Physical Symptoms and Depressive Symptoms Among Individuals With HIV Infection GARY S. BELKIN, M.D., M.P.H. JOHN
A.
FLEISHMAN, PH.D., MICHAEL D. STEIN, M.D.
JOHN PIETTE, PH.D., VINCENT MOR, PH.D.
The allfhors im'estigate the importance ofphysical symptoms as a correlate of depressi"e symptoms and suicidal thoughts in a large ( N = 88/ ) community-hased samplc of persons infected with human immunodeficiency "irus. The study (}I'ercomes limitatiof/S of prior research hy minimi:ing (}I'erlap in mcasures of affcetil'e and physical symptoms. studying a more dil'l'1"se population. and ineluding correlates such as ml'asures of social support,jimction. cmploymellt. insurance c(}l'erage. and cognitil'e impairmellt in the analysis. The allfhors' data support the notion that in diagnosing depression in the medically ill, concern (}I'er isolating physical symptoms as eithl'l" "ajjectil'c" or "physical" may hc exaggeratcd.
I
nfection with the human immunodeficiency virus (HIV) has been associated with psychiatric morbidity and distress as is the case with other frequently terminal diseases. such as cancer,ln In particular. consistently high levels of depressive symptoms on self-report have been demonstrated. and the prevalence of depressed mood among HIV-infected inpatients is similar to that seen among other medical inpatients:· 7- 1ll HIV-infected individuals may also show an increased tendency to have suicidal thoughts and may be at greater risk for suicide,~·'·II-I' In contrast to depressive symptoms or mood. two methodologically thorough attempts at diagnosis of major depres-
Received May 16. 1991: revised August ~O. 1991: accepted September 4. 1991. From Massachusells General Hospital and Harvard University. Boston: and the Center for Gerontology and Health Care Research. Brown University. Providence, RI. Address reprint re4uests to Dr. Mor. Center for Gerontology and Health Care Research. Brown University. Box G. Providence. RI O~9 i~. Copyright © 199~ The Academy of Psychosomatic Medicine.
sion in this population suggest a prevalence range of approximately ~"SC)/()_lO%.x.II' The correlates of depressive symptoms in HIV-infected individuals remain unclear. Many of the studies reported to date have focused on comparing levels of distress on the basis of disease stage (i,e .. HIV-negative. HIV-positive asymptomatic. acquired immune deficiency syndrome IAIDSI. AIDS-related complex IARCI).x.71714 Some investigators have found that patients with AIDS have less psychological distress and depressive symptomatology than those with ARC or those who are HIV-positive but asymptomatic.x.,x.~" However. in other terminal illnesses. particularly cancer, reported physical symptoms (perceived or real) are a more important predictor of depressive symptoms than clinical disease stage. This appears to be true of HIV disease as well. A detailed study of clinical staging and immunological parameters found an association between depressive disorders or distress and the number of HIV-related symptoms, which "warrants further study... 14 One of the PSYCIIOSOMATICS
Belkin et al.
