Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast.

Objectives: Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes.

Methods: A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina.

Results: Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness.

Conclusions: In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HIV/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed.

Key Words: AIDS, HIV, mental health, patient care, substance-related disorders

**********

The initiation of highly active antiretroviral therapy (HAART) has resulted in longer survival and reduced morbidity among HIV-infected individuals. (1) However, many people living with HIV/AIDS are not receiving the potential benefits of these treatments, either because they have not been prescribed the medications, or because of poor medication adherence. (2) Suboptimal adherence to antiretroviral therapy may result in treatment failure and the development of a drug-resistant virus. (2-8) Given the relation between adherence, patient outcome, and secondary HIV prevention, it is crucial to address the challenges associated with antiretroviral therapy adherence. (7) Mental illness and substance abuse have been consistently linked with lowered likelihood of receiving HAART (9,10) and poorer medication adherence. (2,7,11-14) In addition, mental health and substance abuse problems in HIV-positive populations have been associated with greater morbidity, decreased quality of life, and a higher risk of unsafe sexual and needle-sharing behaviors, which lead to further HIV transmission. (15-20)

Because substance use and mental disorders have been found to be underlying factors in both the spread of the disease (16-20) and the difficulty in treating those infected, (21,22) it is critical to determine the prevalence of these comorbidities so that interventions can be formulated to adequately address the problem. The HIV Cost and Services Utilization Study (HCSUS), a large national study of HIV-infected individuals receiving medical care, documented higher prevalence of mental illness (48%), substance abuse (19%), and co-occurring mental illness and substance abuse (13%) among HIV-infected individuals (23) in comparison to the general population (22%, 9.5%, and 3%, respectively). (24) Additional studies that have investigated the prevalence of substance abuse and mental illness in urban HIV clinics or specific HIV-positive populations, including men who have sex with men and injection drug users, (25-35) also identified levels higher than those in the general population. However, no studies have focused on the prevalence of substance abuse and/or mental illness in HIV populations in the deep South. (36) Although the national HCSUS study includes a sample of people living with HIV in the South, the study was not designed to provide regional estimates. Rather, comparisons must be made to the national estimates from the HCSUS study. (37)

Nationally, the number of new AIDS diagnoses increased 2.2% from 2000 to 2002. (38) In contrast, six Southeastern states that make up the deep South--North Carolina, South Carolina, Louisiana, Georgia, Alabama, and Mississippi (36)--have demographically similar HIV epidemics, and had a 26.5% increase in the number of new AIDS cases from 2000 to 2002. (38) Among the rest of the Southern states, the rate of increase was 9.0%. (38) Such increases demonstrate the urgent need to better understand the population being infected, which includes obtaining estimates of the level of substance use and mental disorders, since these comorbidities can influence prevention and treatment efforts. The repercussions of mental illness and substance use disorders may be particularly dire in the Southeast, where psychiatric treatment options are often limited, poverty and lack of insurance are highly prevalent, and HIV-related stigma is high. (39-41) In an effort to identify the extent of mental health and substance abuse problems among HIV-positive persons in the Southeast, this study describes the prevalence of these comorbidities within two large infectious diseases clinics in North Carolina and examines the relation of patient characteristics and psychiatric comorbidities.

Materials and Methods

Sample

Data for this study were obtained from two academic medical center Infectious Diseases Clinics as part of an ongoing multisite study of persons triply diagnosed with HIV, substance abuse, and mental illness. Both clinics were located in small metropolitan cities in North Carolina, populations under 250,000, and were the primary medical providers for the majority of HIV-infected patients in the surrounding rural areas.

