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The Prevalence of Distress in Persons With Human Immunodeficiency Virus Infection

Received June 5, 2001; revised September 20, 2001; accepted September 24, 2001. From the AIDS Center, Mount Sinai Medical Center, New York, NY. Address correspondence to Dr. Cohen, AIDS Center, Box 1009, Mount Sinai Medical Center, One Gustave Levy Pl, New York, NY, 10029. Address reprint requests to Dr. Cohen, 220 West 93rd St, Apartment 14A, New York, NY 10025.

ABSTRACT

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The purpose of this study was to assess the prevalence of distress, anxiety, and depression in persons with human immunodeficiency virus (HIV) infection and determine the feasibility of screening in an urban HIV primary care setting. A convenience sample of 101 patients in the waiting room of an acquired immunodeficiency syndrome clinic completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Distress Thermometer. The patient's demographic, medical, and psychiatric histories were obtained through chart review. The results of the Distress Thermometer revealed that 72.3% had a score of 5 or greater, demonstrating high distress. The results of the HADS revealed that 70.3% had high anxiety, with a score of 7 or greater. On the HADS depression questions, 45.5% had a score of 7 or greater, indicating depression. Analysis of the total HADS scores, including anxiety and depression, revealed that 53.5% had a score of greater than 15 and were experiencing significant distress. Patients with high viral loads were more likely to be distressed (P < 0.0005). Patients with high viral loads were also more likely to have higher anxiety or depression scores on the HADS. Patients who had CD4 counts higher than 500/mm³ were less likely to be depressed. This study demonstrates a high prevalence of distress, anxiety, and depression among persons with HIV. The HADS and the Distress Thermometer showed a good correlation with each other (P < 0.0005), and these questionnaires can provide a simple and efficient method for rapid screening in an HIV clinic setting.

Key Words: AIDS/HIV • Other Addictive Disorders • Distress

INTRODUCTION

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Persons infected with human immunodeficiency virus (HIV) are living longer and healthier lives as a result of better medical care, major advances in antiretroviral therapy, and prophylaxis of some of the initially fatal complications.¹ However, many continue to experience distress from symptoms such as pain, fatigue, insomnia, anxiety, and depression. Some people with HIV are also at increased risk for comorbid psychiatric disorders because of the high prevalence of drug dependence.² Patients with advanced acquired immunodeficiency syndrome (AIDS) are especially vulnerable to dementia and suicide.³ In addition to these special vulnerabilities, persons with HIV and AIDS are also subject to family crises, financial stressors, losses, and a multiplicity of medical illnesses. Anxiety and depression may be factors in both quality of life and adherence to the complex regimen for HIV treatment.⁴

As AIDS continues to be the leading cause of death among Americans aged 25–44 years old, heterosexual transmission of HIV, especially from men to women, is increasing.⁵ Recognition and treatment of distress, anxiety, depression, and other psychiatric symptoms in HIV-positive persons can improve care, increase adherence, and decrease the transmission of HIV.^6–8

A study by Lyketsos et al.⁹ at an HIV primary care clinic found a high prevalence of distress in HIV-infected persons. The authors identified 52% of their participants as having significant depression by using the General Health Questionnaire and the Beck Depression Inventory and found that 65.6% had a history of a substance use disorder.⁹ Community samples had identified only 4%–15% of participants as having a current major depressive disorder and 20%–35% as having substance abuse.^10–12

Patients with psychiatric morbidity are at greater risk for poor adherence to antiretroviral therapy and higher risk for treatment failure. A study by Gordillo et al.⁷ found that patients who were depressed had poorer compliance with antiretroviral treatment. Adherence to antiretroviral medications is an important factor in illness outcome because most antiretroviral therapies require adherence 95% of the time for optimal effectiveness.⁸ Patient compliance has become more important because advances in antiretroviral therapy have led to a shift from inpatient care to the outpatient setting. With the shift to ambulatory care and the pressure to see more patients in shorter periods of time, clinicians may have more difficulty recognizing, diagnosing, and treating distress and related psychiatric problems. To screen a large number of patients in an efficient, timely manner, many clinics have relied on assessment questionnaires. This study examines the prevalence of distress, anxiety, and depression among persons with HIV and the feasibility of using screening questionnaires in the setting of a crowded waiting room in an HIV primary care clinic.

METHODS

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The subjects were a convenience sample of people in the waiting room at the AIDS Center of the Mount Sinai Hospital, New York City. This clinic provides comprehensive care for nearly 1,800 HIV-positive persons. Patients were approached while they were waiting for their appointments and were asked to complete two questionnaires. Very few patients (<10%) declined to participate. Of those who declined, most said that they did not want to participate because our study provided no financial incentive, unlike other studies conducted at that time. Two individuals declined because of language difficulties; they were unable to understand either Spanish or English and could not await translators. Two declined because of child-care concerns and time constraints. This study was approved by the Mount Sinai Hospital Institutional Review Board.

