Depression may be the most prevalent psychological challenge facing
HIV-infected individuals (Psychiatric News, January 3, 2003). And if
depression itself isn't enough of a burden for these individuals, it may also
contribute to hastening their death from AIDS, a new study suggests.
The study was headed by Judith Cook, Ph.D., a professor of psychiatry at
the University of Illinois at Chicago. Results were published in the July
American Journal of Public Health.
Several years ago, Jeannette Ickovics, Ph.D., of Yale University and
coworkers reported that HIV-positive women who had chronic depression were
twice as likely to die as were HIV-positive women with no chronic depression.
Cook and her coworkers thus decided to try to replicate the findings of this
study, but to go further—that is, to take not just demographic and
disease status into consideration, but also other possible confounding
Between 1994 and 2002, 1,716 HIV-positive women participated in the study
at six nationwide sites—Brooklyn, N.Y.; Bronx, N.Y.; Chicago; Los
Angeles; San Francisco; and Washington, D.C. Subjects were assessed at
six-month intervals regarding HIV status, antiretroviral therapy use, mental
health treatment, substance abuse, depression, and mortality.
Cook and her colleagues used the 20-item Center for Epidemiologic Studies
Depression Scale (CES-D) to assess subjects' depressive symptoms. The scale
has excellent reliability and validity and is commonly used to study HIV
populations. Its sensitivity for a DSM-III diagnosis of major
depression is impressive.
CES-D scores that indicated depression at 75 percent or more of the study
visits were classified as "chronic," 26 percent to 74 percent were
classified as "intermittent," and no more than 25 percent were
classified as "little or none."
About one-third of the subjects suffered from chronic depression, another
third from intermittent depression, and the final third from little or no
depression. A total of 147 (9 percent) subjects died from AIDS-related causes
during the eight-year study period.
Cook and her team then found that there was a link between chronic
depression in subjects and death from AIDS-related causes. Whereas only 6
percent of subjects who had little or no depression and only 7 percent of
subjects who had intermittent depression died from AIDS-related causes during
the study period, 13 percent of subjects with chronic depression did.
The researchers also looked to see whether they could find a similar link
when they controlled for HIV disease status (viral load and CD4 cell count),
antiretroviral therapy use, mental health treatment, substance abuse, and
demographic factors. They again found such a relationship, with subjects who
were chronically depressed significantly more likely to die during the study
than were subjects with intermittent or little or no depression.
Thus, it is crucial to treat HIV-positive women who are depressed, Cook and
her team concluded in their study report. In fact, they also discovered that
depressed subjects who received mental health treatment were significantly
less likely to die from AIDS-related causes than were depressed subjects who
got no such treatment.
"We had previously shown that depressive symptoms were negatively
related to initiating highly active antiretroviral therapy [HAART], so I
expected a relationship between depressive symptoms and poor disease
outcome," Cook told Psychiatric News. "What I didn't
necessarily expect was that depressive symptoms would influence mortality
independently of use of HAART and level of adherence to HAART. It was also
somewhat unexpected, but gratifying, to find an association between use of
mental health services and reduced mortality over and above all the other
factors that were controlled for in our analysis."
"This study underscores the importance of integrating mental health
treatment and research into mainstream HIV care," Francine Cournos,
M.D., a professor of clinical psychiatry at Columbia University and chair of
the APA Committee on AIDS, told Psychiatric News. "At a
minimum, treating depression among women with advanced HIV disease will
greatly improve the quality of their lives, and the possibility exists that it
will prolong their lives as well."
The study was funded by the National Institutes of Health.
An abstract of the report, "Depressive Symptoms and
AIDS-Related Mortality Among a Multisite Cohort of HIV-Positive Women,"
is posted online at<www.ajph.org/cgi/content/abstract/94/7/1133>.▪