As part of the multisite study, routine screening for symptoms of mental illness and substance use problems using a standardized screening instrument was initiated in the Infectious Diseases Clinics. Clinic medical providers or research staff obtained verbal informed consent and administered the screening instrument. Collection of screening data occurred between January 2000 and August 2002 in clinic A and between October 2000 and August 2001 in clinic B. The shorter data collection time in clinic B resulted in fewer subjects (n = 265); however, these subjects were representative of the HIV-positive patients seen at clinic B (n = 1,002) in terms of race, age, sex, insurance status, HIV RNA levels, and CD4 count.

Of the patients screened at clinic A (n = 1,169), only those who participated in that center's clinical database (n = 1,097, 93%) were included in this analysis. This sample was representative of all patients screened and all HIV-positive patients seen during the course of the study at clinic A (n = 1,414) with respect to race, age, sex, insurance status, CD4 count, and HIV RNA levels. Seven percent of patients approached at clinic A and 5% at clinic B were not screened, either because they refused or because they were unable to complete the screening instrument. Institutional review board approval was received from each site.

Data

The substance use items in the mental health and substance use screening instrument included the three questions from the Alcohol Use Disorders Identification Test (AUDIT), which measures frequency and amount of alcohol use. (42-45) Substance use items also included the questions from the Two-Item Conjoint Screen for Alcohol and Other Drug Problems, (44) which screens for problems of abuse and dependence, and two questions created for use in this study regarding frequency of prescription and nonprescription drug use. The substance use items were scored to establish a substance use problem, which was characterized by frequency of substance use, amount of substance use, and perceived problematic use of alcohol or drugs. (46)

Mental health screening questions included five items from the Composite International Diagnostic Interview (CIDI), (47,48) which queried about symptoms of depression, anxiety, and panic in the last year. We chose to assess for symptoms of depression, anxiety, and panic because they are highly prevalent psychiatric disorders that co-occur with many of the less prevalent disorders, and would be expected to identify individuals with clinically significant functional impairment. The screener also included a question about use of medications for depression or "nerve problems" in the previous year. Having symptoms of mental illness was defined as reporting any symptoms of depression, anxiety, or panic and/or use of medications for depression or "nerve problems" in the previous year. Because the purpose of the screener was to indicate the potential presence of a psychiatric disorder rather than to discern the specific disorder, only the presence of mental illness symptoms was reported rather than the specific type of symptom. Demographic and medical data were obtained through clinic databases.

A subset of patients who screened positive both for mental illness symptoms and substance use problems and met specific geographical residence requirements (n = 81) were eligible to participate in the multisite study of persons triply diagnosed with HIV, mental illness, and substance use disorders. This study included administration of the Structured Clinical Interview for DSM-IV Disorders (SCID) within 1 to 2 weeks after being screened. (49) Ninety-six percent (n = 78) of eligible patients consented to participate and completed the SCID. The positive predictive value of the screener in comparison to the SCID was 96% for mental disorders, 99% for substance use disorders, and 95% for both mental disorders and substance use disorders.

Analysis

Descriptive statistics were used to provide information about patient characteristics and symptoms of mental illness and substance use problems. We used Pearson [chi square] tests to explore the association between patient characteristics, including age, race, sex, CD4 count, viral load and rural/urban residence, and symptoms of mental illness and substance use problems. We also stratified the sample by race and sex to evaluate whether there were significant differences in symptoms of mental illness and substance use problems between racial and sex groups by using Pearson [chi square] tests.

Results

Of the 1,362 study participants, one third were female, nearly two thirds were black, and 81% resided in a rural zip code (rural was defined as less than 1,000 persons per square mile). Forty-five percent of participants had HIV RNA levels greater than 500. The demographic and clinical characteristics of participants from the two clinics were nearly identical (Table 1), with the exception of the proportion living in rural zip codes (83% in clinic A and 73% in clinic B, P < 0.001).

Sixty percent of patients reported symptoms of mental illness and close to one third (32%) reported substance use problems (Table 2). Nearly one quarter (23%) reported both substance use problems and symptoms of mental illness and less than one third (31%) reported neither mental illness symptoms nor substance use problems. No significant differences in symptoms of mental illness or substance use problems were detected between the clinics.