Patients completed the Hospital Anxiety and Depression Scale (HADS), which consists of 14 questions, 7 measuring anxiety and 7 measuring depression. Each question was rated on a scale of 0 to 3, with a possible score of 0–21 for depression or anxiety and a possible total score of 0–42. Based on the work of Zigmund and Snaith,¹³ HADS scores of 7 or greater for anxiety or depression, and a total score of 15 or greater, were considered significant for measuring distress. Patients were also asked to complete the Distress Thermometer, which is a vertical analogue scale with 0 representing the least distress and 10 representing the most distress experienced by the patient. The two questionnaires were read to each patient and took approximately 5 minutes to complete, which included time for explanation and reading of informed consent.

The results were analyzed using Pearson's ² test and analysis of variance. The patients' demographic, medical, and psychiatric histories were obtained through a chart review. Viral loads and CD4 counts were obtained from the medical chart. The procedure for viral-load determination at Mount Sinai is by the Amplicor PCR Diagnostics HIV1 Monitor Test, Roche Commercial Kit. The viral-load range is from <400 to >750,000 copies/mL with regular assay and from <40 to >75,000 copies/mL with the ultrasensitive assay. Two of the authors reviewed the charts.

RESULTS

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The demographic results are summarized in Table 1. The results of the Distress Thermometer and the HADS revealed that many of our patients were experiencing high levels of distress, anxiety, and depression. Of 101 patients, 73 had a score of 5 or greater on the Distress Thermometer, indicating high distress. The results of the HADS revealed that 71 patients had high anxiety, with a score of 7 or greater. On the HADS depression questions, 46 patients had a score of 7 or greater, indicating depression. Table 2 and Table 3 summarize the complete results of these questionnaires.

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TABLE 1. Patient characteristics

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TABLE 2. The Distress Thermometer

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TABLE 3. The Hospital Anxiety and Depression Scale

The ² test showed no significant differences in anxiety, depression, or total HADS scores between men and women. There were also no significant differences in scores among patients of different ethnicities.

Younger patients were significantly more likely to be distressed, with a score of greater than 5 on the Distress Thermometer (P = 0.019). Younger patients were also more likely to have anxiety, with a score of greater than 7 on the HADS (P = 0.045). Table 4 and Table 5 group the patients by decade of age and demonstrate that younger patients reported significantly higher levels of distress.

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TABLE 4. Decade of age and Distress Thermometer scores

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TABLE 5. Decade of age and HADS Anxiety scores

The patients had CD4 counts ranging from 0 to 1,219 and viral loads ranging from <40 to >750,000 copies/mL. Patients with a high viral load (especially when viral load was >10,000 copies/mL) were more likely to be distressed (P < 0.0005). Patients with high viral loads were also more likely to have higher anxiety or depression scores on the HADS. Patients who had CD4 counts higher than 500 were less likely to be depressed. Table 6, Table 7, Table 8, and Table 9 demonstrate the relations of distress, anxiety, and depression to the CD4 count and viral load.

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TABLE 6. Distress, anxiety, and depression, and average viral load

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TABLE 7. CD4 count and HADS Depression scores

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TABLE 8. Viral load and Distress Thermometer scores

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TABLE 9. Viral load and HADS Depression scores

Patients with chart documentation of substance-use disorders had significantly higher Distress Thermometer scores (Table 10).

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TABLE 10. Drug use and Distress Thermometer scores

The HADS depression and anxiety scores were highly correlated (r = 0.659, P < 0.0005). The HADS anxiety and depression scores also correlated well with the Distress Thermometer scores. The total HADS score, which includes the anxiety and depression scores, was also strongly correlated with the Distress Thermometer scores (r = 0.688, P < 0.0005). The complete results are presented in Table 11.

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TABLE 11. HADS and Distress Thermometer correlation

DISCUSSION

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Our sample of HIV-infected individuals had a high prevalence of distress, anxiety, and depression. Many of our patients (72.3%) were above threshold on the Distress Thermometer scale. A large number also tested as significantly anxious (70.3%) or depressed (45.5%) on the HADS. As in the HIV-positive patients evaluated by Lyketsos et al.^6,9 at Johns Hopkins, our study documented that a majority of patients in an HIV clinic suffer from significant emotional distress and could benefit from psychiatric care.

Most of our patients were Latino American (Puerto Rican, other Caribbean, or South American) and African American. There were no significant differences in distress, anxiety, or depression among patients of different ethnicities or gender. Patients with chart documentation of substance use were more likely to have higher scores on the Distress Thermometer. The small number of patients who were documented as having substance use may reflect the reluctance of patients to disclose such information to their primary care provider.

