Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States.

BACKGROUND: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. SUBJECTS AND METHODS: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. RESULTS: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. CONCLUSIONS: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Use of mental health and substance abuse treatment services among adults with HIV in the United States.

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.

Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons.

OBJECTIVE: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS: Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Alcohol consumption and compliance among inner-city minority patients with type 2 diabetes mellitus.

OBJECTIVE: To examine the relation between alcohol consumption and self-reported compliance with prescribed therapies for type 2 diabetes mellitus among underserved minority patients. DESIGN: Cross-sectional sampling of consecutive patients with diabetes was performed following routine visits to their primary care physicians. Interviewers measured compliance using the Summary of Diabetes Self-Care Questionnaire and alcohol use using the timeline followback method and the Alcohol Use Disorders Identification Test. SETTING: Seven inner-city medical clinics that provide primary care services to low-income residents of South Central Los Angeles, Calif. PARTICIPANTS: A total of 392 ethnic minority patients (61% Hispanic, 29% African American) with type 2 diabetes mellitus. MAIN OUTCOME MEASURES: Self-report compliance with prescribed diet, exercise, home glucose monitoring, medications, and outpatient follow-up. RESULTS: Drinking any alcohol-containing beverage within 30 days was associated with poorer adherence to prescribed dietary recommendations for the consumption of fiber (t = 2.4; P<.05), fat (t = 4.2; P<.01), sweets (t = 2.7; P<.01), and energy (calories) (t = 2.0; P<.05). Drinkers were also less likely to exercise for at least 20 minutes per day (t = 2.2; P<.05), comply with oral medication regimens (t = 4.6; P<.01), or attend outpatient follow-up visits (r = -0.11; P<.05). Alcohol use did not significantly alter compliance with home glucose monitoring, insulin use, or hemoglobin A(1c) levels, although there was a trend toward higher hemoglobin A(1c) levels among drinkers (11.0 vs 10.4). Multivariate analysis of the data demonstrates that when demographic characteristics, health care utilization, and other diabetes-related variables are held constant, the relation between alcohol use and dietary compliance remained significant. CONCLUSION: Alcohol consumption may be associated with poorer compliance with recommendations for some self-care behaviors among inner-city minority patients with diabetes. Arch Fam Med. 2000;9:964-970

Health-related quality of life among people with HIV disease: results from the Multicenter AIDS Cohort Study.

To examine the effect of HIV status, symptomatology and CD4+ lymphocyte level on health-related quality of life, the Medical Outcomes Study Short-Form Health Survey (SF-36) was administered to 2,295 gay men enrolled in the Multicenter AIDS Cohort Study (MACS) in 1994. Distinct physical and mental health factors of the SF-36 were found. Seropositive asymptomatic individuals and seropositive individuals with CD4+ lymphocytes > or = 500/mm3 scored as well as seronegative participants on all of the mental health domain scales, but lower on the general health perceptions and physical health composite score. Seropositive individuals with at least one symptom or with CD4+ lymphocytes below 200/mm3 scored significantly lower on all of the SF-36 scales and summary scores than seronegative controls. The SF-36 was found to exhibit similar mental and physical health factors for an adult gay male population to that previously seen in general population samples and in patient groups with other diseases. In conclusion, HIV-positive men who are asymptomatic or have CD4+ lymphocytes above 500/mm3 have similar perceived mental health but worse perceived physical health than seronegative men. HIV-positive men who are symptomatic or have CD4+ lymphocytes below 200/mm3 have worse perceived mental and physical health than seronegative men.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Accessing HIV testing and care.

With the many recent improvements in the medical management of HIV, the benefits of early detection of the virus have increased. People found to be HIV-positive can be offered immediate referrals for medical care and a comprehensive continuum of services. However, it is estimated that, among the 650,000 to 900,000 seropositive persons in the United States, about one third are unaware of their serostatus. Many of those who are tested for HIV do not return for their results. Among those less likely to return for results are young people and black Americans. Many factors at the individual, system and societal levels negatively impact whether individuals at risk for HIV seek HIV testing in the first place, whether they return for their results, and whether they get appropriate care after they are found to be HIV-positive. Some solutions are offered to improve the identification of new HIV infections. These include social marketing campaigns to encourage individuals to be tested for HIV. Also, more use of the rapid HIV test, which will substantially increase the number of people obtaining their HIV results, is recommended. New computer technologies, such as telemedicine, also have the potential to improve linkages to care for newly diagnosed individuals. In addition, it is essential that HIV care continue to be readily available through the Ryan White Care Act.

Protease inhibitor use among a community sample of people with HIV disease.

