Prevalence of Treated & Untreated Prevalence of Treated & Untreated Depression in a Cohort of HIV+ Depression in a Cohort of HIV+ Women: Impact on Antiretroviral Women: Impact on Antiretroviral

Therapy Utilization & HIV Disease Therapy Utilization & HIV Disease OutcomesOutcomes

Judith A. Cook, PhDJudith A. Cook, PhD

University of Illinois at ChicagoUniversity of Illinois at ChicagoDepartment of PsychiatryDepartment of Psychiatry

Presented at APHA Annual Meeting & Expo Presented at APHA Annual Meeting & Expo San Francisco, CA, October 30, 2012San Francisco, CA, October 30, 2012

Collaborators & FundersCollaborators & Funders Mardge H. Cohen, Mardge H. Cohen, Core Center, Chicago, ILCore Center, Chicago, IL Rebecca Schwartz, Rebecca Schwartz, Population Health, Hofstra UniversityPopulation Health, Hofstra University Pamela Steigman, Pamela Steigman, Psychiatry, UICPsychiatry, UIC Dennis Grey, Dennis Grey, Psychiatry, UICPsychiatry, UIC Nancy Hessol, Nancy Hessol, Pharmacy, University of California, SFPharmacy, University of California, SF Elizabeth T. Golub, Elizabeth T. Golub, Public Health, Johns Hopkins UniversityPublic Health, Johns Hopkins University Kathryn Anastos, Kathryn Anastos, Albert Einstein College of MedicineAlbert Einstein College of Medicine Daniel Merenstein, Daniel Merenstein, Family Medicine, Georgetown UniversityFamily Medicine, Georgetown University Joel Milam, Joel Milam, Preventive Medicine, University of Southern CAPreventive Medicine, University of Southern CA

Estimates of Depression Estimates of Depression Prevalence in Different U.S. Study Prevalence in Different U.S. Study

PopulationsPopulations GeneralGeneral HIV+HIV+ HIV+HIV+PopulationPopulation MenMen WomenWomen20%20%aa 21%21%bb 51%51%ee

20%20%cc

15%15%dd

a Kessler et al., 1994, a Kessler et al., 1994, Arch Gen PsychArch Gen Psychb Lyketsos et al., 1993, b Lyketsos et al., 1993, JAMAJAMAc Hays et al., 1992, c Hays et al., 1992, J Consult Clin PsychJ Consult Clin Psychd Sambamoorthi et al., 2000, d Sambamoorthi et al., 2000, J Gen Int MedJ Gen Int Mede Cook et al., 2003, e Cook et al., 2003, JAIDSJAIDS

Research Has Established a Link Research Has Established a Link Between Tx for Depression & Between Tx for Depression &

Positive HIV OutcomesPositive HIV Outcomes

Depression treatment is associated with Depression treatment is associated with lower medical costs, greater HAART use lower medical costs, greater HAART use and adherence, curtailed HIV disease and adherence, curtailed HIV disease progression, and lower AIDS-related progression, and lower AIDS-related mortality.mortality.

DEPRESSIONTREATMENT

POSITIVE HIV OUTCOMES

Cook, Grey et al., 2006Cook, Grey et al., 2006AIDS CareAIDS Care

Use of antidepressants plus mental health Use of antidepressants plus mental health therapy, or use of mental health therapy therapy, or use of mental health therapy alone significantly increased the alone significantly increased the probability of HAART utilization, compared probability of HAART utilization, compared to receiving no depression treatment.to receiving no depression treatment.

Turner, Laine et al., 2003Turner, Laine et al., 2003J Gen Intern MedJ Gen Intern Med

Women diagnosed with depression who Women diagnosed with depression who received psychiatric and antidepressant tx received psychiatric and antidepressant tx had nearly a two-fold greater adjusted had nearly a two-fold greater adjusted odds of adherence to ART, compared to odds of adherence to ART, compared to women whose depression was untreated. women whose depression was untreated.

Cook, Grey et al., 2004Cook, Grey et al., 2004Am J Public HealthAm J Public Health

While depressed women were more than While depressed women were more than twice as likely to experience AIDS-related twice as likely to experience AIDS-related mortality as non-depressed (controlling for mortality as non-depressed (controlling for HAART use & adherence), those receiving HAART use & adherence), those receiving MH tx were significantly less likely to die. MH tx were significantly less likely to die.

Sambamoorthi, Walkup et al., 2000Sambamoorthi, Walkup et al., 2000J Gen Int Med.J Gen Int Med.

Antidepressant treatment for depressed Antidepressant treatment for depressed HIV-positive individuals was associated HIV-positive individuals was associated with a 24% reduction in monthly total with a 24% reduction in monthly total healthcare costs even controlling for healthcare costs even controlling for socioeconomic and clinical characteristics. socioeconomic and clinical characteristics.

Women’s Interagency Women’s Interagency HIV Study (WIHS)HIV Study (WIHS) Cohort study of HIV-positive women Cohort study of HIV-positive women

recruited in 6 cities: Chicago, Los recruited in 6 cities: Chicago, Los Angeles, San Francisco/Bay Area, Angeles, San Francisco/Bay Area, Bronx, Brooklyn, Washington, DCBronx, Brooklyn, Washington, DC

Data collection bi-annually beginning in Data collection bi-annually beginning in 1994 (11994 (1stst cohort) until present cohort) until present

Bi-annual in-person interviews, physical Bi-annual in-person interviews, physical exam, blood work, gynecological examexam, blood work, gynecological exam

Chart abstraction of medical recordsChart abstraction of medical records

World Mental Health (WMH)World Mental Health (WMH)Composite International Diagnostic Composite International Diagnostic

