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The Examination of Emotion Dysregulation as a Moderator of Depression and HIV-Relevant Outcome Relations Among an HIV+Sample a

a

ab

Charles P. Brandt , Jafar Bakhshaie , Michael J. Zvolensky , c

Kristin W. Grover & Adam Gonzalez

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Department of Psychology, University of Houston, 126 Heyne Building, Houston, TX 77204, USA b

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Department of Behavioral Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA c

Department of Psychology, University of Vermont, 2 Colchester Ave, Burlington, VT 05405, USA d

Department of Psychiatry and Behavioral Science, Stony Brook University, 101 Nicolls Rd, Stony Brook, NY 11794, USA Published online: 22 Sep 2014.

To cite this article: Charles P. Brandt, Jafar Bakhshaie, Michael J. Zvolensky, Kristin W. Grover & Adam Gonzalez (2015) The Examination of Emotion Dysregulation as a Moderator of Depression and HIV-Relevant Outcome Relations Among an HIV+Sample, Cognitive Behaviour Therapy, 44:1, 9-20, DOI: 10.1080/16506073.2014.950323 To link to this article: http://dx.doi.org/10.1080/16506073.2014.950323

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Cognitive Behaviour Therapy, 2015 Vol. 44, No. 1, 9–20, http://dx.doi.org/10.1080/16506073.2014.950323

The Examination of Emotion Dysregulation as a Moderator of Depression and HIV-Relevant Outcome Relations Among an HIV 1 Sample Charles P. Brandt1, Jafar Bakhshaie1, Michael J. Zvolensky1,2, Kristin W. Grover3 and Adam Gonzalez4

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1

Department of Psychology, University of Houston, 126 Heyne Building, Houston, TX 77204, USA; 2Department of Behavioral Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Department of Psychology, University of Vermont, 2 Colchester Ave, Burlington, VT 05405, USA; 4Department of Psychiatry and Behavioral Science, Stony Brook University, 101 Nicolls Rd, Stony Brook, NY 11794, USA Abstract. The present study examined whether emotion dysregulation moderated the relations between depressive symptoms and HIV symptoms, HIV medication adherence due to medication side effects, avoidant coping, and distress tolerance among people living with HIV/AIDS (PLHA). Participants included 115 PLHA (16.8% female; Mage ¼ 49.70, SD ¼ 8.57). Results indicated that there was a significant interaction between depressive symptoms and emotion dysregulation in relation to HIV symptoms, HIV medication adherence due to medication side effects, avoidant coping, and distress tolerance. The form of the interaction indicated that PLHA experiencing higher depressive symptoms and higher levels of emotion dysregulation reported the highest levels of HIV symptoms and lowest levels of distress tolerance. Additionally, results indicated that at lower levels of depressive symptoms, very high levels of emotion dysregulation predicted higher rates of medication nonadherence, whereas at higher levels of depressive symptoms, very high levels of emotion dysregulation predicted the lowest rates of medication nonadherence. Moreover, those experiencing lower levels of depressive symptoms and higher levels of emotion dysregulation reported the greatest rates of avoidant coping. In total, the present results suggest a complex interplay between emotion dysregulation and depressive symptoms with regard to HIV symptoms, medication nonadherence, and self-regulatory processes (e.g., avoidant coping, distress tolerance) among PLHA. Key words: HIV/AIDS; emotion dysregulation; depression; medication adherence; avoidance. Received 25 March 2014; Accepted 28 July 2014 Correspondence address: Charles P. Brandt, Department of Psychology, University of Houston, 126 Heyne Building, Houston, TX 77204, USA. Email: [email protected]

There is consistent empirical evidence that people living with HIV/AIDS (PLHA) often report symptoms of negative affect and subsequent clinical impairment related to such symptoms (Leserman, 2003). These negative affect symptoms can be elicited by numerous factors, including HIV infection (Tsao, Dobalian, Moreau, & Dobalian, 2004), social stress (e.g., stigma; Berger, Ferrans, & Lashley, 2001), chronic life stress (O’Leary, 1990), pre-existing psychological vulnerabilities (e.g., personality characteristics; Gonzalez, Zvolensky, Parent, Grover, & Hickey, 2012), or some combination of these, and q 2014 Swedish Association for Behaviour Therapy

possibly other factors. Of the negative affect states, depressive symptoms and related clinical disorders have been among the most common for PLHA (Bing et al., 2001; Cruess & Evans, 2003; Maj et al., 1994). For example, PLHA are approximately two times more likely to have a history of major depressive disorder than individuals without HIV/AIDS (Ciesla & Roberts, 2001). Depressive symptoms among PLHA are associated with a variety of negative health outcomes. For example, depressive symptoms are related to poor antiretroviral (ART) medication adherence (Arnsten et al., 2002;

