Prevalence and Persistence of Psychiatric and Substance Abuse Disorders Among
Mothers Living with HIV
Kathleen Malee, Claude Mellins, Yanling Huo, Katherine Tassiopoulos,
Renee Smith, Susannah Allison, Suad Kapetanovic, Deborah Kacanek,
Patricia Sirois, Paige Williams, Mitzie Grant, Daniel Marullo, Angela Aidala
for the Pediatric HIV/AIDS Cohort Study
January 14, 2013 International Workshop on HIV and Women
Toronto, Canada
Background
Women living with HIV are at high risk for Psychiatric Disorders
(PD) and Substance Abuse Disorders (SAD):
Biological mechanisms:
chronic illness
potential for chronically activated inflammatory pathways
increased risk for depression
Genetics
Environmental factors, including trauma
Psychosocial challenges
poverty, stress, limited resources
Background
Early studies:
High lifetime prevalence of Psychiatric and/or Substance
Abuse Disorders
often under-recognized and undertreated
31% prevalence of depression during pregnancy
associated with substance abuse in pregnancy, past history
of psychiatric disorder
Few studies investigated prevalence and persistence of disorders
among mothers living with HIV in the era of HAART
Risks Associated with Psychiatric and Substance Abuse Disorders in
Mothers Living with HIV Mothers:
Inconsistent ART utilization/poor adherence
HIV disease progression
especially once the intense prenatal experience ends
Children:
Delayed cognitive and/or language development
Impaired parent-child relationships, maltreatment
Disruptive behavioral disorders
Poor school and social adaptation
Depression and anxiety disorders
Study Objectives To examine the prevalence and types of Psychiatric and
Substance Abuse Disorders among mothers living with HIV
infection.
To estimate, in a subset of mothers with HIV who had at least two
mental health evaluations, the proportion with: a) remitting, b) new,
and c) persisting disorders.
To identify key biomedical and psychosocial factors significantly
associated with: a) prevalent and b) persistent Psychiatric and
Substance Abuse Disorders.
Study Population Prospective cohort study: Surveillance Monitoring of ART Toxicities
(SMARTT)
22 sites in the United States, including Puerto Rico
1223 biological mothers of HIV-exposed but uninfected children
evaluated for prevalent disorders:
689 completed initial and follow-up evaluations 1-3 years
later and were evaluated for persistence of Psychiatric
and/or Substance Abuse Disorders
128 mothers without HIV, enrolled at 9 of the 22 SMARTT sites,
were included as a comparison group for prevalent disorders
Client Diagnostic Questionnaire-CDQ Aidala et al., 2004
Psychiatric screening tool based on the PRIME-MD, developed to assess most common disorders in adults affected by HIV (Spitzer, Kroenke,Williams, 1999).
Psychiatric Disorders Major Depressive Disorder Other Depressive Disorder Panic Disorder Generalized Anxiety Disorder Post-traumatic Stress Disorder Psychosis
Substance Abuse Disorders Alcohol Abuse Disorder Substance Abuse Disorder
Background Characteristics HIV+ (N=1223) HIV- (N= 128) P-value*
Race: Black 751 (67%) 85 (69%) 0.69
Ethnicity: Latina 429 (35%) 33 (26%) 0.04
Age ≥ 35 years 407 (33%) 25 (20%) 0.001
Education ≥ high school 803 (66%) 104 (81%) <0.001
Employed 458 (38%) 71 (55%) <0.001
Functional Limitations
0
1-2
≥3
790 (65%)
311 (26%)
108 ( 9%)
105 (82%)
16 (13%)
7 (5%)
<0.001
Mental health treatment 136 (11%) 9 (7%) 0.18
* Fisher’s Exact Test
Background Characteristics HIV+ HIV- P-value*
Alcohol use during pregnancy 121 (10%) 8 (6%) 0.21
Illicit substance use during
pregnancy 115 (10%) 4 (3%) 0.01
Health problems
0
1
2
≥3
0 (0%)
720 (60%)
289 (24%)
200 (17%)
88 (69%)
21 (16%)
12 (9%)
7 (5%)
<0.001
WASI Full Scale IQ: Mean (s.d.) 86.7 (13.4) 91.3 (13.7) <0.001
* T-Test with Equal Variance for Full Scale IQ; Fisher’s Exact Test for others.