OBJECTIVES: Protease inhibitors have become integral to HIV disease management. This paper examines sociodemographic factors affecting patient use and perceived knowledge of protease inhibitors, and the relationship between protease inhibitor use and perceived health. METHODS: 1034 people with HIV disease from a large AIDS services organization completed a mailed self-administered survey that assessed sociodemographics, protease inhibitor use and perceived knowledge, and perceived change in health status over the previous year. Multiple logistic regression was used to determine sociodemographic factors independently associated with protease inhibitor use and perceived knowledge, and perceived overall health status. RESULTS: Two thirds (66%) of correspondents included in the sample were currently taking protease inhibitors and 52% reported being very knowledgeable about these medications. Adjusting for sociodemographic factors, those who were currently not taking protease inhibitors were more likely to be African American, non-English speaking, earning <$9600 U.S. annually, or uninsured. Among protease inhibitor users, those who reported less knowledge about the drugs were more likely to be nonwhite, earning <$9600 U.S. annually, and not college educated. Protease inhibitor use was independently associated with perceived improved overall health and having been college educated. CONCLUSIONS: Further efforts should be directed toward increasing use and knowledge of protease inhibitors among disadvantaged populations.

Effect of race on insurance coverage and health service use for HIV-infected gay men.

OBJECTIVE: To determine whether race is associated with health insurance coverage and health service use among gay and bisexual men in the Baltimore center of the Multicenter AIDS Cohort Study. METHODS: Data from eight semiannual study visits between 1991 and 1996 were used. Descriptive, stratified, and logistic regression analyses were conducted to determine whether race is associated with insurance coverage, medical, or dental service use, after controlling for socioeconomic variables. RESULTS: No difference was found between blacks' and whites' likelihood of having health insurance, private insurance, using inpatient, emergency department services, or antiretroviral medications. Whites were more likely to use outpatient services, particularly if CD4 cell counts were high, and were more likely to use dental services, although blacks were more likely to have dental insurance. CONCLUSIONS: Further research must be conducted to examine cultural, social, and psychological factors that help explain why white gay men use more outpatient and dental services, when other service use is unrelated to race. Investigators should be precise when using race as a variable in health services and epidemiologic research, emphasizing when racial differences truly exist versus when the variable race is a surrogate for another factor.

Effects of depressed mood versus clinical depression on neuropsychological test performance among African American men impacted by HIV/AIDS.

The utility of self-report measures in identifying those at risk for depressive disorder and the adverse impact of depression versus depressed mood and HIV serostatus on neuropsychological (NP) test performance were examined in a large sample (N = 243) of gay and bisexual African American men. Results indicate high rates of depression relative to recent population estimates, regardless of methodology, but that the use of standard cut-scores for self-report inventories may significantly overestimate psychiatric morbidity. Limited independent effects of serostatus or depression on NP test performance were observed. More importantly, a complex set of adverse effects of depression and its interaction with serostatus which varied according to the methodology used to assess depression were observed. These findings are discussed in light of ongoing controversy regarding the relative influence of depression on neuropsychological functioning among people living with HIV/AIDS.

Functional status and well-being in patients with glaucoma as measured by the Medical Outcomes Study Short Form-36 questionnaire.

PURPOSE: This study aimed to determine whether patients with glaucoma have different functional status and well-being than patients without glaucoma. DESIGN: Prospective case-control study. PARTICIPANTS: The study population was recruited from 2 university-based glaucoma clinical practices and a university-based general ophthalmology clinic and consisted of 121 patients with open-angle glaucoma, 42 with diagnosis of glaucoma suspect, and 135 with no chronic ocular conditions except cataract. INTERVENTION: Administration of Medical Outcomes Study 36-item short-form survey (SF-36) was performed. Demographic information, medical history, and responses to the SF-36 questionnaire were elicited by an interviewer. Medical record review was performed to obtain clinical examination data and to substantiate the medical and demographic data obtained by the interviewer. MAIN OUTCOME MEASURES: The SF-36 scores by diagnostic group, demographic characteristics, and medical history were examined. Secondary outcome measures were SF-36 scores in patients with glaucoma by visual field impairment and glaucoma medication use. RESULTS: Patients with glaucoma consistently had lower scores, control subjects had higher scores, and glaucoma suspects had scores intermediate between the two groups. After adjusting for the possible influence of all the other covariate factors, glaucoma was found to be a strong predictor of lower SF-36 scores. CONCLUSION: Patients with glaucoma have lower scores, indicating less-functional status, than patients without glaucoma as tested by the SF-36 survey questionnaire.

The African-American Health Project (AAHP): study overview and select findings on high risk behaviors and psychiatric disorders in African American men.

The AAHP investigated the neurobehavioral and psychosocial sequelae of HIV-1 and substance use in urban African American men. A community resident sample of 502 African American men stratified by HIV-1 serostatus, drug use and sexual orientation were recruited. A comprehensive battery of measures of neurobehavioral and health status, lifestyle and psychosocial characteristics were administered to all participants, and a stratified sub-sample of 120 participants were tested using state of the art brain imaging techniques to investigate differences in the functional and neurophysiologic effects of HIV-1 and substance use. An overview of the methodology of the AAHP and results on high risk sexual and substance use behaviors, and psychiatric disorders are presented and discussed. The sample was primarily HIV-negative (63%), heterosexual (49% gay or bisexual) and a high percentage used substances during the past year (56% used drugs and 30% moderate/heavy drinkers). High-risk sexual practices were relatively prevalent, and a high percentage reported a history of STDs and other infections. Finally, 25% had a current psychiatric disorder, with gays/bisexuals and HIV-seropositives evidencing greater psychiatric vulnerability. More research is needed to further explore the apparent greater risk for psychiatric disorders among gay and bisexual men, and to determine whether being African American and lower social class exacerbate this risk.