Interview (CIDI) Interview (CIDI) Allows researchers to assess & study the impact of Allows researchers to assess & study the impact of

mental & substance use disordersmental & substance use disorders Valid & reliable way for trained non-clinicians to Valid & reliable way for trained non-clinicians to

generate diagnoses using the generate diagnoses using the DSM-IVDSM-IV framework. framework. Measures prevalenceMeasures prevalence Measures severityMeasures severity Determines risk factorsDetermines risk factors Assesses service useAssesses service use Assesses use of medicationsAssesses use of medications Assesses who is treated, who isn’t, & barriers to Assesses who is treated, who isn’t, & barriers to

treatmenttreatment

CIDI Participants (N=889)CIDI Participants (N=889)

Average Age:Average Age: 48 years (min-max = 27-77) 48 years (min-max = 27-77)

Race/Ethnicity: Race/Ethnicity: 65% African American; 15% Hispanic/Latina; 65% African American; 15% Hispanic/Latina;

17% White; 3% Other17% White; 3% Other

Education:Education: 34% < HS education; 33% HS/GED; 25% some 34% < HS education; 33% HS/GED; 25% some

college; 8% college education/advanced degreecollege; 8% college education/advanced degree

Marital Status:Marital Status: 29% never married; 28% married/ cohabiting; 29% never married; 28% married/ cohabiting;

12% divorced; 11% widowed; 6% separated; 14% other12% divorced; 11% widowed; 6% separated; 14% other

Employment:Employment: 32% employed at time of interview 32% employed at time of interview

Income: Income: 51% < $12,000 annually51% < $12,000 annually

Insurance Coverage: Insurance Coverage: 96% insured96% insured

12-month Prevalence of Depressive 12-month Prevalence of Depressive Disorder (DD): General U.S. Population Disorder (DD): General U.S. Population

Compared to HIV+ WomenCompared to HIV+ Women

U.S. U.S. WIHSWIHSWomenWomen SampleSample

Major DDMajor DD 8.6%8.6%aa 17.9%17.9%

DysthymiaDysthymia 1.9%1.9%aa 8.7%8.7%

Minor DDMinor DD 1.0%1.0%bb 1.6%1.6%

a Source: National Comorbidity Survey-Replication, Kessler et al., 2005 b Source: Klier et al., 2000

Logistic Regression: HAART Use Among Logistic Regression: HAART Use Among HIV+ Women with Depression Diagnosis HIV+ Women with Depression Diagnosis

VariablesVariables O.R.O.R. SignificanceSignificance

Depression txDepression tx 3.233.23 p<.05p<.05

AgeAge 1.081.08 p<.05p<.05

High School Ed+High School Ed+ 0.000.00 nsns

Income < $12,000Income < $12,000 0.050.05 p<.01p<.01

MinorityMinority 0.000.00 nsns

Logistic Regression: Unsuppressed Viral Load Logistic Regression: Unsuppressed Viral Load (>1,000 copies/ml) Among HIV+ Women (>1,000 copies/ml) Among HIV+ Women Treated and Not Treated for DepressionTreated and Not Treated for Depression

VariablesVariables O.R.O.R. SignificanceSignificanceDepression txDepression tx 0.370.37 p<.05p<.05AgeAge 0.960.96 nsnsHigh School Grad+High School Grad+ 0.780.78 nsnsIncome < $12,000Income < $12,000 1.731.73 nsnsMinorityMinority 1.581.58 nsnsOn HAARTOn HAART 0.180.18 p<.001p<.001

% of Women Reporting Mental % of Women Reporting Mental Health Tx by Type of Professional*Health Tx by Type of Professional*

TypeType %% NNPsychiatristPsychiatrist 7171 7979Social WorkerSocial Worker 4646 5252Medical DoctorMedical Doctor 3434 3838CounselorCounselor 3131 3535PsychologistPsychologist 2929 3333PsychotherapistPsychotherapist 2323 2626Non-Medical Health Prof (RN, etc)Non-Medical Health Prof (RN, etc) 1212 1414Spiritual AdvisorSpiritual Advisor 1919 2121

Does not add to 100% since women could report >1 type of professional

Helpfulness (“a lot” or “some”) of Mental Helpfulness (“a lot” or “some”) of Mental Health Tx by Type of Professional*Health Tx by Type of Professional*

TypeType %% NNPsychiatristPsychiatrist 8989 7070Social WorkerSocial Worker 8383 4343Medical DoctorMedical Doctor 8484 3232CounselorCounselor 8080 2828PsychologistPsychologist 7676 2525PsychotherapistPsychotherapist 8585 2222Non-Medical Hlth. Prof. (RN, etc)Non-Medical Hlth. Prof. (RN, etc) 8686 1212Spiritual AdvisorSpiritual Advisor 8686 1818

Does not add to 100% since women could report >1 type of professional

Additional Features of Tx for Additional Features of Tx for DepressionDepression

71.4% of 71.4% of all womenall women reporting depression reporting depression tx said their tx helped “a lot” tx said their tx helped “a lot”

79.5% of women reporting depression tx 79.5% of women reporting depression tx reported a prescription for psychiatric reported a prescription for psychiatric medication medication

ConclusionsConclusions

Prevalence of depression in this cohort of Prevalence of depression in this cohort of HIV+ women was two- to four-fold greater HIV+ women was two- to four-fold greater than in the general U.S. population of womenthan in the general U.S. population of women

Most depressed women reported receiving Most depressed women reported receiving tx from a professional; the large majority tx from a professional; the large majority reported that tx was helpful.reported that tx was helpful.

Depressed women receiving MH tx were Depressed women receiving MH tx were significantly more likely to be on HAART, & significantly more likely to be on HAART, & were less likely to have unsuppressed viral were less likely to have unsuppressed viral loads.loads.