Prevalence of Psychiatric and Substance Abuse Disorders by HIV Status
0%
5%
10%
15%
20%
25%
30%
35%
40%
Any PD/SAD Any PD Any SAD
HIV+
HIV-
Prevalence of Specific Disorders
HIV+
N = 1223
HIV-
N = 128 P-value *
Any Anxiety Disorder 141 (12%) 16 (13%) 0.77
Any Depressive Disorder 146 (12%) 10 (8%) 0.19
Any Substance Abuse Disorder 107 (9%) 11 (9%) 1.00
Psychosis 52 (4%) 3 (2%) 0.48
PTSD 281 (23%) 27(21%) 0.66
Co-morbidity 187 (15%) 16(13%) 0.39
*Fisher’s Exact Test
Types of Trauma Exposure HIV+
N=1223
HIV-
N=128 P-value*
Physical abuse during childhood 285 (24%) 18 (14%) 0.01
Sexual assault during adulthood 167 (14%) 8 (6%) 0.01
Prior experience of accident or
natural disaster 279 (23%) 44 (35%) 0.004
Prior experience of witnessing
violence or war
528 (44%) 71 (55%) 0.01
*Fisher’s Exact Test
Factors Associated with Presence of PD/SAD in Mothers with HIV Infection at Initial Evaluation: Multivariate Associations
Adjusted
Odds
Ratio
95%
Confidence
Interval
P-value
Age < 35 years 1.39 1.09 - 1.75 0.01
Single parenthood 1.35 1.08 - 1.68 0.01
Functional limitations ≥ 3 3.57 2.49 - 5.14 <0.001
Alcohol use during pregnancy 1.61 1.11 - 2.34 0.01
Illicit substance use during pregnancy 1.91 1.27 - 2.88 0.002
Psychiatric and Substance Abuse Disorders During Follow-up of Mothers Living with HIV (N=689)
0%
10%
20%
30%
40%
50%
60%
New PD/SAD RemittingPD/SAD
PersistingPD/SAD
Ever PD/SAD
13.5%
13.5%
21%
48%
Psychiatric and Substance Abuse Disorders During Follow-up of Mothers Living with HIV
79%
21%
39%
61%
0%10%20%30%40%50%60%70%80%
No newPD/SAD
New PD/SAD RemittingPD/SAD
PersistingPD/SAD
Among mothers with any disorder at entry (N=238)
Among mothers with no disorder at entry (N=451)
Factors Associated with Persistent PD/SAD vs. No Disorder in Mothers with HIV at
Follow-up (N=503): Multivariate Associations
Adjusted
Odds
Ratio
95%
Confidence
Intervals
P-value
Annual household income ≤ 20 K 2.44 1.33 - 4.76 0.01
Functional limitations ≥ 3 9.14 3.97 - 22.03 <0.001
Alcohol use during pregnancy 4.01 1.85 - 8.83 <0.001
Illicit substance use during pregnancy 2.46 1.12 - 5.46 0.03
Summary and Conclusions Psychiatric disorders and substance abuse disorders among mothers
living with HIV:
significant co-morbid conditions
persist in a significant portion of the mothers
Mothers living in high-risk communities:
similar risk for psychiatric and substance abuse disorders, regardless of HIV status
Limited use of mental health treatment programs and services by mothers in this study
Concern that disorders will exacerbate existing health problems and prevent adequate health-promoting behaviors for mothers with HIV, especially those with persistent disorders
Limitations Use of screening instrument to identify disorders:
CDQ is well-validated for assessing psychiatric disorders in
primary care settings and among populations affected by HIV. Sensitivity, specificity and overall accuracy are 91%, 78%, and
85%, respectively (Aidala et al., 2004).
Non-random selection of Reference comparison group
Lack of longitudinal data for Reference comparison group
Implications for Programs and Policy Screening, diagnosis and early treatment of PD/SAD should
be key components of comprehensive HIV care, especially for women at highest risk:
History of alcohol or drug use
Multiple functional limitations
Limited resources (income, family)
Psychological, societal, cultural and institutional barriers to mental health care must be identified and addressed.
Monitoring of children of women with PD/SAD is necessary, given increased risk for poor outcomes.
Special Thanks
We are especially grateful to all of the mothers who generously shared their experiences, thoughts and time with us during this longitudinal investigation.
Acknowledgements
We thank the Study Participants, PHACS Community Advisory Board, Frontier Science Inc., and Westat.
PHACS is funded by:
Under cooperative agreements with Harvard School of Public Health (HD052102, 3 U01 HD052102-05S1, 3 U01 HD052102-06S3) and Tulane School of Medicine (HD052104, 3U01HD052104-06S1)
Acknowledgments • The following institutions participated in
conducting PHACS: • Baylor College of Medicine • Bronx Lebanon Hospital Center • Children's Diagnostic & Treatment Center • Children’s Hospital, Boston • Children’s Memorial Hospital • Jacobi Medical Center • New York University School of Medicine • St. Christopher’s Hospital for Children • St. Jude Children's Research Hospital • San Juan Hospital/Department of Pediatrics • SUNY Downstate Medical Center
• Tulane University Health Sciences Center • University of Alabama, Birmingham • University of California, San Diego • University of Colorado Health Sciences Center • University of Florida/Jacksonville • University of Illinois, Chicago • University of Medicine and Dentistry of New Jersey • University of Miami • University of Southern California • University of Puerto Rico Medical Center