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Gordillo, del Amo, Soriano, & GonzalezLahoz, 1999; Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Singh et al., 1996; Wendorf & Mosack, 2013). The effects of depression on ART adherence are evident across the PLHA population, including different ethnic groups (Kumar & Encinosa, 2010; Malow et al., 2013). Additionally, depressive symptom effects are apparent in a variety of contexts, including those varying in levels of financial resources as well as social support (Gonzalez et al., 2004). Depressive symptoms also are related to an increased likelihood of high-risk HIV-relevant behaviors (e.g., unsafe sex, needle-sharing; Amirkhanian, Kelly, & McAuliffe, 2003; Kelly et al., 1993), as well as poorer perceived and objective health indices (Sikkema et al., 2011), lower quality of life (Sherbourne et al., 2000), and greater rates of AIDS mortality (Ickovics et al., 2001). Furthermore, depressive symptoms have been found to be associated with maladaptive coping among PLHA (Gonzalez, Solomon, Zvolensky, & Miller, 2009; Simoni & Ng, 2000). Despite the established negative impact of depressive symptoms on numerous aspects of health and well-being among PLHA, little attention has been directed at moderators of these associations. Identification of a moderator is often clinically-relevant in that it helps explicate the subgroups of PLHA most or least “at risk” for specific negative outcomes (Holmbeck, 2002). Emotion dysregulation is one promising integrative, emotion-based construct for bridging the gaps in our knowledge about the relation between depressive symptoms and HIV-relevant outcomes. Emotion dysregulation reflects difficulties in the self-regulation of affective states and difficulties in self-control over affect-driven behaviors (Mennin, Heimberg, Turk, & Fresco, 2005). To the extent that the impact of depressive symptoms is based on the regulation of such emotional states (Gross, 1998), understanding the role of emotion dysregulation in the depressive symptoms – HIV relation may provide clinically useful information. Among the general population, emotion dysregulation (higher-order factor), as measured by the Difficulties in Emotion Regulation Scale (DERS), is related to increased levels of negative affect (Gratz & Roemer, 2004; Kashdan, Zvolensky, & McLeish, 2008; Vujanovic, Zvolensky, & Bernstein,

COGNITIVE BEHAVIOUR THERAPY

2008), avoidance-oriented coping in response to life stress (Bonn-Miller, Vujanovic, & Zvolensky, 2008), and lower self-efficacy for risky sexual behavior (Rellini, Zvolensky, & Rosenfield, 2012). Only a few studies have examined the significance of emotion dysregulation among PLHA. For example, in one study, emotion dysregulation was significantly positively related to anxiety and depressive symptoms, pain-related anxiety, and HIV-related symptom distress after accounting for HIV-specific variables (e.g., CD4 T-cell count; Brandt, Gonzalez, Grover, & Zvolensky, 2013). Additionally, in a separate investigation, emotion dysregulation mediated the relation between distress tolerance and anxiety and depressive symptoms among those with PLHA (Brandt, Zvolensky, & Bonn-Miller, 2013). This work suggests emotion dysregulation is related to depression as well as a variety of HIV-relevant negative factors. Yet, it remains unclear whether this construct may moderate the relation between depressive symptoms and HIV symptoms, medication nonadherence, and self-regulatory processes (e.g., avoidant coping, distress tolerance). This information could provide a novel treatment strategy for PLHA suffering from depressive symptoms, as emotional regulation is a malleable trait (Mennin et al., 2005). For example, the extent to which an HIV positive individual can regulate their emotional experience may minimize the negative effects of depressive symptoms and vice versa. An increased regulatory capacity may have an influence on HIV specific (e.g., medication adherence) and non-HIV specific (e.g., coping strategies) behaviors. The current study sought to empirically examine whether emotion dysregulation moderated the relation between depressive symptoms and HIV symptoms, HIV medication nonadherence due to medication side effects, avoidant coping, and distress tolerance among PLHA. These criterion variables were chosen as variables that have been shown to be related to depressive symptoms and affect physical as well as mental health. Because it was expected that depressive symptoms and emotion dysregulation would interact to differentially relate all criterion variables, a moderation analysis was used. This perspective was driven by the conceptual model that if an individual possesses or learns greater emotion regulation

