Judith A. Cook, PhD University of Illinois at Chicago Department of Psychiatry

1. Prevalence of Treated & Untreated Depression in a Cohort of HIV+ Women: Impact on Antiretroviral Therapy Utilization & HIV Disease Outcomes Judith A. Cook, PhD University of Illinois at Chicago Department of Psychiatry Presented at APHA Annual Meeting & Expo San Francisco, CA, October 30, 2012

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

3. Estimates of Depression Prevalence in Different U.S. Study Populations General HIV+ HIV+ Population Men Women 20%a 21%b 51%e 20%c 15%d a Kessler et al., 1994, Arch Gen Psych b Lyketsos et al., 1993, JAMA c Hays et al., 1992, J Consult Clin Psych d Sambamoorthi et al., 2000, J Gen Int Med e Cook et al., 2003, JAIDS

4. Research Has Established a Link Between Tx for Depression & Positive HIV Outcomes Depression treatment is associated with lower medical costs, greater HAART use and adherence, curtailed HIV disease progression, and lower AIDS-related mortality. DEPRESSION TREATMENT POSITIVE HIV OUTCOMES

5. Cook, Grey et al., 2006AIDS Care • Use of antidepressants plus mental health therapy, or use of mental health therapy alone significantly increased the probability of HAART utilization, compared to receiving no depression treatment.

6. Turner, Laine et al., 2003J Gen Intern Med • Women diagnosed with depression who received psychiatric and antidepressant tx had nearly a two-fold greater adjusted odds of adherence to ART, compared to women whose depression was untreated.

7. Cook, Grey et al., 2004Am J Public Health • While depressed women were more than twice as likely to experience AIDS-related mortality as non-depressed (controlling for HAART use & adherence), those receiving MH tx were significantly less likely to die.

8. Sambamoorthi, Walkup et al., 2000J Gen Int Med. • Antidepressant treatment for depressed HIV-positive individuals was associated with a 24% reduction in monthly total healthcare costs even controlling for socioeconomic and clinical characteristics.

9. Women’s Interagency HIV Study (WIHS) • Cohort study of HIV-positive women recruited in 6 cities: Chicago, Los Angeles, San Francisco/Bay Area, Bronx, Brooklyn, Washington, DC • Data collection bi-annually beginning in 1994 (1st cohort) until present • Bi-annual in-person interviews, physical exam, blood work, gynecological exam • Chart abstraction of medical records

10. World Mental Health (WMH)Composite International Diagnostic Interview (CIDI) • Allows researchers to assess & study the impact of mental & substance use disorders • Valid & reliable way for trained non-clinicians to generate diagnoses using the DSM-IV framework. • Measures prevalence • Measures severity • Determines risk factors • Assesses service use • Assesses use of medications • Assesses who is treated, who isn’t, & barriers to treatment

11. CIDI Participants (N=889) Average Age: 48 years (min-max = 27-77) Race/Ethnicity: 65% African American; 15% Hispanic/Latina; 17% White; 3% Other Education: 34% < HS education; 33% HS/GED; 25% some college; 8% college education/advanced degree Marital Status: 29% never married; 28% married/ cohabiting; 12% divorced; 11% widowed; 6% separated; 14% other Employment: 32% employed at time of interview Income: 51% < $12,000 annually Insurance Coverage: 96% insured

12. 12-month Prevalence of Depressive Disorder (DD): General U.S. Population Compared to HIV+ Women U.S. WIHS WomenSample Major DD 8.6%a 17.9% Dysthymia 1.9%a 8.7% Minor DD 1.0%b 1.6% a Source: National Comorbidity Survey-Replication, Kessler et al., 2005 b Source: Klier et al., 2000

13. Logistic Regression: HAART Use Among HIV+ Women with Depression Diagnosis VariablesO.R.Significance Depression tx 3.23 p<.05 Age 1.08 p<.05 High School Ed+ 0.00 ns Income < $12,000 0.05 p<.01 Minority 0.00 ns

14. Logistic Regression: Unsuppressed Viral Load (>1,000 copies/ml) Among HIV+ Women Treated and Not Treated for Depression VariablesO.R.Significance Depression tx 0.37 p<.05 Age 0.96 ns High School Grad+ 0.78 ns Income < $12,000 1.73 ns Minority 1.58 ns On HAART 0.18 p<.001

15. % of Women Reporting Mental Health Tx by Type of Professional* Type %N Psychiatrist 71 79 Social Worker 46 52 Medical Doctor 34 38 Counselor 31 35 Psychologist 29 33 Psychotherapist 23 26 Non-Medical Health Prof (RN, etc) 12 14 Spiritual Advisor 19 21 Does not add to 100% since women could report >1 type of professional

16. Helpfulness (“a lot” or “some”) of Mental Health Tx by Type of Professional* Type %N Psychiatrist 89 70 Social Worker 83 43 Medical Doctor 84 32 Counselor 80 28 Psychologist 76 25 Psychotherapist 85 22 Non-Medical Hlth. Prof. (RN, etc) 86 12 Spiritual Advisor 86 18 Does not add to 100% since women could report >1 type of professional

17. Additional Features of Tx for Depression • 71.4% of all women reporting depression tx said their tx helped “a lot” • 79.5% of women reporting depression tx reported a prescription for psychiatric medication

18. Conclusions • Prevalence of depression in this cohort of HIV+ women was two- to four-fold greater than in the general U.S. population of women • Most depressed women reported receiving tx from a professional; the large majority reported that tx was helpful. • Depressed women receiving MH tx were significantly more likely to be on HAART, & were less likely to have unsuppressed viral loads.