Accuracy of available prevalence estimates is unclear because most studies of psychiatric disorders among people with HIV used convenience samples, often of the historic risk groups, had small sample sizes, or were confined to specific geographical areas. Population-based estimates of psychiatric disorders among HIVpositive people are scarce.
The landmark HIV Cost and Services Utilization Study (HCSUS) found that a large, nationally representative probability sample of adults receiving medical care for HIV in the United States in early 1996 (N = 2,864: 2,017 men, 847 women) reported major depression (36%), anxiety disorder (16%), and drug dependence (12%) (Bing et al., 2001; Galvan et al., 2002), as well as heavy drinking at a rate (8%) almost twice that found in the general population and high rates of drug use (50%). The HCSUS study remains the most comprehensive view we have of the prevalence of psychiatric disorders among people living with HIV/ AIDS, though the study was not designed as a diagnostic assessment of psychiatric disorders among people with HIV/AIDS and so rates of psychosis, bipolar disorder, alcohol abuse or dependence, and substance abuse, among others, were not obtained. Disorders of alcohol and other drug (AOD) abuse are differentiated from dependence in the Diagnostic and Statistical Manual of Mental Disorders (currently in version IV-R) in terms of intensity and duration of use, with dependence indicating a greater severity of addiction. The HCSUS study reported different use thresholds for alcohol than for other substances. Another important aspect of the HCSUS study is that people with HIV who are receiving medical care may be different from those not receiving medical care in terms of underlying co-morbidities and their impact on illness progression.
Hospital admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but a recent study of hospitalizations of 8376 patients in six U.S. HIV care sites showed that among patients hospitalized at least once, the third most common admission diagnosis after AIDS-defining illnesses (21%) and gastrointestinal disorders (9.5%) was a mental illness (9%) (Betz et al., 2005). This study also found that compared with Caucasians, African Americans had higher admission rates for mental illnesses but not for AIDS-defining illnesses. Overall, the majority of these patients were hospitalized for reasons other than AIDS-defining illnesses, and the relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV.
One probability sample study was conducted using South Carolina Hospital Discharge Data from all of the state's 68 hospitals: Among 378,710 adult cases of discharge from all hospitalizations and emergency room visits during 1995, 422 had a diagnosis of HIV/ AIDS and mental illness (using ICD 9 criteria), 1353 had a diagnosis of HIV/AIDS alone, and 67,092 had a diagnosis ofmental illness alone. People with a mental illness, regardless of race, gender, or age, were 1.44 times as likely to have HIV/AIDS than people without a mental illness (Stoskopf et al., 2001). In this study, two categories of mental illness—alcohol/drug abuse and depressive disorders—were found to have relative risks significantly associated with HIV infection.
The prevalence of current alcohol use disorders among people with HIV infection has been estimated to range from 3% to 12% (Brown et al., 1992; Rabkin, 1996; Dew et al., 1997; Rabkin et al., 1997; Ferrando et al., 1998). In the HCSUS study, participants were screened for heavy drinking in the previous 12 months, and 3% were found to meet criteria for this condition. In the general population, the prevalence of current alcohol use disorders was estimated to be 7% to 10% (Regier et al., 1993; Kessler et al., 1994).
The HCSUS study screened participants for drug dependence in the previous 12 months, and 2.6% were found to meet criteria for this disorder. Specific drugs for which dependence had developed were not reported. Earlier studies had provided estimates of 2% to 19% for current drug use disorders (Brown et al., 1992; Rabkin, 1996; Dew et al., 1997; Rabkin et al., 1997; Ferrando et al., 1998). The general population prevalence for drug use disorders was estimated to be about 3% (Regier et al., 1993; Kessler et al., 1994).
On the basis of these studies, it appears that the prevalence of current AOD use disorders was not different for people living with HIV compared with general-population estimates. However, lifetime prevalence for both alcohol and other drug use disorders does appear to be higher among people with HIV infection than in the general population. Across studies, the lifetime prevalence of alcohol use disorders for people with HIV was 26% to 60% (Rabkin, 1996; Dew et al., 1997; Ferrando et al., 1998) compared with a general population prevalence of 14% (Regier et al., 1990) to 24% (Kessler et al., 1994). Similarly, the lifetime prevalence of drug use disorders for people with HIV was 23% to 56% (Rabkin, 1996; Dew etal., 1997; Ferrando et al., 1998), whereas for the general population it was 6% (Regier et al., 1990) to 12% (Kessler et al., 1994).
Although mood disorders encompass the range of unipolar and bipolar conditions, mania secondary to HIV infection is rare, generally occurring in late stages of AIDS. By contrast, depression and anxiety disorders are seen throughout the course of HIV infection, and the conditions commonly coexist (McDaniel and Bla-lock, 2000). There is an increased likelihood of the emergence of symptoms during pivotal disease points (such as HIV antibody testing, declines in immune status, and occurrence of opportunistic infections).
Depression is the most common reason for psychiatric referral among people with HIV-infection (Strober et al., 1997). Overall, rates of depression among people with HIV infection are nearly 50% (Bing et al., 2001; Ickovics et al., 2001; Morrison et al., 2002). Among HIV-infected patients referred for psychiatric evaluation, rates of major depression range from 8% to 67% (Acuff et al., 1999), and up to 85% of HIVseropositive individuals report some depression symptoms (Stolar et al., 2005). In a meta-analysis of published studies, Ciesla and Roberts (2001) found that people with HIV were almost twice as likely as those who were seronegative to be diagnosed with major depression, and that depression was equally prevalent in people with both symptomatic and asymptomatic HIV.
Depression is frequently underdiagnosed and when recognized is often poorly treated, particularly in primary medical settings where HIV/AIDS patients receive care. Clinicians working with HIV/AIDS patients must consider underlying medical causes for depression (for example, medication side effects, brain infections, and endocrine disorders). Rates are generally lower among community-based HIV-positive samples and are highest among IDUs and women engaging in high-risk behaviors. Elevated rates of depression are also seen among patients with more advanced HIV disease, particularly those hospitalized for medical illness. Other risk factors for depression include prior history of depression, substance abuse, unemployment, lack of social support, use of avoidance coping strategies, HIV-related physical symptoms, and multiple losses (Goodkin et al., 1996).
Estimates of the prevalence of anxiety disorders in HIV/AIDS patients range from almost negligible to as high as 40% (Dew et al., 1997; Rabkin et al., 1997; Blalock et al., 2005). The rates vary for numerous reasons, including a host of psychosocial correlates and because anxiety frequently coexists with depression and substance use problems. Higher rates generally are seen as HIV illness progresses. Despite the wide range of prevalence estimates, a pattern emerged in the late 1990s: several studies showed a point prevalence of anxiety disorders in HIV-seropositive patients not significantly different from that of HIV-seronegative clinical comparison groups, even though lifetime rates are higher in the HIV clinical population than in the general population (Dew et al., 1997; Rabkin et al., 1997; Sewell, et al., 2000).
Harris et al., 1991; Prier et al., 1991; Boccellari et al., 1992), with more recent studies from Europe indicating a prevalence closer to 3% for new-onset psychosis (de Ronchi et al., 2000; Alciati et al., 2001). In one study, HIV/AIDS was the leading cause of death among young semirural New York patients experiencing their first hospitalization for a psychotic episode (Susser et al., 1997).
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