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capacity, depressive symptoms may have less of a negative impact on an array of clinically significant HIV processes; in contrast, a more limited capacity for emotion regulation may contribute to a more negative impact on these same processes. Overall, it was expected that all significant associations would be evident above and beyond the variance accounted for by CD4 T-cell count, sex, race, and data collection location site. Specifically, CD4 Tcell count was chosen to control for disease stage, whereas race and sex were included to adjust for common factors that co-vary with depression among this population (Brandt, Gonzalez, et al., 2013; Tsao et al., 2004).

Methods Participants Participants included 115 adults living with HIV/AIDS recruited from AIDS service organizations (ASOs) in Vermont and New Hampshire (VT/NH), as well as New York City (NYC) as part of a larger study. Participants were eligible to participate if they were at least 18 years old, had a selfreported diagnosis of HIV/AIDS, and had the ability to give informed, written consent, assessed by their ability to read the consent form and explain the study purpose. The majority of participants (85.2%) were male and the mean age was 49.70 (SD ¼ 8.57). In terms of race, 39.1% of the sample identified as White/Caucasian, 33.1% identified as Black, 22.6% identified as Hispanic, and 5.2% identified as “mixed/other” (e.g., Native American, French). Although 74.2% reported obtaining at least a high school degree, 79.5% of participants reported current unemployment, and 57.4% reported earning less than $10,000 annually. On average, participants reported an average CD4 T-cell count of 476 (SD ¼ 296.4; range ¼ 0 –1340) and 57.4% reported a diagnosis of AIDS.

Procedure Interested persons who self-reported a diagnosis of HIV or AIDS contacted the research clinic in VT or the ASO in NYC and were scheduled for an in-person appointment. To reduce error in reporting, participants were told that they would be asked to report their most recent CD4 T-cell count and viral load during the appointment. Eligible persons

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came into the research clinic or their ASO and were informed about the study. After consenting to participate participants selfreported demographic (e.g., age, location) and medical information (e.g., HIV/AIDS status) and completed a battery of self-report measures (randomly ordered to prevent a response set bias). Participants were compensated $25 for completing all questionnaires. This study was approved by the institutional review board of The University of Vermont.

Measures Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007). The IDAS is a 64-item self-report measure indexing symptoms of anxiety and depression. For the current study, the “general depression” subscale (20 questions; e.g., “I felt depressed”) was used to index depressive symptoms. Items are rated by participants on a 5-point Likerttype scale (from 1 ¼ not at all to 5 ¼ extremely). The IDAS-general depression showed good internal consistency in the current sample (Cronbach a for General Depression ¼ .91). Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). The DERS was used to assess emotional dysregulation in the current sample. This scale consists of 36 items (e.g., “I am clear about my feelings”), rated on a 5-point Likert-type scale (1 ¼ almost never, 5 ¼ almost always). The combined score of these items comprises a global index of emotion dysregulation (Gratz & Roemer, 2004). As in past work (Brandt, Gonzalez, et al., 2013), the DERS total score was employed as a global index of the inability to effectively modulate emotional states. The DERS-total score demonstrated good internal consistency in the current sample (Cronbach a ¼ .94). AIDS Clinical Trials Group Symptoms Distress Module (ACTG-SDM; Justice et al., 2001). The ACTG-SDM was employed to measure distress related to HIV symptoms. Participants rate, on a 5-point Likert-type scale (0 ¼ I do not have this symptom to 4 ¼ It bothers me a lot), the extent to which they experience each of 20 symptoms commonly associated with HIV as distressing (e.g., muscle aches, nauseas, headaches). This scale has demonstrated good construct validity with relations to physical and mental health-related quality of life independent of disease state (as

