As the leading cause of death among young adults in the United States,1 AIDS remains one of the most formidable challenges for all medical professions. Because of the profound psychological and psychosocial complications associated with HIV infection, mental health clinicians increasingly encounter treatment scenarios involving HlV-affected patients. There is ample empirical evidence that HIV-positive individuals undergo major life stress, including significant depressive illness,2'4 which can have profound negative consequences on parameters such as survival5; physical, social, and role functioning6; and quality of life.7 Clinicians have also been concerned about suicide risk among HIVpositive persons from early on in the epidemic* Others have found that untreated depression is associated with increased risk behaviors (including injection drug use and unsafe sexual practices) in both "at-risk" individuals89 and known HIV-positive persons.10 Unlike other medical illnesses where the consequences of depression may have negative effects primarily influencing the patient's individual treatment outcome, in the case of HIV infection, depression may present important public health implications for primary and secondary AIDS prevention, thus making appropriate recognition and management of depression both a private and public health concern.
PREVALENCE OF DEPRESSIVE DISORDERS AND DEPRESSIVE SYMPTOMATOLOGY
In the early stages of the AIDS epidemic, consultation-liaison psychiatrists first reported that depression was a common problem in individuals diagnosed with AIDS11 with rates ranging from 1.4% to 43% for major depression diagnoses and 13% to 54% for diagnoses of adjustment disorder with depressed mood.12"16 However, because these studies included patients referred for psychiatric services, they likely overestimated the prevalence of depression in the general HIV-positive population.
There are several studies that have addressed the prevalence of depression in volunteer HIV-positive individuals not referred for psychiatric treatment, providing less biased prevalence estimates. Prom a computer-assisted review of psychiatric and psychological journals dating from 1981 to 1996, we found 11 published studies that assessed the prevalence of major depression in HIV-positive population samples2·4·6'1724 (Table). We included for review only those studies that involved a clinician assessment of major depressive disorder according to specified diagnostic criteria. Most of the studies had samples from high-risk populations including gay or bisexual men and injection drug users (IDUs). Several studies included HIV-positive women. Results indicated considerable variation in prevalence rates, ranging from 0% to 35%. The heterogeneity of prevalence estimates may be accounted for by differing applications of diagnostic criteria regarding the inclusion or exclu· sion of neurovegetative symptoms and by relatively small sample sizes in most studies.
Prevalence Rates of Major Depression Among HIV-Positive Persons
Additional research examining self-reported depressive symptoms also found elevations among HIV-positive individuals. For example, HIV-positive gay men and HIV-positive women have been found to exhibit elevated levels of depressive symptoms compared with general population norms on measures such as the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CESj3) 25-30 jn addition, high levels of depressive symptoms have been found among various groups of individuals notified of seropositivity.3133
Comparison of Depression Prevalence Across Samples
In order to address the significance of the prevalence rates of depression found in the HIV-positive population, it is useful to compare these rates with those found in community epidemiologic studies and in HIV-negative controls. In terms of the general population, the most comprehensive prevalence estimate of major depression is 2.2%.34 This rate is significantly lower than the rate of 6.3% found in a representative study of HIV-positive individuals18 (e = 5.74; P<0.05).
Although rates of major depression among HIV-positive patients are higher than in the general population, these rates are similar to those found among HIV-negative matched controls.2,4,20,24 In addition, when self-reported depressive symptoms among asymptomatic HIVpositive persons are compared with those in HIVnegative controls, no significant differences are found.25,27"29,35 Likewise, some researchers have found no difference in depressive symptoms between individuals testing HTV positive versus those testing HIV negative.36'39 However, control subjects in all of these studies were recruited from the same high-risk communities as those who were HTV positive (eg, gay men, IDUs, low socioeconomic status women, and so forth). This method of sampling may contribute to the similar levels of depression found for HIV-positive and HIV-negative individuals, because several studies have shown high rates of depression among IDUs20 and gay men,4 and high rates of depressive symptomatology among at-risk women.36,39 The etiology of these high rates is not well understood, although Folkman40 and Lyketsos and Federman41 have suggested that the widespread presence of AIDS in these communities may increase psychosocial stressors, fears of becoming infected, and loss of friends and loved ones to AIDS such that increases in depression are seen in HlV-affected communities and not simply restricted to HIV-infected individuals.
