Depression, including antidepressant use, has not been widely studied in the HIV-positive population or at all in HIV-positive Native Hawaiians. Of 1016 clients in Hawaii's HIV Seropositivity and Medical Management Program in 2001-2002, 300 (30%) reported having depression and half reported taking antidepressants. Native Hawaiians had the lowest depression rates of any group. Antidepressant use did not vary by race/ethnicity

Juday, Timothy R

Richmond-Crum, Suzanne M.

eVols at University of Hawaii at Manoa

Depression and Antidepressant Useamong People Living with HIV in Hawaii:Focus on Native HawaiiansAbstractDepression. tncludng antidepressant use hs not beenwidely studred n the HlVoosrtive popu!at!on or at all/n Hl%oosrtive Native Hawaiians, Of 1016 clients inHa wa//h H/V Seropositivity and Medical ManagementProgram in 2001-2002, 300 (30%) reported havingdepression and half reported taking antidepressants.Native Havvaiians had the lowest depression ratesof any group. Antidepressant use did not vary byrace/ethnicity.IntroductionDepression is canmon symptoni of HIV disease.with an estiniated pres alence of 22 /—450 Penzak eta!. 2000L Studies have found an association betseendepression and negative effects on the health of HIV-.infected indis iduals. including delays in proteaseinhibitor initiation, acceleration in disease progression.and an increase in the probability ot death Leser—man 2000. Mavnc ci al. 1996j. Qual it\ of life issueshave also become mncreasinelv important for peoplewith H IV disease. particularly those on antiretroviraltherapv.Antidepressants offer the promise of easingthe symptoms of depression among H IV—infectedindividuals and of possibly lowering total health carecosts (Sambamoorthi et a!. 2000).This research investigates self-reported depressionand antidepressant use among HIV-positive individualsin Hawaii during 2001 to 2002. It focuses on the importance of race/ethnicity, particularly Native Hawaiianethnicity, as ss elI as other factors in explaining self—reported depression and self—reported antidcpre’s antuse.While depression and the use of antidepressants havebeen studied in some 1—11 V—positive popul atm m s. mostnotabl\ svhite.Atrmcan Americans. and Hispanics.there are no published studies of Naims e Hawanans.in addition, previous rcsearc h on depression andantidepressant use in H I V—positive persons has onlyfocused on the Medicaid population (see Samiihanioorthiet al. 200flc Because l’theeconomicall and sociall’discrsc population used in this studs. it can pros idebroader insights. I- r example. the research assessesstudy outcomes.MethodsThe data source is Hawaii’s HIV Seropositivitv andMedical Management (HSPAMM) Program. whichcontains sociodemographic, behavioral, and medicaldata on HIV infected persons throughout the State ofHawaii. KSPAMM is the largest and most representative source of data on HIV-positive individuals inHawaii. I {SPAMM is a statewide program administered by the STD/AIDS Prevention Branch of theHawaii Department of Health. Any person residingin Hawaii ss ho is H V—positive, regardless of incomelevel, is eligible l’or HSPAMM. The program paysall costs associated with a standard set of services atsemi—annual ph sician visits. each visit, extensiveinformation is collected from patient questionnaires.phssician exammations. and laborator\ testing. ‘l’heHSPAMM program follows these individuals longitudinaHv through the use of a unique identifier clientcoding s stem.Over 2,500 individuals have participated in HSPAMM since its inception in 1989. Data for thisanalysis were obtained for all HSPAMM enrolleeswho made at least one HSPAMM visit during 2001or 2002. If multiple visits were recorded for anenrollee during the two-year period (which is likelysince HSPAtvIM covers two visits per year). unIvthe first recorded visit for the two—year period ss asused. During 2001 and 2ff 