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measured by CD4 T-cell count and viral load; Justice et al., 2001) and associations with lesser ability to tolerate distress (O’Cleirigh, Ironson, & Smits, 2007) and greater perceived stigma (Vanable, Carey, Blair, & Littlewood, 2006). The ACTG-SDM evidenced good internal consistency in the current sample (Chronback a ¼ .94). Side Effects Coping Scale (SECope; Johnson & Neilands, 2007). The SECope is a 20item self-report scale measuring ways in which individuals cope with HIV infection. The SECope indexes five methods of coping: Positive emotion focused coping, social support seeking, Nonadherence to HIV medication, taking medication for side-effects of HIV medication, and information seeking. For the current study, “nonadherence” was used to index participants who stopped taking HIV medication as a coping behavior (e.g., “Reduce the dose of the medication that is causing the side effect”). The SECope nonadherence score demonstrated good internal consistency, as in past work (Overall Cronbach a ¼ .92; Cronbach a for nonadherence subscale ¼ .80; Johnson & Neilands, 2007). Brief COPE (BCOPE; Carver, 1997). The BCOPE is a 28-item measure on which respondents indicate, on a 4-point Likerttype scale (1 ¼ I usually don’t do this at all to 4 ¼ I usually do this a lot), how they cope with stressful situations. The BCOPE indexes 14 different types of coping strategies (e.g., humor, denial). For the current paper, four of the 14 Brief COPE scales were used to index avoidant coping. The scales were as follows: (1) behavioral disengagement (e.g., “I’ve been giving up trying to deal with it”), (2) substance use (e.g., “I’ve been using alcohol or drugs to make myself feel better”), (3) denial (e.g., “I’ve been saying to myself, ‘this isn’t real’”), and (4) self-distraction (e.g., “I’ve been turning to work or other activities to take my mind off things”). These four scales have been used as a composite index of avoidant coping in HIVspecific as well as non-HIV specific work (e.g., Brandt, Zvolensky, Vujanovic, et al., in press; Fontaine, Manstead, & Wagner, 1993; Phelps & Jarvis, 1994; Sica, Novara, Dorz, & Sanavio, 1997; Vosvick et al., 2003). Cronbach’s a coefficient for avoidant coping was .75 in the present sample. Distress Tolerance Scale (DTS; Simons & Gaher, 2005). The DTS is a 15-item self-report

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scale on which respondents indicate, on a 5point Likert-type scale (1 ¼ strongly agree to 5 ¼ strongly disagree), the extent to which they perceive they can tolerate distressing emotional states (e.g., “Feeling distressed or upset is unbearable to me”; Simons & Gaher, 2005). The DTS-total score indexes a global tolerance of distress and evidenced good internal consistency in the present sample (Chronback a ¼ .89).

Data analytic strategy First, a series of zero-order correlations were conducted to examine associations between study variables. Second, to test the moderating role of emotion dysregulation in the relation between depressive symptoms and the criterion variables, the Modprobe SPSS macro/ syntax (Hayes & Matthes, 2009) was employed. In all models, the predictor and proposed moderator variables were mean centered. Criterion variables introduced into all models included: data collection location (VT/NH vs. NYC), sex, race, and CD4 T-cell count. The form of the statistically significant interactions was subsequently examined using simple slopes analyses provided by the Modprobe SPSS macro. Finally, the JohnsonNeyman technique (Aiken & West, 1991; Hayes & Matthes, 2009) was used to identify regions of significance among the moderator variable (emotional dysregulation) where the effect of the focal predictor (depressive symptoms) on the criterion variables is statistically significant. This approach helps to determine at which levels of emotional dysregulation there is a positive, negative, or no relationship between depression and criterion variables.

Results See Table 1 for a summary of zero-order correlations and descriptive data. Depressive symptoms evidenced a significant positive relation with HIV symptoms and BCOPEavoidance, and a significant negative relation with distress tolerance. Emotion dysregulation evidenced a significant positive relation with HIV symptoms and BCOPE-avoidance, as well as a significant negative relation to distress tolerance. See Table 2 for a summary of hierarchical multiple regression models. In terms of HIV

2

3

b

a

*p , .05, **p , .001. Location coded as 0 ¼ VT/NH, 1-NYC Sex coded as 0 ¼ male, 1 ¼ female c Side Effects Coping Scale d Brief COPE e Distress Tolerance Scale f AIDS Clinical Trials Group Symptoms Distress Module g Difficulties in Emotion Regulation Scale h Inventory of Depression and Anxiety Symptoms.