only large studies of HIV-infected individuals '7 found that HIV-related physical symptoms were more important predictors of depressive symptoms than actual disease stage. Absence of a confidant also predicted depressive symptoms. whereas demographic characteristics had weak effects. Exploration of depressive symptoms in HIV is relevant to a familiar topic in medical psychiatry: distinguishing physical from affective symptoms. As with affective disorders in the context of other medical illnesses, the symptoms and course of the underlying HIV infection complicate understanding the significance of depressive symptoms. Although prior work suggests a strong association between physical symptoms and affective disorder in those with HIV, few studies have systematically investigated this association in a large and diverse sample of individuals. Prior studies suffer from several limitations. First. patients are often recruited only from clinical settings, and, with some exceptions,17 most empirical research is based on small samples (e.g .. 13,~ 45,x 65,'X 124 1Y ) that preclude detailed examination of correlates of depressive symptomatology. Additionally, male homosexuals have been the subjects of most studies,x.Jn.J7-,y.~J which thus largely ignores depression among women and intravenous drug users (lVDUs). By use of a large community-based sample of individuals infected with HIV, the present study investigates the association of physical symptoms with depressive symptoms and the presence of suicidal thoughts. The effects of demographic variables. social support, physical disability, and cognitive impairment are also examined. METHODS Sampling Participants were individuals with HIV over age 18 years. who were interviewed in 1988-1989 as part of the evaluation of the Robert Wood Johnson Foundation's AIDS Health VOLUME 33· NUMBER 4· FALL 1992
Services Program, a multi-site demonstration of community-based care for AIDS patients. Personal interviews were held with 1,031 program clients in nine communities: Newark and Jersey City (186 respondents), Atlanta (182 respondents), New Orleans (135 respondents), Dallas (168 respondents). Miami (45 respondents). Ft. Lauderdale (75 respondents). Seattle (57 respondents), and Nassau County, NY (183 respondents). We recruited respondents from the primary local community-based AIDS service organization (except in New Jersey and Florida) and from outpatient HIV clinics at public hospitals. Overall, 621 respondents were recruited from clinics and 410 from community-based organizations (CBOs). In all sites, direct service providers made the initial request to participate in the study. Overall, of the 1.268 people referred to the interviewers by direct service providers. 1.031 (81 %) were interviewed. Major reasons for failure to conduct an interview include refusal (7%), death (2%), and failure to locate (3%). Agency staff reported that clients who were more physically or mentally impaired or who were less connected to the service system were apparently less likely to be referred for interviewing. In general. the clinic sample overrepresents males, homosexuals. and whites, whereas the CBO sample overrepresents whites and IVDUs. (More detailed comparisons of samples are reported elsewhere.~~) Despite these biases, our sample is more diverse, particularly in risk group and gender characteristics. than most of the cited literature. Dependent Variables Depression was measured using the RAND depression screener.~·l which combines six items from the Center for Epidemiological Studies-Depression Scale (CES-D)~~ with two items from the Diagnostic Interview Schedule (DlS).~~ The six CES-D items concern dysphoric mood (i.e .• feel depressed, restless sleep. enjoy life. have crying spells, feel sad. and feel that people dislike you) and do not measure 417
Physical and Depressive Symptoms and HIV
neurovegetative symptoms (e.g.. loss of appetite) that may result from physical conditions. The DIS items ask respondents about feeling "sad. blue. or depressed" for 2 weeks or more in the past year and whether the respondent has felt depressed or sad much of the time for a period of 2 years. Items from the instruments were combined using the weights and procedures developed by Burnam et al.~\ Respondents were classified as either "depressed" or "nondepressed" using the cutoff score of 0.06 that was proposed by Burnam et al. ~.\ to maximize the sensitivity of the screener for depressive disorder within the past month. Using this cutpoint. Burnam et al.