2, HSPAMM had 1 .016enrol lees.The SAS S\ stem version 8.2 was used for all statistical anaL ses. Logistic regression was applied tothe data to identif the variables associated ss ith depression and antidepressant use among HIV-inl’eetedindividuals in the HSPAMM program. Lisingstepss iseselection, all ‘ armables with a p—s’alue of less than ((.3(1wei’e remus ed h’om successive models until the iuostparsimonious model was found for each dependentvariable. Adjusted odds ratios OR) and associatedconfidence intervals were calculated from parimeterthe importance of income and health insurance onAuthors:- Department of Public HealthSciences and Epidemiology.University of Hawai at Manoa.Honolulu. HI IT.R.J.)- STD AIDS Prevention Branch,Hawai Department of Health,Honour.. HI IS.M PhD)Cor,esoocerceT’ro% RJ.oa P-V MPAHa’aPr.jc Heat”Sce”r.es ad EcoemocorEast-dec R°aoBo’rec D’%FHOEC,,. Ph%6-56’HAIurH MED:CAL •.!:. .L. r-: APRL.90estimate transformations. Odds ratios that exceed Iindicate an increased likelihood (statistical significanceof p<(.05) of self-reported depression or self-reporteduse of antidepressant medication, respectively.Both of the dependent variables are dichotomous, The first dependent variable is self-reporteddepression. Depression is defined as self-reporteddepression lasting at least two months, self-reportedhospitalization for depression during the past sixmonths, or self-reported antidepressant use during thepast six months. The second dependent variable isself-reported antidepressant use Antidepressant useis defined as self-reported antidepressant use duringthe past six months.Data for the independent variables were self-reported (gender. race/ethnicity, born in Hawaii, age,income, medical insurance, antiretroviral use, smokecigarettes. drink alcohol, use marijuana, and use harddrugs). or obtained from laboratory data (likelihoodof developing an AIDS-related illness within threeyears). Hard drugs were defined as cocaine, heroinand/or methamphetamines. Likelihood of developingan AIDS-related illness is apatient severity index thatcombines both the patient’s CD4+T lymphocyte countand RT-PCR HIV plasma viral load, and estimates thelikelihood that a patient will develop an AIDS-relatedillness within three years (Panel on Clinical Practicesfbr Treatment of WV Infection, 2001). The threecategories are: less than I % likelihood of developing an AIDS-related illness, 2%-16% likelihood ofdeveloping an AIDS-related illness, and greater than32% likelihood of developing anAIDS-related illnesswithin three years. All independent variables weredichotomous except race/ethnicity and likelihood ofdeveloping an AIDS-related illness.ResultsTable I presents the sociodemographic. medical, andalcohol and drug use characteristics for the entirestud population, for the subset with self-reporteddepression. and for the subset on antidepressant medication. There were 1.016 HIV-infected persons inthe study population and 300(30%) had self-reporteddepression. Of the 300 individuals with self reporteddepression, 146(49%) reported taking antidepressantmedication.For the entire study population. females comprised11% and males 89%. Asians accounted for 12%.Native Hawai ians or Part Native Hawaiians 14%,Hispanics 7%, whites 58%. and other races and ciiinicities 9%, In the study population, 75% was notborn in Hawaii and 61% was 40 years of age or older.Approximately 39% had income less than S I (),000per year. and only 1 3% had no medical insurancecoverage. Over two-thirds of clients (70%) were onantiretroviral drugs and less than one-quarterof clients(22%) cit. in thL most su Lrcl ill of thc thi U. patientTable I — Characteristic at Study Papulatioi and Analytic SubseHSPAMM S m SeltReported SeltReporteda P e Depression Antidepressant UseNumber Percent Number Percent Number PercentN 1,016 100% 30Cr 100% 146r 100%GenderFemale 113 11 34 11 16 11Male 897 89 