 48 (90.6) 0.43
†P-value base on t-test or Chi-square test as appropriate. HAART = Highly Active Antiretroviral Therapy; HIV = Human Immunode-
ficiency Virus; IQR = Interquartile Range.

18 The Effect of Cognitive Behavioral Therapy and Changes of Depressive Symptoms among Thai Adult
HIV-Infected Patients
Table 2. Psychosocial factors in studied patients according to Cognitive Behavioral Therapy condition.
Psychological factors CBT group
(n = 40) Non-CBT group (n = 80) p-value†
Life stress event (%) 0.01
Low level 2 (5.0) 11 (13.8)
Average level 29 (72.5) 65 (81.3)
High level 9 (22.5) 4 (5.0)
Social support (%) 0.06
Low level 3 (7.5) 17 (21.3)
Average level 33 (82.5) 49 (61.3)
High level 4 (10.0) 14 (17.5)
Mild Cognitive Impairment (%) 33 (82.5) 66 (82.5) 1.00
†P-value base on Chi-square test for categorical variables.
Table 3. TDI scores in adult HIV-infected patients at baseline, immediately post-treatment and 3 months follow-up.
CBT group Non-CBT group Mean difference 95% CI
Baseline (n = 40) (n = 80)
:Mean TDI score (SD) 26.70 (4.87) 25.28 (4.83) 1.42 –0.43, 3.28
Immediately post-treatment (n = 40) (n = 78)
: Mean TDI score (SD) 11.15 (7.10) 21.68 (7.00)
:Mean change of TDI total
score from baseline(SD) 15.55 (6.47) 3.54 (4.57) 12.01 9.98 - 14.05
3 months follow-up (n = 38) (n = 70)
:Mean TDI score (SD) 7.89 (6.01) 22.51 (6.66)
:Mean change of TDI total
score from baseline (SD) 18.92 (6.50) 2.99 (4.65) 15.93 13.55 - 18.32
CBT = Cognitive Behavioral Therapy TD I = Thai Depression Inventory
< 0.001).
From univariate analysis, to compare baseline charac-
teristics between CBT versus non-CBT group, we found
that there were statistically significant higher score of life
stress event in the CBT group (p < 0.05). In addition,
from literature review, age [35], gender [36], life stress
event [37] and social support [38] were associated with
depression. Therefore, regarding multivariate analysis,
we selected these variables and incorporated into the
linear regression model to control for confounding ef-
fects. The result revealed statistically significant associa-
tion between CBT and changes of depression both im-
mediately and at 3-month post-treatment as shown in
Table 4. These finding supported that the effect of CBT
for treatment of depression among HIV-infected patients
was sustained over time after treatment.
5. Disscussion
Our study found that CBT was associated with changes
in depression score both immediately and at 3-month
post-treatment. These findings were consistent with sev-
eral studies in western countries which demonstrated the
efficacy of CBT for HIV-infected patients with depres-
sion in diverse populations [15,33,39-41]. In addition,
our study demonstrated that, immediately and 3-month
post-treatment, the mean TDI score among patients in the
CBT group decreased substantially from the baseline.
These changes in TDI score were more profound than
other studies. Kelly et al. [42], found that the mean
change of depression score in CBT group was 6.2 imme-
diately and 3.2 at 3-month poat-treatment. In Thailand,
CBT has been used for treatment of depression in non
HIV-infected patients. It was tailored to suit the Thai
cultural context based on Buddhism for addressing spiri-
tual aspect combined with therapeutic techniques most
applicable for group of patients who have some stigma-
tization. CBT has several techniques to alleviate depres-
sion [43] especially cognitive restructuring and active
coping style [24,44]. Consequently, these techniques
resulted in high retention and adherence to treatment
instruction among patients. Previous studies showed that
participation in homework assignments in CBT group
treatment was associated with improved outcomes
[45,46]. In addition, several studies found that therapist
could be effective treatment deliverer [3,24]. The thera-
pist will focus on the patient’s difficulty and problems
with empathy, encourage other group members by asking
to support and share their ideas in the process. CBT
modules are made to approach in each treatment session.
The first module, Psycho-education, informs about de-
pressive symptoms, using motivational interviewing to
help clients chang e their hopeless cog nition b y ask ing the
clients finding someone or something to make their
hopeness and worthness for the rest of their life, collabo-
ratively sets an agenda for the session, introduction to
CBT for depression and also teach them to understand