a

4

5

6

7

8

9

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– 2.11 .51** 2.05 .05 .39** .195* .05 .22* .01 1. Location 2. Sexb – 2.14 .26** .14 2 .07 2 .022 .14 .13 .30** 3. Race – .10 .06 .22* .260** .06 .27** .14 4. CD4 T-cell count – 2 .11 2 .15 2 .15 2.11 2 .04 2 .04 5. HIV symptom countc – .25** .27** 2.28** .42** .43** 6. SECope-nonadherenced – 2 .29** .25** .16 .09 7. BCOPE- avoidancee – 2.38** .39** .30** 8. DTS-totalf – 2 .60** 2 .50** 9. DERS- totalg – .67** 10. IDAS-general depressionh –

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Table 1. Descriptive data and zero-order relations among study variables

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63% 14.8% 39.1% 476 13.04 3.77 18.13 42.01 91.89 47.58

(NYC) (female) (White) (296.4) (6.24) (3.89) (4.59) (11.80) (24.88) (14.28)

– – – 0 – 1340 0 – 20 0 – 16 8 – 32 14 – 70 39 – 150 21 – 83

Mean (SD) or % Observed range

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Brandt, Bakhshaie, Zvolensky, Grover and Gonzalez

Table 2. Moderation Analyses Predictor

DR 2 ( p)

Model F (df)

.05 (ns)

1.49 (4, 110)

p

Standardized b

ns ,.05 ns ns

.01 .20 .10 2 .17

,.05 ,.10

.27 .23 2 .004

, 0.01 ns ns ns

.36 .02 .05 2 .14

ns ns

.03 .07 2 .002

ns ns ,.05 ¼ .05

.07 .07 .26 2 .19

,.05 ns

.26 .10 2 .006

ns ns ns ns

2 .04 2 .09 2 .08 .02

, .001 ,.10

2 .51 2 .19 .005

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a

HIV symptom count Step 1 Locationb Sexc Race CD4 cell count Step 2 DERSd Depressione Step 3. Interaction Final R 2 SECope_Nonadherencef Step 1 Locationb Sexc Race CD4 cell count Step 2 DERSd Depressione Step 3. Interaction Final R 2 BCOPE_Avoidanceg Step 1 Locationb Sexc Race CD4 cell count Step 2 DERSd Depressione Step 3. Interaction Final R 2 DTSh Step 1 Locationb Sexc Race CD4 cell count Step 2 DERSd Depressione Step 3. Interaction Final R 2 a

.18 (,.001)

12.27 (2, 108)

.04 (, .05) .27

6.43 (7, 107)

0.17 (,0.001)

5.80 (4, 110)

0.01 (ns)

0.39 (2, 108)

.05 (, .05) 0.23

6.75 (7, 107)

.10 (, .05)

3.20 (4, 110)

.10 (, .01)

6.80 (2, 108)

.08 (,.001) 0.29

12.30 (7, 107)

.02 (ns)

0.42 (4, 110)

.38 (,.001)

33.36 (2, 108)

.02 (, .05) .41

4.27 (7, 107)

AIDS Clinical Trials Group Symptoms Distress Module Recruitment site coded as 0 ¼ VT/NH, 1-NYC Sex coded as 0 ¼ male, 1 ¼ female d Difficulties in Emotion Regulation Scale e Inventory of Depression and Anxiety Symptoms f Side Effects Coping Scale g SECope h Distress Tolerance Scale b c

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Figure 1. Effects of depression and emotion dysregulation on HIV symptom count.