Changes in depressive symptoms as AIDS develops. The Multicenter AIDS Cohort Study.

OBJECTIVE: The authors sought to determine whether rates of depressive symptoms change from early- to late-stage HIV-1 infection and to determine the predictors of depressive symptoms as AIDS develops. METHOD: The data for this study were from 911 HIV-seropositive men-community volunteers from four U.S. cities-who entered the 10-year Multicenter AIDS Cohort Study without a diagnosis of AIDS and subsequently developed AIDS. The subjects underwent semiannual follow-ups during the study period. The outcome measures-overall depressive symptoms, nonsomatic depressive symptoms, syndromal depression, and severe depression-were assessed over the 5 years before and the 2 years after AIDS diagnosis from responses on the Center for Epidemiologic Studies Depression Scale (CES-D Scale). RESULTS: Depressive symptoms were stable over time from month 60 to month 18 before AIDS developed. However, beginning 12-18 months before AIDS diagnosis, there was a significant rise in all measures of depression, which reached a plateau within 6 months before AIDS developed. At this plateau, there was a 45% increase in mean CES-D Scale scores above baseline. An elevated CES-D Scale score in the earlier stages of infection, a self-report of AIDS-related symptoms (such as rash and lymphadenopathy), concurrent unemployment, cigarette smoking, and limited social supports were consistent predictors of higher rates of depression as AIDS developed. CONCLUSIONS: There is a dramatic, sustained rise in depressive symptoms as AIDS develops, beginning as early as 18 months before clinical AIDS is diagnosed. Prior depression, HIV-disease-related factors, and psychological stressors contribute to this rise. This robust phenomenon invites further characterization.

Depressive symptoms over the course of HIV infection before AIDS.

The objective of this study was to describe the prevalence and course of depressive symptoms before AIDS in HIV-infected homosexual men. A descriptive and comparative analysis of data from HIV-infected and -uninfected homosexual men in the Multicenter AIDS Cohort Study was performed. The Center for Epidemiologic Studies Depression Scale (CES-D) was the primary measure of depressive symptoms. The prevalence of depressive symptoms and CES-D caseness estimates in the AIDS-free HIV-infected homosexual men were stable over time. Small differences between HIV seropositive and seronegative men were detected on the CES-D and on three of its subscales. These were mostly accounted for by less hope, and by more fearfulness, insomnia, and anorexia in the seropositive cohort. We concluded that there does not appear to be an overall increase in depressive symptoms in HIV-infected homosexual men from the time of infection until prior to AIDS. However, this group of men consistently report specific depressive symptoms more often. Implications of these findings for the clinical care of HIV-infected patients is discussed.

Changes in employment, insurance, and income in relation to HIV status and disease progression. The Multicenter AIDS Cohort Study.

While patterns of health care financing for HIV have received considerable attention in the literature, the financial impact of disease on individuals living with HIV infection has been underexplored, particularly in relation to disease progression. Therefore, we sought to document changes in employment, income, and insurance coverage over time among HIV-negative, HIV-positive, and AIDS-diagnosed gay and bisexual men participating in the Multicenter AIDS Cohort Study (MACS) and to document measures of financial hardship. Persons with AIDS (PWAs) were 2.7 times more likely to lose full-time employment over a 6-month period than seronegative persons (p < 0.05), and loss of employment was strongly associated (p < 0.001) with both loss of private health insurance and loss of income. Twenty-seven percent of PWAs reported having financial difficulty meeting their basic expenses, compared with 10% of seronegative (p < 0.001), and 15% of PWAs, compared with only 9% of seronegative persons, said that, for financial reasons, they had not sought medical care that they thought they needed (p = 0.028). When 27% of PWAs in a cohort such as this report financial difficulty meeting their basic expenses, it is clear that the response of our public health and social welfare systems has not been adequate. Given that the problems experienced by most persons infected by HIV are considerably more severe than those experienced by MACS participants, the imperative for action is even greater.

The World Health Organization's cross-cultural study on neuropsychiatric aspects of infection with the human immunodeficiency virus 1 (HIV-1). Preparation and pilot phase.

The WHO launched a multicentre study to explore the nature and prevalence of HIV-1-associated neurological, psychiatric, and neuropsychological abnormalities in persons living in different geographical and sociocultural contexts. The study is being conducted in Brazil, Germany, Kenya, Thailand, the United States of America, and Zaire. A comprehensive instrument for the collection of neuropsychiatric data (including a battery of neuropsychological tests suitable for cross-cultural use) has been developed, and the feasibility of the recruitment and assessment procedure designed for the main phase has now been demonstrated.

The many faces of AIDS: opportunities for intervention.

Social and cultural issues may have a profound impact on different populations' responses to the AIDS epidemic. To maximize their own effectiveness, clinicians need to be aware of special needs and concerns.