Men were significantly more likely than women to report substance use problems (P < 0.001) (Table 3). More women reported having any symptoms of mental illness than men, but this number was not statistically significant (P = 0.079). However, women did report a significantly higher number of mental illness symptoms (P = 0.0003). Nonwhite patients were less likely to report symptoms of mental illness than were white patients (P = 0.001). However, when the sample was stratified by sex, there were no differences identified by race for women (66% white, 62% nonwhite; P = 0.57), whereas men who were nonwhite were less likely than white men to report symptoms of mental illness (66% white, 52% nonwhite; P < 0.001). Patients over age 45 were less likely to have symptoms of mental illness (P = 0.023), substance use problems (P = 0.03), or symptoms of both disorders (P = 0.028) than younger patients. Patients with HIV RNA levels of 500 or above were more likely to have symptoms of mental illness (P = 0.042), substance use problems (P < 0.001), or symptoms of both mental illness and substance use problems (P < 0.001).

Discussion

The results of this large-scale study reveal a disturbingly high prevalence of symptoms of mental illness and substance use problems among individuals receiving HIV care in North Carolina. Sixty percent of subjects reported symptoms of mental illness, 32% reported substance use problems, and nearly one quarter identified both symptoms of mental illness and substance use problems. The Infectious Diseases Clinics included in these studies do not specifically target high-risk populations. Rather, these clinics serve almost all HIV-infected individuals in the geographic areas where they are located as well as the regions that surround them. Yet, the results are substantially higher than those identified in the general population (24) and in the national HCSUS study. (23) The prevalence of co-occurring mental illness symptoms and substance use problems (23%) is nearly double the prevalence of co-occurring mental illness and substance use problems reported from the HCSUS study (13%) (23) and 7 times greater than that identified for the general population (3%). (24)

Left untreated, symptoms of mental illness and substance use problems can have serious negative consequences, including greater mortality and morbidity, reduced quality of life, and poorer medication adherence. (2,7,11-15,50) Providing the necessary treatment for co-occurring mental illness and substance use disorders may be particularly problematic in the Southeastern United States because of limited availability of mental health and substance abuse treatments (39,40) as well as some of the highest levels of poverty and people without health insurance in the country. (51, 52) Poverty and lack of health insurance have been associated with higher levels of mental illness and substance abuse (20,23) and may act as barriers to identification and treatment of co-occurring disorders. (41,51,52) Although some of the differences in the prevalence of symptoms of mental illness and substance abuse identified in this study compared with previous studies may have been due to different definitions and measures of mental illness and substance abuse, factors such as poverty and lack of insurance may also offer some explanation for the greater prevalence of symptoms of mental illness and substance use problems identified in this study.

The results of this study must be taken in the context of its limitations. This clinic-based study only sampled patients engaged in HIV medical care, yet mental health and substance abuse problems are known to negatively affect access to care, (22,53) rendering a possible selection bias toward underestimation of prevalence. In addition, the screening methods did not provide psychiatric diagnoses, so we cannot conclusively determine the prevalence that would have resulted from more thorough diagnostic instruments. However, we believe it is unlikely that the screening methods resulted in an overestimate of the prevalence of mental illness and substance use disorders because of the high concordance (95%) between screening positive for both symptoms of mental illness and substance use problems and having SCID diagnoses of both a mental disorder and a substance use disorder among the subsample of subjects who received the SCID.

Furthermore, this was a cross-sectional study; therefore, we are unable to identify the contribution of either higher incidence or longer duration of mental illness and substance abuse in this population to the higher prevalence identified in this study relative to previous studies. Whether HIV-infected patients in the Southeastern United States have a higher incidence of substance use disorders and mental illness or whether they are more likely to go untreated, resulting in a higher prevalence, is unclear. Finally, the generalizability of this study to other areas of the country may be limited, as cultural climates may differ regionally.