265 89 129 89EthnicityAsian 119 12 28 10 7 5Native Hawaiian 139 14 25 8 12 8Hispanic 73 7 25 8 10 7Other 96 9 32 11 12 8White —_582 58 188 63 104 72Born in HawaiiYes 256 25 61 21 20 14No 750 75 235 79 123 86Age400rmoreyears 615 61 182 61 102 71Less than 40 years 393 39 116 39 42 29Income$10,000 or more/year 597 61 155 53 95 66Less than $10000/year 385 39 136 47 48 34Medical InsuranceYes 873 87 257 86 137 94No 132 13 42 14 9 6AIDS Illness Likelihood>32% 214 22 68 24 26 192% to 16% 222 24 63 23 22 16<1% 525 54 149 53 87 65Antiretroviral UseYes 714 70 210 70 124 85No 302 30 90 30 22 15Smoke CigarettesYes 402 40 140 47 62 43No 607 60 158 53 83 57Drink AlcoholYes 432 43 115 39 57 39No 570 57 182 61 88 61Use MarijuanaYes 510 50 174 58 79 54No 501 50 124 42 67 46Use Hard DrugsYes 188 19 66 22 24 16No 822 61 231 78 122 84= Variable totals may not add up to 1.016 or 300 or 146, respectively. oue to missing valuesseverity of illness categories. Fewer than half of all clients used alcohol or anyspecific drug, except for marijuana, which was used by 50% of all clients,Table 2 presents adjusted odds ratios and associated confidence intervals forself-reported depression among clients in the entire study population. HIV-infectedNative Hawaiians in the HSPAMM program were significantly less likely to haveself-reported depression than whites (OR=0.42, 95% Cl t).25-0.7 1). While Asiansalso were less likely than whites to have self-reported depression. the differencewas not statistically significant tOR=0.62. 95% Cl 0.37-1 .02t.Three other variables in the model were also found to have an effect on self-reported depression in the study population. First, individuals who smokedcigarettes were more likely to have self-reported depression (OR=l.6l, 9Sf-CI 1 .18—2.20). Second, individuals who drank alcohol were less likely to have>clt icportcd dprLssIon (OR=0 68 95% CI 049 093) Thud those w.ho usud1AVVAH MF/DCAL. JOURNAL., VOL ArRL2UrJ.551Table 2— Adjusted Odo Ratios for Depression and At depressant UseLogistic Regression Logistic Regressionfor Self-Reported for Self-ReportedDepression Antidepressant UseOR 95%Cl OR 95%ClNGenderFemaleMaleEthnicityAsian 0.62 [0.37-1.02]Native Hawaiian 0.42* [0.25-0.71]Hispanic 0.98 [0.55-1.75]Other 1.09 [0.65-1.80]White Ret RefBorn in HawaiiYes 0.67 [0.33-1.35]No Ret RefAge40 or more years 1.67 [0.94-2,98]Less than 40 years Ret RetIncome$10,000 or more/year 0.75 [0.55-1.03] 2,06* [1.1 6-3.67]Less than $1 0000/year Ret Ret Ret RefMedical InsuranceYes 2.21 [0.90-5.44]No Ret RetAIDS Illness Likelihood>32% 0.73 [0.36-1.45]2%to 16% 0.53 [0.26-1.09]<1% Ret RetAntiretroviral UseYes 1.19 [0.86-1.66] 3.03’ [1.55-5.91]No Ret Ret Ret RetSmoke CigarettesYes 1,61* [1.18-2,20] 1.53 [0.85-2.77]No Ret Ret Ret RetDrink AlcoholYes 0.68* [0.49-0.93]No Ref RetUse MarijuanaYes 1,39* [1.01-1.90]No Ret RetUse Hard DrugsYes 0.64 [0.31-1.32]No Ret Ret*= 95% confidence interval does not include 1.0marijuana were more likely to have self-reported depression (OR=l.39, 95ff Ci1.01-I .90).Table 2 presents adjusted odds ratios and assocmted contIdence intervals forself-reported antidepressant use among members of the study population withself-reported depression. The final logistic regression model created throughstepwise selection did not include the race/ethnicity variable, Thus, race/ethnicity. including Native Hawaiian ethnicity, is not considered to he an importantdeterminant in whether an HIV-infected individual with self-reported depressionis on antidepressant medication.The logistic regression model did identify two variables of significance forantidepressant use in this population. Depressed individuals with an incomeof $ 10,000 or more per year were more likely to he treated with antidepressantmedication (OR=2.06. 