~\ report sensitivities in several samples ranging from 0.87 to 0.70 and specificities ranging from 0.96 to 0.65. Respondents' suicidal thoughts were measured by one item. which asked how often in the past week the respondents had "thought about suicide." The respondents used a four-point response scale (less than I day. 1-2 days. 3-4 days. 5-7 days). Independent Variables Sociodemographic variables measured included gender and race (white non-Hispanic vs. nonwhite or Hispanic). Respondents reporting any episode of intravenous drug use in the prior 8 years. including those who were homosexual/bisexual. were classified as IVDUs. Employment and insurance coverage (none/public/private) were also noted. Social support was assessed by responses to questions on the perceived availability of friends or relatives to provide assistance with each of seven tasks (e.g.. help with household chores, help with bathing or dressing. provide transportation, provide loan of $100). Items similar to these have been used in established measures of instrumental social support.~6 Responses were summed to create an overall social support scale (Cronbach's .uioll. New York. John Wiley. IlJ1l9 29. Agresti A: Categoriml Del/a Allalysis. New York. John Wiley. 1990 30. Wells KB. Stewan A. Hays RD. et al: The functioning and well-being of depressed patients. lAMA 262:914919. 19119 31. Klerman GL: Depressivedisorders. Arch Gi'll Psychiatry 46:1156-11511. 19119 32. Moflic HS. Paykel ES: Depression in medical inpatients. Hrl Psychiatr." 126:346-353. 1975 33. SchwabJJ. Bialow M. Brown J. et al: Diagnosing depression in medical inpatients. A/lllllllem Med 67:695-707. 1967 34. Bukberg J. Penman D. Holland JC: Depression in hospitalized cancer patients. Psycllll.wm Mi>d 46: 199-212. IlJ1l4 35. Derogatis LR. Morrow GR. Fellig J. et al: The prevalence of psychiatric disorders among cancer patients. lAMA 249:751-757. 19113 36. Peck A: Emotional reactions 10 having cancer. Americall lO/lmal of Roelllgelll,logy 114:591-599. 1972 37. Endicoll J: Measurement of depression in patients with cancer. Calleer 53(suppll:2243-22411. 1984 311. Rodin G. Voshart K: Depression in the medically ill: an overview. Am 1 Psychiatry 143:696-705. 1986 39. Emmons CA. Felling JH. Zonderman AB: A comparison of the symptoms of medical and psychiatric patients matched on the Beck Depression Inventory. Gell Hosp Psychiatry 9:398-404. 19117 40. Kathol RG. Mutgi A. Williams J. et al: Diagnosis of major depression in cancer patients according 10 four sels of criteria. Am 1 Psychiatry 147: 1021-1024. 1990 41. Cavanaugh SVA: Diagnosing depression in the hospitalized patient with chronic medical illness. 1 Clill Psychiatry 45: 13-16.1984 42. Plumb MM. Holland J: Comparative studies of psycho-
PSYCHOSOMATICS
Belkin et al.
logical function in patients with advanced cancer: I. self-reported depressive symptoms. Psychnsnm Med 39:264-276. 1977 43. Kathol RG. Noyes R Jr. Williams J. et al: Diagnosing depression in patients with medical illness. Psychosomatics 31:434-440.1990 44. Perry S: Organic mental disorders caused by HIV: update on early diagnosis and lreatmenl. Am J Psychiatry 147:696-710.1990 45. Navia BA. Jordan BD. Price RW: The AIDS dementia complex: I. clinical features. Ann Neurnl 19:517-524. 1986 46. Krell P. Wisniewski A. Jensen P: Relationship between cognitive dysfunction and mood state at different stages of HIV disease. Presented at the Sixth International Conference on AIDS. San Francisco. June 1990 47. Velin R. Healon R. Alkinson J. el al: Neuropsychological change at one-year follow-up in HIV infecled males. Presented at the Sixlh International Conference on AIDS. San Francisco. June 1990 48. Kessler RC. Price RH. Wonman CB: Social factors in psychopalhology: stress, social suppon. and coping processes. Annu Rei' Psychol 36:531-572. 1985 49. Cohen S. Syme LE: Social Support and Health. New York. Academic. 1985 50. Cohen S. Wills TA: Slress, social suppon. and the buffering hypothesis. Psychol Bull 98:310-357. 1985 51. Rounsaville BJ. Weissman MM. Kleber HD: An evalu-
VOLUME 33· NUMBER 4· FALL 1992
ation of depression in opiate addicls. Research in Community and Memal Health 3:257-289. 1983 52. Perry S, Jacobsberg L, Fishman B: Suicidal ideal ion and HIV tesling. JAMA 263:679~2. 1990 53. Davidson L: Suicide and violence in the medical selling, in Principles of Medical Psychiatry. edited by Stoudemire A. Fogel B. Orlando. FL, Grune & Stratton. 1987. pp 219-235 54. Fox BH, Stanek EJ, Boyd SC. et al: Suicide rates among cancer patients in Connecticul. Journal of Chronic Disorders 35:89-100, 1982 55. Louhivouri A. Hakama M: Risk of suicide among cancer patients. Am J Epidemiol 109:59-65. 1979 56. Reich P, Kelly MJ: Suicide allempts by hospitalized medical and surgical patients. N En~1 J Med 294:298301. 1976 57. Kellner CH. Best CL. Robens JM. et al: Self-destructive behavior in hospitalized medical and surgical palients. Psychiatr Clin North Am 2:279-289. 1985 58. Murphy GE: On suicide prediction and prevention. Arch Gen Psychiatry 40:343-344. 1983 59. Brown JH. Henteleff P. Barakal S. et al: Is it normal for lerminally ill patients to desire death? Am J Psychiatry 143:208-211. 1986 60. Brown GR. Rundell JR: Suicidal tendencies in women with human immunodeficiency virus infection (letter). Am J Psychiatry 146:560--561. 1989
427
A.