Patients who were younger were more likely to experience greater distress when compared with older patients. Patients were especially more likely to be distressed during the second or third decade of life when compared with patients in the fourth or fifth decade of life. Younger patients may have received their diagnosis more recently than older patients, who may have had more years to adjust to and accept their HIV diagnosis.

Patients who had a low CD4 count or high viral load were significantly more likely to be distressed, anxious, and depressed than patients with better control of their HIV infection. The specific reason for this association is not clear. A low CD4 count or high viral load may precipitate feelings of distress, depression, and anticipatory loss. Patients with depression are less likely to take medication because of feelings of hopelessness and difficulties with memory and concentration.⁷ The HIV infection itself has effects on cognition and mood that may also prevent patients from taking medication regularly. A high viral load in the brain is reported to damage the glial cells, leading to AIDS dementia. AIDS dementia is reversible with highly active antiretroviral therapy, unlike many other types of dementia.¹⁴ However, patients with HIV dementia and AIDS-related mood instability or psychosis often become nonadherent to their medication regimen because of severe memory problems and difficulty with concentration. These patients may have had higher scores on the HADS and the Distress Thermometer because of worsening depression and anxiety.

The patients screened in our study had a high prevalence of distress, anxiety, and depression because of the high prevalence of psychiatric disorders in our patient population. At Mount Sinai AIDS Center, 640 of nearly 1,800 registered patients were referred for psychiatric consultation. Substance-related disorders were diagnosed in 70% of referred patients, depression in 58%, posttraumatic stress disorder in 42%, and dementia in 36%.

Rates of psychiatric distress are even higher in inner-city AIDS nursing homes.¹⁵ In a study of patients in an AIDS nursing home, Cohen¹⁶ found the patients to be younger and more medically and psychiatrically ill than patients described in previous studies. In this nursing home, 82.5% of patients had substance abuse, 83% had a diagnosis of dementia, and 65% had psychiatric diagnoses other than cognitive disorder or substance abuse.

Previous studies have demonstrated that in busy ambulatory care settings, many clinicians do not identify patients with significant psychological distress.^17,18 Spontaneous disclosure of distress or psychiatric problems is difficult for many patients. To address this problem, Roth et al.¹⁹ conducted a pilot program to determine the feasibility of using a rapid screening evaluation to assess for distress in men with prostate cancer. They used the Distress Thermometer to assess for distress with a visual analogue scale, as well as the HADS as part of the screening assessment. They evaluated 121 patients at the cancer clinic using these two self-assessment questionnaires and found that about one-third of the patients had moderate to severe distress.

Many studies have used the HADS to screen patients in medical settings.^20–24 Hopwood et al.²⁴ used the HADS to screen patients with advanced breast cancer and found that this scale had good predictive value in identifying anxiety and depression. Few studies have used the HADS in HIV primary care centers, and no studies before this one have used the Distress Thermometer to screen for distress in persons with HIV and AIDS.^20–22

Our study has demonstrated the feasibility of using the Distress Thermometer and the HADS to screen for distress, anxiety, and depression in an HIV primary care clinic. One of the main limitations of the study design was that it did not incorporate a full psychiatric examination of each participant. Another limitation was that we chose measures because they were short and easy to administer in a crowded waiting room. The use of the Structured Clinical Interview for DSM-IV would have been helpful to correlate psychiatric diagnoses with levels of distress, anxiety, and depression in our population.

The HADS screens patients by focusing on emotional distress and cognitive aspects of depression. Unlike other screening tests for depression and anxiety, the HADS avoids questions concerning physical symptoms, such as weight loss or insomnia, which may be confused with medical illness. The HADS and Distress Thermometer correlated well with each other. Although neither screening instrument provides a diagnostic assessment for the wide range of psychiatric disorders, they were useful in screening for emotional distress. The HADS and Distress Thermometer can be administered quickly while a patient is waiting for an appointment. We are currently using these two questionnaires to screen and monitor patients who are involved in a hepatitis C treatment study because major depression is a common side effect of interferon treatment.

The HADS and the Distress Thermometer are brief questionnaires that can be readily incorporated into the intake evaluation of every patient registering at an ambulatory AIDS clinic. Along with initial weight, vital signs, and laboratory testing, a baseline assessment of distress, anxiety, and depression would be a valuable addition to a comprehensive intake evaluation. Obtaining a baseline assessment is important because certain antiretroviral agents, other medications, and illnesses can contribute to or considerably worsen depression and anxiety. Furthermore, if the results are readily available, high scores can serve as indicators for mental health or other interventions from nursing, social services, or other disciplines. Although these tests should not be a substitute for clinical evaluations, they are useful tools for rapid evaluation of a large number of patients. The high prevalence of significant levels of distress confirms the need for easy access to psychiatric care in the HIV clinic setting. We recommend the integration of psychiatric care into HIV primary care to alleviate distress, improve adherence, increase survival, and improve quality of life in this vulnerable population.