Disease Progression and Diagnostic Issues
In contrast to the studies reviewed above, which found no difference in depression among asymptomatic HIV-positive and HIV-negative controls, when studies have involved HIVpositive individuals with more severe HIV disease, higher levels of depression are found for HIV-positive groups than for HIV-negative controls.4244 These findings suggest that there may be an association between HIV disease progression and depressive symptoms. In fact, several studies have found an association between the severity of HIV-related physical symptoms and the severity of depressive symptoms.28,45,46 However, other studies report no association between depressive symptoms and stage of HTV disease.24,47*50 In addressing these contrasting findings, Mayne et al6 found that while depression was independent of physical symptoms, depressive affect was associated with higher mortality risk. These researchers hypothesized that behaviors associated with depression (noncompliance, increased substance use) may speed progression of HIV disease, underscoring the importance of diagnosis and treatment of depression in this population.
In considering the relationship between HIV-related symptoms and depressive symptoms, researchers and clinicians are faced with the dilemma of making diagnostic discriminations when overlap exists in the somatic symptoms of depression and of HIV infection (eg, fatigue, insomnia, loss of appetite or weight, apathy, and difficulties in concentration). One way clinicians may proceed with regard to this dilemma is to exclude somatic symptoms from the criteria for depressive diagnoses in this population. Supporting this approach, Fell et al27 initially found significant differences between HIV-positive symptomatic men and HIV-negative men on the BDI but found no differences when five somatic items were omitted, suggesting that the physical symptoms of HIV disease were accounting for the apparent elevation in depressive symptomatology in the HIV-positive sample. In contrast, the validity of a more inclusive approach to diagnosis is implied by Perkins et al,53 who found that the vegetative symptoms of insomnia and fatigue were correlated with depressive symptoms but were unrelated to markers of disease progression. In addition, Lipsitz et al20 found that when overlapping somatic symptoms were controlled by statistical covariation, diagnosis of depression was still associated with more advanced HIV disease. These results suggest that somatic symptoms are important to the diagnosis of depression among medically ill HIV-positive individuals. In addressing this diagnostic dilemma, we suggest that clinicians utilize more inclusive criteria because undertreating depression may have serious health consequences in this population, whereas researchers may favor a more stringent approach to increase specificity.
In summary, despite the variability in prevalence estimates, those infected with HIV appear to experience depressive disorders at a similar rate as individuals from at-risk groups who are HIV negative but at higher rates than the general population. Although these findings have been based on limited data, together they suggest that depression among HIVpositive individuals is not so rare as to be of limited concern and not so commonplace as to be considered an expectable response to HIV infection. As such, major depression appears to be a significant mental health concern for HIVpositive individuals.
Because communities hit particularly hard by HIV infection seem to have elevated rates of depression and depressive symptomatology, it is important to investigate the psychological factors, which may be associated with depression among individuals who are HIV positive. Such associated factors provide important areas for adjunctive diagnostic inquiry and potential targets of intervention.
Premorbid Psychological Functioning
Research comparing depressed and nondepressed HIV-positive individuals indicates that past psychiatric history is associated with current depressive diagnoses. For example, Ritchie, Ross, and Radke,23 assessing the Diagnostic and Statistical Manual, 3rd edition-revised (DSM-III-R) diagnoses of depression among HIV-positive and HIV-negative US army personnel, found that men receiving depression diagnoses were more likely to report a history of treatment for mental illness. In addition, Ostrow et al32 compared HIV-positive men categorized as depressed on the basis of a selfreport depression score to men categorized as non-depressed on this same measure. They found that depressed men were more likely to report previous use of antidepressant medication than were non-depressed men. Together, results from these studies suggest that current depressive symptomatology among HIV-positive men may be related to a history of psychiatric disorder in general, and possibly to previous depressive symptoms in particular.
Several cross-sectional studies indicate strong negative relationships between both qualitative and quantitative measures of social support and levels of depressive symptoms among HIV-positive gay or bisexualmen23,22.214.171.124.53 J1n^ among HIV-positive menwith hemophilia.42 Furthermore, this researchsuggests that, in contrast to other populations, HIV-positive gay men report that social support from friends is more relevant to depression than is family support.54,55 Although results from cross-sectional studies provide substantial evidence to support a relationship between social support and concurrent depression, longitudinal studies provide more equivocal evidence regarding the role of social support in predicting future depression (Leserman et al, unpublished manuscript, 1993).56 Thus, the direction of causality between social support and depression should not be assumed (eg, high levels of depression may contribute to, as well as result from, lower levels of social support).