FLEISHMAN, PH.D., MICHAEL D. STEIN, M.D.
JOHN PIETTE, PH.D., VINCENT MOR, PH.D.
The allfhors im'estigate the importance ofphysical symptoms as a correlate of depressi"e symptoms and suicidal thoughts in a large ( N = 88/ ) community-hased samplc of persons infected with human immunodeficiency "irus. The study (}I'ercomes limitatiof/S of prior research hy minimi:ing (}I'erlap in mcasures of affcetil'e and physical symptoms. studying a more dil'l'1"se population. and ineluding correlates such as ml'asures of social support,jimction. cmploymellt. insurance c(}l'erage. and cognitil'e impairmellt in the analysis. The allfhors' data support the notion that in diagnosing depression in the medically ill, concern (}I'er isolating physical symptoms as eithl'l" "ajjectil'c" or "physical" may hc exaggeratcd.
I
nfection with the human immunodeficiency virus (HIV) has been associated with psychiatric morbidity and distress as is the case with other frequently terminal diseases. such as cancer,ln In particular. consistently high levels of depressive symptoms on self-report have been demonstrated. and the prevalence of depressed mood among HIV-infected inpatients is similar to that seen among other medical inpatients:· 7- 1ll HIV-infected individuals may also show an increased tendency to have suicidal thoughts and may be at greater risk for suicide,~·'·II-I' In contrast to depressive symptoms or mood. two methodologically thorough attempts at diagnosis of major depres-
Received May 16. 1991: revised August ~O. 1991: accepted September 4. 1991. From Massachusells General Hospital and Harvard University. Boston: and the Center for Gerontology and Health Care Research. Brown University. Providence, RI. Address reprint re4uests to Dr. Mor. Center for Gerontology and Health Care Research. Brown University. Box G. Providence. RI O~9 i~. Copyright © 199~ The Academy of Psychosomatic Medicine.
sion in this population suggest a prevalence range of approximately ~"SC)/()_lO%.x.II' The correlates of depressive symptoms in HIV-infected individuals remain unclear. Many of the studies reported to date have focused on comparing levels of distress on the basis of disease stage (i,e .. HIV-negative. HIV-positive asymptomatic. acquired immune deficiency syndrome IAIDSI. AIDS-related complex IARCI).x.71714 Some investigators have found that patients with AIDS have less psychological distress and depressive symptomatology than those with ARC or those who are HIV-positive but asymptomatic.x.,x.~" However. in other terminal illnesses. particularly cancer, reported physical symptoms (perceived or real) are a more important predictor of depressive symptoms than clinical disease stage. This appears to be true of HIV disease as well. A detailed study of clinical staging and immunological parameters found an association between depressive disorders or distress and the number of HIV-related symptoms, which "warrants further study... 14 One of the PSYCIIOSOMATICS
Belkin et al.
only large studies of HIV-infected individuals '7 found that HIV-related physical symptoms were more important predictors of depressive symptoms than actual disease stage. Absence of a confidant also predicted depressive symptoms. whereas demographic characteristics had weak effects. Exploration of depressive symptoms in HIV is relevant to a familiar topic in medical psychiatry: distinguishing physical from affective symptoms. As with affective disorders in the context of other medical illnesses, the symptoms and course of the underlying HIV infection complicate understanding the significance of depressive symptoms. Although prior work suggests a strong association between physical symptoms and affective disorder in those with HIV, few studies have systematically investigated this association in a large and diverse sample of individuals. Prior studies suffer from several limitations. First. patients are often recruited only from clinical settings, and, with some exceptions,17 most empirical research is based on small samples (e.g .. 13,~ 45,x 65,'X 124 1Y ) that preclude detailed examination of correlates of depressive symptomatology. Additionally, male homosexuals have been the subjects of most studies,x.Jn.J7-,y.~J which thus largely ignores depression among women and intravenous drug users (lVDUs). By use of a large community-based sample of individuals infected with HIV, the present study investigates the association of physical symptoms with depressive symptoms and the presence of suicidal thoughts. The effects of demographic variables. social support, physical disability, and cognitive impairment are also examined. METHODS Sampling Participants were individuals with HIV over age 18 years. who were interviewed in 1988-1989 as part of the evaluation of the Robert Wood Johnson Foundation's AIDS Health VOLUME 33· NUMBER 4· FALL 1992