95% Cl 1.16-3.67). Also.depressed persons on antiretroviral therapy were morelikely to take antidepressant medication (OR=3.03,95% Cl 1.55-5.91).DiscussionThe prevalence of depression among HSPAMMenrollees—30 percent—is similar to other studiesof depression in HIV-positive individuals (Penzaket al. 20)0), However, since this group may includesome individuals who do not have clinical depression, the actual prevalence of clinical depression inthis population is probably lower. The proportion ofdepressed HSPAMM clients on antidepressants—49percent—is similar to that cited in another publishedstudy (Sambamoorthi et al. 200€]).The analysis shows important differences betweenracial/ethnic groups in self-reported depression. Native Hawaiians had significantly lower adjusted ratesof depression than whites and the lowest rates of anyracial/ethnic group in the study. Asians also had loweradjusted rates of depression than whites, but the rateswere not statistically significant.These results raise interesting questions. Why doNative Hawaiians have the lowest depression ratesof any racial/ethnic group? is it due to cultural reasons, family support in Hawaii, support networks inHawaii. genetic factors, coping strategies? Furtherstudies investigating these questions might providevaluable insight into depression among HIV-positivepeople in Hawaii and allow for the development ofbetter treatment and coping strategies not only for Native Hawaiians with H1V. but also ft)r other affectedracial/ethnic groups.The study found that persons using tobacco weresignificantly more likely than non-users to haveself reported depression. The higher likelihood ofdepression among tobacco smokers and marijuanausers may be a result of depressed individuals treating their depression through tobacco or marijuanause. Conversely, alcohol drinkers were significantlyless likely than non-drinkers to have self-reporteddepression. These findings appear counterintuitive.as one might expect drinkers to have higher rates ofdepression. The explanation may bean artefactual one.as this variable does not separate social drinking fromalcohol abuse. Individuals who drink in moderationmay find alcohol to he a way to relax and cope withstress, instead of creating or deepening depression ascan he the case in alcohol abuse,The study found no significant differences in antidepressant use by race/ethnicity. This finding is apositive result of the study. It suggests that there arenot race-related differences in access to antidepressantmedication for HSPAMM clients with self-reporteddepression.HAVO,N ME/DCAL. ./OURNAL., VOL V.4, VP//V. PLOP92While antidepressant use was not associated with race/ethnicit.it was associated with takine antirctroiral medication. Since thestudy results do not indicate that taking antiretro iral medicationpredisposes one to depression. they may suggest that taking medication br HIV increases the vi lingncss of an individual to takeantidepressant medication for their depression.Antidepressant use was income sensiti\ e. Individuals with incomesgreater than S10.0(tO per ear were more llkel\ to he treated withanttdepressants. These results indicate that. in spite of the gencr—Otis cligihilit requirements and henetits as ailahle through its HIVDrug Assistance Program Li DAP). income is still a key factor indetermining whether an HR-positive individual receives neededmedication in Hawaii. More research is needed into why these barriers exist and how to improve access to appropriate medicationsfor Hawaii’s HR—positive poor population.A critical issue raised by this research is why only half of HIVinfected persons ss ith self-reported depression are taking anOdepressants. While some HSPAMM patients reporting depressivesymptoms may not have clinical depression and some may betreating their depression through non-pharmacological means (e.g..psychotherapy), it is likely that many patients who could be helpedthrough antidepressants are not being treated. Some physicians mayconsider depressed mood