REFERENCES

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1. Selik RM, Chu SY, Ward JW: Trends in infectious diseases and cancers among persons dying of HIV infection in the United States from 1987 to 1992. Ann Intern Med 1995; 123:933-936[Abstract/Free Full Text]
2. Lyketsos CG, Federman EB: Psychiatric disorders and HIV infection: impacting one another. Epidemiol Rev 1995; 17:152-164[Free Full Text]
3. Alfonso CA, Cohen MA: HIV dementia and suicide. Gen Hosp Psychiatry 1994; 16:45-46[CrossRef][Medline]
4. Hedge B, Petrak JA: Take as prescribed: a study of adherence behaviors in people taking anti-retroviral medications (abstract). 12th International AIDS Conference, Geneva, 1998
5. Rosenburg PS, Biggar RJ: Trends in HIV incidence among young adults in the United States. JAMA 1998; 279:1894-1899[Abstract/Free Full Text]
6. Lyketsos CG, Fishman M, Hutton H, et al: The effectiveness of psychiatric treatment for HIV-infected patients. Psychosomatics 1997; 38:423-432[Abstract/Free Full Text]
7. Gordillo V, Amo JD, Soriano V, et al: Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS 1999; 13:1763-1769[CrossRef][Medline]
8. Paterson DL, Swindells S, Mohr J, et al: Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med 2000; 133:21-30[Abstract/Free Full Text]
9. Lyketsos CG, Hutton H, Fishman M, et al: Psychiatric morbidity on entry to an HIV primary care clinic. AIDS 1996; 10:1033-1039[Medline]
10. Brown GR, Rundell JR, McManis SE, et al: Prevalence of psychiatric disorders in early stages of HIV infection. Psychosom Med 1992; 54:588-601[Abstract/Free Full Text]
11. Atkinson JH, Grant I, Kennedy CJ, et al: Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. A controlled study. Arch Gen Psychiatry 1988; 45:859-864[Abstract]
12. Maj M, Janssen R, Starace F, et al: WHO Neuropsychiatric AIDS study, cross-sectional phase I. Study design and psychiatric findings. Arch Gen Psychiatry 1994; 51:39-49[Abstract]
13. Zigmund AS, Snaith RP: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67:361-370[Medline]
14. Gendelman HE, Zheng J, Coulter CL, et al: Suppression of inflammatory neurotoxins by highly active antiretroviral therapy in human immunodeficiency virus-associated dementia. J Infect Dis 1998; 178:1000-1007[Medline]
15. Perkins DO, Stern RA, Golden RN, et al: Mood disorders in HIV infection: prevalence and risk factors in a nonepicenter of the AIDS epidemic. Am J Psychiatry 1994; 151:233-236[Abstract/Free Full Text]
16. Cohen MA: Psychiatric care in an AIDS nursing home. Psychosomatics 1998; 39:154-161[Abstract/Free Full Text]
17. Stoudemire A: Psychiatry in medical practice: implications for the education of primary care physicians in the era of managed care: part 1. Psychosomatics 1996; 37:502-508[Abstract/Free Full Text]
18. Ormel J, Koeter MWJ, van den Brink W, et al: Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry 1991; 48:700-706[Abstract]
19. Roth AJ, Kornblith AB, Batel-Copell L, et al: Rapid screening for psychological distress in men with prostate carcinoma. Cancer 1998; 82:1904-1908[CrossRef][Medline]
20. Carretero B, Burgess AP, Soler P, et al: Reliability and validity of an HIV-specific health-related quality-of-life measure for use with injecting drug users. AIDS 1996; 10:1699-1705[Medline]
21. Burgess A, Dayer M, Catalan J, et al: The reliability and validity of two HIV-specific health-related quality-of-life measures: a preliminary analysis. AIDS 1993; 7:1001-1008[Medline]
22. Savard J, Laberge B, Gauthier JG, et al: Evaluating anxiety and depression in HIV-infected patients. J Pers Assess 1998; 71:349-367[CrossRef][Medline]
23. Payne DK, Hoffman RG, Theodoulou M, et al: Screening for anxiety and depression in women with breast cancer. Psychiatry and medical oncology gear up for managed care. Psychosomatics 1999; 40:64-69[Abstract/Free Full Text]
24. Hopwood P, Howell A, Maguire P: Psychiatric morbidity in patients with advanced cancer of the breast: prevalence measured by two self-rating questionnaires. Br J Cancer 1991; 61:349-352

Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Cohen, M. Articles by Jacobson, J. M. Search for Related Content PubMed Citation Articles by Cohen, M. Articles by Jacobson, J. M. AIDS/HIV Stress

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