Services Program, a multi-site demonstration of community-based care for AIDS patients. Personal interviews were held with 1,031 program clients in nine communities: Newark and Jersey City (186 respondents), Atlanta (182 respondents), New Orleans (135 respondents), Dallas (168 respondents). Miami (45 respondents). Ft. Lauderdale (75 respondents). Seattle (57 respondents), and Nassau County, NY (183 respondents). We recruited respondents from the primary local community-based AIDS service organization (except in New Jersey and Florida) and from outpatient HIV clinics at public hospitals. Overall, 621 respondents were recruited from clinics and 410 from community-based organizations (CBOs). In all sites, direct service providers made the initial request to participate in the study. Overall, of the 1.268 people referred to the interviewers by direct service providers. 1.031 (81 %) were interviewed. Major reasons for failure to conduct an interview include refusal (7%), death (2%), and failure to locate (3%). Agency staff reported that clients who were more physically or mentally impaired or who were less connected to the service system were apparently less likely to be referred for interviewing. In general. the clinic sample overrepresents males, homosexuals. and whites, whereas the CBO sample overrepresents whites and IVDUs. (More detailed comparisons of samples are reported elsewhere.~~) Despite these biases, our sample is more diverse, particularly in risk group and gender characteristics. than most of the cited literature. Dependent Variables Depression was measured using the RAND depression screener.~·l which combines six items from the Center for Epidemiological Studies-Depression Scale (CES-D)~~ with two items from the Diagnostic Interview Schedule (DlS).~~ The six CES-D items concern dysphoric mood (i.e .• feel depressed, restless sleep. enjoy life. have crying spells, feel sad. and feel that people dislike you) and do not measure 417
Physical and Depressive Symptoms and HIV
neurovegetative symptoms (e.g.. loss of appetite) that may result from physical conditions. The DIS items ask respondents about feeling "sad. blue. or depressed" for 2 weeks or more in the past year and whether the respondent has felt depressed or sad much of the time for a period of 2 years. Items from the instruments were combined using the weights and procedures developed by Burnam et al.~\ Respondents were classified as either "depressed" or "nondepressed" using the cutoff score of 0.06 that was proposed by Burnam et al. ~.\ to maximize the sensitivity of the screener for depressive disorder within the past month. Using this cutpoint. Burnam et al.~\ report sensitivities in several samples ranging from 0.87 to 0.70 and specificities ranging from 0.96 to 0.65. Respondents' suicidal thoughts were measured by one item. which asked how often in the past week the respondents had "thought about suicide." The respondents used a four-point response scale (less than I day. 1-2 days. 3-4 days. 5-7 days). Independent Variables Sociodemographic variables measured included gender and race (white non-Hispanic vs. nonwhite or Hispanic). Respondents reporting any episode of intravenous drug use in the prior 8 years. including those who were homosexual/bisexual. were classified as IVDUs. Employment and insurance coverage (none/public/private) were also noted. Social support was assessed by responses to questions on the perceived availability of friends or relatives to provide assistance with each of seven tasks (e.g.. help with household chores, help with bathing or dressing. provide transportation, provide loan of $100). Items similar to these have been used in established measures of instrumental social support.~6 Responses were summed to create an overall social support scale (Cronbach's .uioll. New York. John Wiley. IlJ1l9 29. Agresti A: Categoriml Del/a Allalysis. New York. John Wiley. 1990 30. Wells KB. Stewan A. Hays RD. et al: The functioning and well-being of depressed patients. lAMA 262:914919. 19119 31. Klerman GL: Depressivedisorders. Arch Gi'll Psychiatry 46:1156-11511. 19119 32. Moflic HS. Paykel ES: Depression in medical inpatients. Hrl Psychiatr." 126:346-353. 1975 33. SchwabJJ. Bialow M. Brown J. et al: Diagnosing depression in medical inpatients. A/lllllllem Med 67:695-707. 1967 34. Bukberg J. Penman D. Holland JC: Depression in hospitalized cancer patients. Psycllll.wm Mi>d 46: 199-212. IlJ1l4 35. Derogatis LR. Morrow GR. Fellig J. et al: The prevalence of psychiatric disorders among cancer patients. lAMA 249:751-757. 19113 36. Peck A: Emotional reactions 10 having cancer. Americall lO/lmal of Roelllgelll,logy 114:591-599. 1972 37. Endicoll J: Measurement of depression in patients with cancer. Calleer 53(suppll:2243-22411. 1984 311. Rodin G. Voshart K: Depression in the medically ill: an overview. Am 1 Psychiatry 143:696-705. 1986 39. Emmons CA. Felling JH. Zonderman AB: A comparison of the symptoms of medical and psychiatric patients matched on the Beck Depression Inventory. Gell Hosp Psychiatry 9:398-404. 19117 40. Kathol RG. Mutgi A. Williams J. et al: Diagnosis of major depression in cancer patients according 10 four sels of criteria. Am 1 Psychiatry 147: 1021-1024. 1990 41. Cavanaugh SVA: Diagnosing depression in the hospitalized patient with chronic medical illness. 1 Clill Psychiatry 45: 13-16.1984 42. Plumb MM. Holland J: Comparative studies of psycho-
PSYCHOSOMATICS
Belkin et al.