symptoms, covariates entered as a block at the first step did not account for a significant portion of variance. However, at the univariate level, sex was a significant predictor. At Step 2, depressive symptoms was a trendsignificant predictor ( p ¼ .07) and emotion dysregulation was a significant predictor of HIV symptoms. At Step 3, there was a significant interactive effect between depressive symptoms and emotion dysregulation with a small effect size (R 2 ¼ .04, p , .01). The effect size of the overall model was moderate (R 2 ¼ .27, p , .001). As seen in Figure 1, simple slope analyses revealed that at low levels of emotion dysregulation, depression was positively associated with HIV symptom count. However, at high levels of emotion dysregulation, depression did not significantly affect HIV symptom count. In terms of HIV medication nonadherence due to medication side effects, covariates entered as a block at the first step accounted for a significant amount of variance in SECope-nonadherence score with recruitment site being the only significant individual predictor. At Step 2, neither depressive symptoms nor emotion dysregulation were related to nonadherence. There was a significant interactive effect between depressive symptoms and emotion dysregulation with a small effect size (R 2 ¼ .04, p , .01). The effect size of the overall model was moderate (R 2 ¼ .23, p , .001). As seen in Figure 2, simple slope analyses revealed that at low levels of emotion dysregulation, depression was positively associated with medication nonadherence. However, depression was inversely associated with medication nonadherence at high levels of emotion dysregulation.

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Figure 2. Effects of depression and emotion dysregulation on nonadherence due to medication side effects.

In terms of avoidant coping, covariates entered as a block at the first step accounted for a significant amount of variance in BECOPE avoidance with race being the only significant individual predictor. At Step 2, only emotion dysregulation was significantly associated with BCOPE avoidance. At Step 3, there was a significant interactive effect between depressive symptoms and emotion dysregulation with a small effect size (R 2 ¼ .08, p , .001). The effect size of the overall model was moderate (R 2 ¼ .29, p , .001). As seen in Figure 3, simple slope analyses revealed that at high levels of emotion dysregulation, depression was negatively associated with avoidant coping. However, at low levels of emotion dysregulation, depression was positively associated with avoidant coping. In terms of distress tolerance, covariates entered as a block at the first step did not

Figure 3. Effects of depression and emotion dysregulation on avoidant coping.

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significantly predict distress tolerance. Additionally, none of the covariates individually predicted distress tolerance. At Step 2, only emotion dysregulation was significantly associated with distress tolerance. At Step 3, there was a significant interactive effect between depressive symptoms and emotion dysregulation with a small effect size (R 2 ¼ .02, p , .05). The effect size of the overall model was moderate (R 2 ¼ .42, p , .001). As seen in Figure 4, simple slope analyses revealed that at high levels of emotion dysregulation, depression did not affect distress tolerance. However, at low levels of emotion dysregulation, depression was negatively associated with distress tolerance. As an additional analysis, the Johnson – Neyman technique was employed using Modprobe macro in order to test the specific “regions of significance” for each significant interactive effect, specifically indicating effects of depression on the criterion variables at very high or very low levels of emotional dysregulation (Aiken & West, 1991; Hayes & Matthes, 2009). These analyses indicated that depression was significantly positively related to HIV symptoms (b ¼ .10 – .31, p , .05 for DERS-total scores lower than 96), HIV medication nonadherence due to medication side effects (b ¼ .08 – .15, p , .05 for DERStotal scores lower than 67), avoidant coping (b ¼ .08 – .24, p , .05 for DERS-total scores lower than 84), and significantly negatively related to distress tolerance (b ¼ 2 .17 to 2 .45, p , .05 for DERS-total scores lower than 94) at low levels of emotional dysregulation. At levels of emotion dysregulation higher

Figure 4. Effects of depression and emotion dysregulation on distress tolerance.

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than the aforementioned cut off scores, the conditional effects of depression on HIV symptoms and distress tolerance were nonsignificant. For HIV medication nonadherence and avoidant coping, however, at very high levels of emotion dysregulation, there was a point of transition between the statistically nonsignificant to a significant negative linear relation between depressive symptoms and these criterion variables (b ¼ 2 .09 to 2 .11, p , .05 for DERS total scores higher than 147; and b ¼ 2 .11 to 2 .16, p , .05 for DERS total scores higher than 136; See Figures 1 and 2).

