Chronic Depression Affects Mortality In HIV-Infected Women

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 factors.

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>.▪