to be a normal state in patients with FIIVdisease, They may attn hute fatigue, sleeping problems. or loss ofappetite solely to HIV or medication side effects and not recognizethe full effects that depression may be having on functioning (Sambamoorthi et al. 2000). Some patients may not want to add anotherdrug to a complex medication regimen or accept side effects furtherlimiting their functioning ( Sambamoorthi et al. 2000). Physiciansshould work with patients to properly treat depressive symptomsas many antidepressant medications bring rapid clinical response,are easily tolerated, and can he used during the latest stages of HIVdisease Sambantoorthi et al. 2000). Further, depression may heinfluencing somatic symptoms and antidepressant treatment canproduce impro ement in these s\ niptoms Sambamoorthi et al.2000.The s1ud had sonic important limitations. First. while retlectiveof the HIV epidemic in Flaw au. O\ er half of the sample was coin—prised of whites: sample sties for other racial/ethnic groups weremuch smaller. Second, because most of the data was self—reportedby respondents and collected by the KSPAMM program throughan anonymous data collection process. the reliahilitn and validitof these data coLild not be veritied. Third. the individuals enrolledin HSPAM\l are likely less disenfranchised individuals. Theseare individuals with a primary care provitler. Individuals who aienot receis ing care for their HR infection or are receiving it in ahaphazard ss a tend not to enroll m the lISPAMM program.This research piusvidesevidcucc that ative Hawauans lis uig withHIV hase a lower prevalence ot depression than other racial/ethnicgroups. but not different antidepressant usage patterns. Asiansalso has e a low er prevalence of depression than whites, althoughthe results were not statistically signiticant. Further research intothe reasons for these differences, as well as other questions associated with depression and antidepressant use in the HIV-positivepopulation in I-law au. could provide important information guidingthe treatment of individuals with HIV infection and improve theirquality of life.ReferencesAnge/no AF. Treisman GJ Management of psychiathc daorders in patents ntected wdh human immunodehdency Urns, C/in Infect Dis. 2001 Sep 15:33(6(:847-56Batki SL. Drug abuse psychiatric disorders, and AIDS. Dual and triple diagnosis.WestJ Med 1990 May:152i31:547-52,Dsua:hy A. Singn N. Factors affecting quahty of life in patIents with FtC mfection.AIDS Read. 2001 Sep 19 450-4, 460-1, 475.Leserman J. Jackson ED. Pelditto JM eta]. Progression toA]DS:fhe etfectsof stress, depressive symptomsand socal support. Psychosom Med. 1999:61:397-406.Mayne T. Vitt:ngooff E. Csesrrey M. et a]. Depressive affect and survival among gay and bisesual mensifected w!ib H]V Arch Intern Med. 1996156:2233-2238.Panel on CInica’ Pracsces fr Treatment of HIV Infection Guidelines for the Use of AntiretroviralAgents in HI V-InfectedAdults and Adolescents. Department of Health and Human Servicesand Heny J. Kaiser Family Foundation. Rocksile. MD August 13, 2001.Penzak SR. Reody ‘iS. Gllmsley SR. Deprepsio in patients wjth HIV infector.Am J Health Syst Pharm. 2000 Feo ‘5:57i4’376A6. auiz 387-9.Sar0amnorth U. Waikup .J. O)sor M, Crysta S Anrdepressant rresimen’. and he.aiTh se’vces uti 05ron ar’ons H]V-,Uecred Aedca.d uentn o’agnoseo with deo.ressiu.n. J Den Intern Med.2300:t5:311-320U.S Census Bureau. Census 20000 Redistricting Data IPL. 94-171) Sun-mary File. U.SDeostnre: of Hewn arrd Human Servces. DeoartmeH of Conn.erc.e. Hvsr.tsJ’]is. t,ID Ma’cr. ‘9.94

Depression and antidepressant use among people living with HIV in Hawaii: focus on Native Hawaiians.

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Depression and antidepressant use among people living with HIV in Hawaii: focus on Native Hawaiians.

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