Several studies have examined the concurrent relationships between coping strategies and depressive symptoms among HIV-positive individuals.19,53,5760 In general, results indicate that the self-reported use of active behavioral coping strategies (eg, "tried to get someone, like a doctor, to do something about it") is associated with lower levels of depression,53,57 whereas selfreported use of avoidance coping strategies (eg, "refused to think about it") is associated with higher levels of depressed mood among HIVpositive gay men.19,53,57,60 Significant concurrent relationships between depression and active behavioral and avoidance coping strategies have also been obtained among HIV-positive gay and bisexual men when the level of depressive symptoms 1 year earlier was controlled.28
TREATMENT OF DEPRESSION IN HIV
The deleterious consequences of depression in HIV-positive persons make effective treatment a paramount concern. To date, a number of effective treatment modalities have been studied for individuals with depression and comorbid HIV disease (for a detailed discussion of specific treatments, see Markowitz, Rabkin, and Perry61).
Tricyclic and Selective Serotonin Reuptake Inhibitor Antidepressants
Research exarxiining the use of traditional antidepressant medications has demonstrated the effectiveness of both tricyclic agents and selective serotonin reuptake inhibitors (SSRIs) among samples of HIV-positive individuals with depression. Specifically, each of the following medications has been shown to decrease levels of depression according to self or clinician assessment: nortriptyline,62 Imipramine,63^ 65 amitriptyline,66 desipramine,66,67 fluoxetine,68 and sertraline.69 In general, more serious and annoying side effects were found among patients treated with tricyclics than SSRIs, particularly among patients with more advanced HIV disease.63,66
Psychostimulants and Other Somatic Treatments
Other less common treatments for depression have been studied among HIV-positive samples, including the use of psychostimulant agents, testosterone replacement, and electroconvulsive therapy (ECT). Stimulants such as methylphenidate and dextroamphetamine have been shown to be effective in treating HrVpositive individuals with (1) depression70; (2) depression and cognitive deficits71,72; (3) depression, lethargy, and associated medical illness70; and (4) depression and/or organic mental disorders.71,73 Psychostimulants appear to produce clinical improvement with minimal side effects, as does testosterone replacement therapy, a modality currently studied in a cohort of HIVpositive men with depressive symptoms and lethargy.74 Finally, right unilateral ECT has been reported to be effective in four cases of depression refractory to pharmacotherapy.75
In addition to case reports62,76 and a pilot study77 commenting on the efficacy of psychotherapy in the treatment of depression, three randomized clinical trials of psychotherapeutic interventions have been published. Group therapy with placebo has been found to be as effective as group therapy plus fluoxetine.78 Social support groups and cognitive-behavioral groups have been found to reduce depressive symptoms significantly as compared with control groups, with social support group members evidencing the greatest reduction in depressive symptoms.79 Finally, Markowitz et al80 found that although both interpersonal psychotherapy and supportive psychotherapy produced improvement in depressive symptoms, interpersonal psychotherapy demonstrated significantly greater efficacy than supportive psychotherapy.
Depression in the presence of HIV infection is a problem for a significant number of people affected by the AIDS virus and demands a comprehensive diagnostic and treatment approach. Mental health clinicians may risk dismissing a disorder that has negative consequences, yet is treatable, if they endorse the notion of depression as a "normal" response to HIV infection. The complexity involved in evaluating depression in individuals whose physical symptoms overlap with vegetative symptoms of depression is important to consider in developing effective assessments. Although there is no consensus about how to distinguish the etiology of somatic symptoms, there is ample evidence to suggest that a more inclusive approach to diagnosis is warranted and may be most beneficial when working with the HTV-infected population. Furthermore, a number of psychosocial factors, including premorbid psychological functioning, social support, and coping strategies, may complicate depressive disorders requiring thorough evaluation and thoughtful intervention by those providing patient care. Fortunately, a growing spectrum of treatment options for depressed HIV-positive individuals has been shown to be effective, including a range of psychopharmacologic and psychotherapeutic treatments. These modalities allow clinicians the opportunity to tailor treatment plans based on individual needs. Finally, depression in the context of HTV disease requires careful attention on the part of clinicians and further study to provide effective treatment interventions that enhance multiple domains of life quality.
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Prevalence Rates of Major Depression Among HIV-Positive Persons