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Longitudinal Analysis From the HIV Epidemiology Research Study

Jeannette R. Ickovics, PhD; Merle E. Hamburger, PhD; David Vlahov, PhD; Ellie E. Schoenbaum, MD; Paula Schuman, MD; Robert J. Boland, MD; Janet Moore, PhD; for the HIV Epidemiology Research Study Group

JAMA. 2001;285:1466-1474.

Context  The impact of depression on morbidity and mortality among women with human immunodeficiency virus (HIV) has not been examined despite the fact that women with HIV have substantially higher rates of depression than their male counterparts.

Objective  To determine the association of depressive symptoms with HIV-related mortality and decline in CD4 lymphocyte counts among women with HIV.

Design  The HIV Epidemiologic Research Study, a prospective, longitudinal cohort study conducted from April 1993 through January 1995, with follow-up through March 2000.

Setting  Four academic medical centers in Baltimore, Md; Bronx, NY; Providence, RI; and Detroit, Mich.

Participants  A total of 765 HIV-seropositive women aged 16 to 55 years.

Main Outcome Measures  HIV-related mortality and CD4 cell count slope decline over a maximum of 7 years, compared among women with limited or no depressive symptoms, intermittent depressive symptoms, or chronic depressive symptoms, as measured using the self-report Center for Epidemiologic Studies Depression Scale.

Results  In multivariate analyses controlling for clinical, treatment, and other factors, women with chronic depressive symptoms were 2 times more likely to die than women with limited or no depressive symptoms (relative risk [RR], 2.0; 95% confidence interval [CI], 1.0-3.8). Among women with CD4 cell counts of less than 200 x 10⁶/L, HIV-related mortality rates were 54% for those with chronic depressive symptoms (RR, 4.3; 95% CI, 1.6-11.6) and 48% for those with intermittent depressive symptoms (RR, 3.5; 95% CI, 1.1-10.5) compared with 21% for those with limited or no depressive symptoms. Chronic depressive symptoms were also associated with significantly greater decline in CD4 cell counts after controlling for other variables in the model, especially among women with baseline CD4 cell counts of less than 500 x 10⁶/L and baseline viral load greater than 10 000 copies/µL.

Conclusions  Our results indicate that depressive symptoms among women with HIV are associated with HIV disease progression, controlling for clinical, substance use, and sociodemographic characteristics. These results highlight the importance of adequate diagnosis and treatment of depression among women with HIV. Further research is needed to determine if treatment of depression can not only enhance the mental health of women with HIV but also impede disease progression and mortality.

Author Affiliations: Department of Epidemiology and Public Health and the Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Conn (Dr Ickovics); Epidemiology Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Hamburger and Moore); Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York (Dr Vlahov); Department of Epidemiology and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Dr Schoenbaum); Department of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Mich (Dr Schuman); and Department of Psychiatry and Human Behavior, Brown University, Providence, RI (Dr Boland).

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