The Effect of Cognitive Behavioral Therapy and Changes of Depressive Symptoms among Thai Adult
HIV-Infected Patients
19
Table 4. Adjusted mean difference of depression scores between CBT group and non-CBT group at immediately post-treat-
ment and 3-month post-treatment from baseline .
CBT Mean difference† 95% CI
Immediately post-treatment 12.13 10.00 - 14.26
3 months follow-up period 15.94 13.69 - 18.18
†Adjusted for age, gender, social support and life stress event.
010 20 3040 50
Depression score
NO CBTCB T
013 013
Figure 2. Depression scores of CBT group and comparison group at baseline, immediately post-treatment and 3-month
post-treatment.
the pattern of relation between situation, automatic
thought and emotion, behavior and physiology. The sec-
ond module, relaxation training which consist of pro-
gressive muscle relaxation training and diaphragmatic
breathing skills, is widely used in behavioral medicine to
teach clients learning about relaxing during stress times.
Next, Activity scheduling module focuses on behavioral
activation occurring pleasure and mastery and teach them
to monitoring life style in each day maximizing activities
that makes clients feel better or under-represented utilize
activities. The forth module is cognitive restructuring
starting from teaching clients to identify negative auto-
matic thoughts that contribute to negative emotions and
maladaptive behaviors. It also evaluates thoughts based
on the evidence such as information and facts but not
interpretations and opinions, modify their dysfunctional
thoughts and th en facilitate them to learn ad aptive cop ing
skills by problem solving module [47]. The problem
solving module uses problem-solving steps which consist
of defining the problem that causes depression, generate
alternative solutions, evaluates the alternatives by
weighing up pros and cons, makes decisions about the
alternatives, and finally, makes a plan about how to im-
plement solutions [48]. However, in our study the sub-
jects in CBT group had voluntarily participated, they
tend to adhere to the treatment and resulted in high reten -
tion rate. This might be another reason for high retention
rate in the CBT group in our study. In Thailand, the
stigmatization is a major social problem among HIV-
infected patients which may contribute to depression.
Some responses from patients’ interview in our study
indicated that provision of social support through group
sharing was valuable in alleviate their depression by
changing the pattern of thought that they were not ones
with stigmatized and serious chronic illness especially
patients who were often isolated from family members,
friends or relatives.
The results of our study indicated the benefit of CBT
in treatment of depression in HIV-infected patients.
Therefore, CBT should be implemented as a routine part
of standard of care in order to integrate psychosocial
treatment dimension into holistic care and improve qual-
ity of life of patients in the long term. However our study
was based on the study population from tertiary care
hospital. Further study of CBT treatment in commu-
nity-based practice should be done to provide more fea-
sibility, availability, and accessibility for patients. In ad-
dition, cost-effectiveness analysis of CBT for treatment
of HIV-infected patients with depression is suggested.
In our study, some patients felt inconvenient to attend

20 The Effect of Cognitive Behavioral Therapy and Changes of Depressive Symptoms among Thai Adult
HIV-Infected Patients
the CBT courses in the hospital due to the problem of
transportation. Previous study showed that the CBT
could be applied by telephone-administration [49].
Therefore further study about telephone-administered
CBT should be conducted in Thailand. Because it has
been shown that depression was associated with adher-
ence to HAART [3,10-14], future research to explore the
association between improvement of depression by CBT
and adherence to HAART regimens and immune func-
tion of HIV-infected patients should be conducted.
The strength of our study was that we focused on
changes of depression both immediately and over time
after treatment with CBT. We also examined the preven-
tion of relapse of depression and found that the effect of
CBT was sustained at 3-month post-treatment. Moreover,
we used the multiple linear regression model to control
the potential confounding effects.
The present study had some limitations. The analysis
was based on the cohor t study. Though we used the mul-
tivariate analysis to adjust for known potential con-
founding variables, we could not control the effects from
other unknown variables. Therefore, a randomized con-
trolled trial should be further conducted. Because sub-
jects in the CBT group were recruited voluntarily the
selection bias might occur. This also raised a possibility
of information bias.
Although this study was designed to examine the sus-
tainable effect of CBT, we only followed up the subjects
for 3 months after treatment. This follow-up time might
be too short to demonstrate the sustainability of CBT.
Further study to assess changing of depression for longer
period after treatment, such as 6 months and 12 months,
should be done. The result of longer period study might
be helpful to answer the question about prevention of
relapse of depression by using the CBT.
6. Acknowledgements
This study was supported by The 90th Anniversary of
Chulalongkorn University Fund (Ratchadapiseksomphot
Endowment Fund). The authors would like to thank all
the personnel at sexually transmitted diseases clinic and
immunology clinic, King Chulalongkorn Memorial Hos-
pital for their kind assistance.
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