Discussion The results indicated that there was a consistent significant interaction between emotion dysregulation and depressive symptoms in terms of the HIV symptoms, HIV medication nonadherence due to medication side effects, avoidant coping, and distress tolerance among PLHA. These significant interactions were small in effect size, yet statistically significant and evident above and beyond the variance accounted for by the main effects of depressive symptoms and emotion dysregulation as well as a variety of relevant “third variables” (covariates). Also, partially in line with hypotheses, individuals with the highest emotion regulation capacity and lowest depressive symptoms reported the lowest HIV symptom count, medication nonadherence, avoidant coping, and highest distress tolerance. However, contrary to hypotheses, depression had a stronger adverse effect on all criterion variables among individuals evidencing greater emotion regulation capacity. The observed, complex interactive findings have at least three possible implications for theory and practice. First, the current results indicate that individuals with higher levels of depressive symptoms and higher levels of emotion dysregulation may be more sensitive to physical symptoms associated with HIV and perceive themselves as less able to tolerate distress than their counterparts reporting lower levels of depressive symptoms, emotion dysregulation, or both of these variables. This finding is in line with current models indicating that depressive symptoms among PLHA negatively affect the perception of

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physical symptoms associated with HIV (e.g., Sikkema et al., 2011) and expands upon this work to indicate a unique moderation effect of emotion dysregulation on this relation. Second, the form of the interaction for depressive symptoms and emotion dysregulation unexpectedly indicated that among those with very high emotion dysregulation, depression decreased rates of missed HIV medication, while among those with low levels of emotion dysregulation, greater depression predicted greater rates of nonadherence. This finding may suggest that depressive symptoms serve as a possible protective factor in the relation between emotion dysregulation and medication nonadherence. This finding is in line with current depression models indicating that depressive symptoms may sometimes increase problem-solving based rumination (Cline-Brown & Watson, 2005); indeed, there are established relations between depression, coping behavior, and medication adherence among PLHA (Wendorf & Mosack, 2013). Finally, the results indicated that among those with very high emotion dysregulation, depressive symptoms is negatively related to avoidant coping strategies, whereas among those with low emotion dysregulation, depressive symptoms is associated with greater rates of avoidant coping. This pattern, similar to the effects of depressive symptoms and emotion dysregulation on medication adherence, suggests that depressive symptoms may possibly play a protective role in the relation between emotion dysregulation and coping behavior among PLHA (Wendorf & Mosack, 2013). Although not the primary aim of this investigation, it is notable that depressive symptoms and emotion dysregulation were distinct—though related—factors, sharing 45% of variance with one another. Thus, these two constructs, assessed by the IDAS and DERS, are theoretically and empirically distinguishable among PLHA. Indeed, the relations of these two factors on HIV symptoms, HIV medication nonadherence due to medication side effects, avoidant coping, and distress tolerance were comparable (see Table 1), suggesting that both constructs may each be important factors to consider among PLHA. There are limitations of the present study and future directions that warrant comment.

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First, although the sample was highly diverse in terms of race, it was limited to an older adult, primarily male group of individuals living with HIV/AIDS. Although men comprise a large percentage of this population (Center for Disease Control, 2012), future studies would benefit from examining more heterogeneous samples of PLHA. Second, the cross-sectional design of the present study does not allow for causal inferences. Therefore, future work should aim to test these relations prospectively to explicate their directional effects. Third, the BCOPE used in the current study to index avoidant coping indexed what participants usually do in stressful situations, and is not necessarily specific to only HIV-related stressors. Future work could further tailor this approach to HIV-specific coping behavior. Fourth, the current study did not take into account some HIV-specific variables such as social stress or HIV-relevant stigma. Future work may benefit by exploring the interplay between depressive symptoms and emotion dysregulation and such social factors. Finally, the present investigation was based on community-recruited PLHA. It is important for future work to extend these findings with clinical populations of PLHA experiencing and seeking treatment for depression. Overall, the results of the current study highlight the importance of emotion dysregulation in terms of better understanding the link between depressive symptoms and HIV symptoms, HIV medication nonadherence due to medication side effects, avoidant coping, and distress tolerance among PLHA. Though the interactive effect sizes were small, ranging from .02 to .08, these findings may serve to conceptually inform the development of tailored intervention strategies for PLHA who are experiencing depressive symptoms and related HIV-management issues. Specifically, the present findings suggest that it may be necessary to assess and clinically address emotion dysregulation in the context of depressive symptoms and HIV specific (e.g., medication adherence) and non-HIV specific (e.g., coping strategies) behaviors among PLHA to enhance mental health functioning.

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Disclosure statement The authors declare that no conflict of interest exists.

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The examination of emotion dysregulation as a moderator of depression and HIV-relevant outcome relations among an HIV+sample.

The present study examined whether emotion dysregulation moderated the relations between depressive symptoms and HIV symptoms, HIV medication adherenc...
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