logical function in patients with advanced cancer: I. self-reported depressive symptoms. Psychnsnm Med 39:264-276. 1977 43. Kathol RG. Noyes R Jr. Williams J. et al: Diagnosing depression in patients with medical illness. Psychosomatics 31:434-440.1990 44. Perry S: Organic mental disorders caused by HIV: update on early diagnosis and lreatmenl. Am J Psychiatry 147:696-710.1990 45. Navia BA. Jordan BD. Price RW: The AIDS dementia complex: I. clinical features. Ann Neurnl 19:517-524. 1986 46. Krell P. Wisniewski A. Jensen P: Relationship between cognitive dysfunction and mood state at different stages of HIV disease. Presented at the Sixth International Conference on AIDS. San Francisco. June 1990 47. Velin R. Healon R. Alkinson J. el al: Neuropsychological change at one-year follow-up in HIV infecled males. Presented at the Sixlh International Conference on AIDS. San Francisco. June 1990 48. Kessler RC. Price RH. Wonman CB: Social factors in psychopalhology: stress, social suppon. and coping processes. Annu Rei' Psychol 36:531-572. 1985 49. Cohen S. Syme LE: Social Support and Health. New York. Academic. 1985 50. Cohen S. Wills TA: Slress, social suppon. and the buffering hypothesis. Psychol Bull 98:310-357. 1985 51. Rounsaville BJ. Weissman MM. Kleber HD: An evalu-
VOLUME 33· NUMBER 4· FALL 1992
ation of depression in opiate addicls. Research in Community and Memal Health 3:257-289. 1983 52. Perry S, Jacobsberg L, Fishman B: Suicidal ideal ion and HIV tesling. JAMA 263:679~2. 1990 53. Davidson L: Suicide and violence in the medical selling, in Principles of Medical Psychiatry. edited by Stoudemire A. Fogel B. Orlando. FL, Grune & Stratton. 1987. pp 219-235 54. Fox BH, Stanek EJ, Boyd SC. et al: Suicide rates among cancer patients in Connecticul. Journal of Chronic Disorders 35:89-100, 1982 55. Louhivouri A. Hakama M: Risk of suicide among cancer patients. Am J Epidemiol 109:59-65. 1979 56. Reich P, Kelly MJ: Suicide allempts by hospitalized medical and surgical patients. N En~1 J Med 294:298301. 1976 57. Kellner CH. Best CL. Robens JM. et al: Self-destructive behavior in hospitalized medical and surgical palients. Psychiatr Clin North Am 2:279-289. 1985 58. Murphy GE: On suicide prediction and prevention. Arch Gen Psychiatry 40:343-344. 1983 59. Brown JH. Henteleff P. Barakal S. et al: Is it normal for lerminally ill patients to desire death? Am J Psychiatry 143:208-211. 1986 60. Brown GR. Rundell JR: Suicidal tendencies in women with human immunodeficiency virus infection (letter). Am J Psychiatry 146:560--561. 1989
427