Conclusion

Despite its limitations, this study provides critical information about the high prevalence of mental health and substance use problems in this largely rural HIV-positive population and demonstrates the need for routine screening for these comorbidities in medical settings. Because of the potentially serious consequences of untreated mental illness and substance abuse, steps should be taken to identify and provide adequate treatment for people with HIV/AIDS who have psychiatric comorbidities. However, many communities may lack the infrastructure and financial resources necessary to provide effective treatment for all people living with HIV/AIDS who have mental disorders and/or substance use disorders. (39,54-57) These shortages raise the question of how to assist these vulnerable individuals so that they do not have poor disease outcomes. Failure to adequately address mental health and substance use problems among HIV-infected individuals is likely to result in substantial societal costs, including productivity loss, injury, and crime, as well as health care expenditures associated with treatment failure and the spread of drug-resistant virus. (23-27)

Table 1. Description of infectious disease clinic samples (n = 1,362)

                                Clinic A   Clinic B  Total
                                n = 1,097  n = 265   n = 1,362

Age (yr)
  25 and younger                 7          7         7
  26-35                         28         31        29
  36-45                         43         41        43
  [greater than or equal to]46  22         22        22
Female                          33         32        33
Race/ethnicity
  Black                         63         62        62
  White                         33         35        34
  Hispanie                       1          1         1
  Other                          3          2         3
CD4 count <200                  29         29        29
Viral load <500                 55         54        55
Live in a rural area            83 (a)     72        81

All data are reported as a percentage.
(a) P < 0.05, two-sided, Pearson [chi square] test.

Table 2. Prevalence of symptoms of mental illness and substance abuse in
the infectious disease clinics (n = 1,357)

                         Clinic A       Clinic B  Total
                         n = 1,092 (a)  n = 265   n = 1,357

Substance abuse          33              30       32
Symptoms of mental       60              60       60
  illness
Both symptoms of mental  24              20       23
  illness and substance
  abuse
Neither symptoms of      31              30       31
  mental illness nor
  substance abuse

(a) Five patients were not included due to missing screener data.
All data are reported as a percentage.

Table 3. Bivariate associations of symptoms of mental illness and
substance abuse with patient characteristics (n = 1,357)

                                 Symptoms of       Substance
                                 mental illness    abuse

Sex
  Female                         63                26 (b)
  Male                           58                36
Race
  Nonwhite                       56 (b)            33
  White                          66                31
Age (yr)
  <26                            54                33
  26-35                          63                32
  36-45                          61                35
  [greater than or equal to]46   54 (a)            27 (a)
Viral load
  [greater than or equal to]500  62 (a)            39 (b)
  <500                           57                24
Cd4 count
  [greater than or equal to]200  63                33
  <200                           58                32

                                 Both substance      Neither substance
                                 abuse and           abuse nor
                                 mental illness      mental illness

Sex
  Female                         21                  33
  Male                           24                  30
Race
  Nonwhite                       23                  33 (b)
  White                          23                  26
Age (yr)
  <26                            20                  33
  26-35                          25                  29
  36-45                          25                  29
  [greater than or equal to]46   18 (a)              36 (a)
Viral load
  [greater than or equal to]500  28 (b)              27 (b)
  <500                           17                  36
Cd4 count
  [greater than or equal to]200  24                  29
  <200                           22                  32

All data reported as a percentage.
(a) P < 0.05, [chi square] test.
(b) P < 0.01, [chi square] test.

Acknowledgments

The authors thank Rodney Thompson and Leslie King for their excellent work with the screener (Leslie for her literature and preliminary writing). They also thank Rachel Stevens, Priya Saigal, and Melissa Moore for their editorial and administrative support and the clinics involved for their assistance in providing space for this study.

Accepted October 5, 2004.

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RELATED ARTICLE: Key Points

* Mental illness and substance abuse have been associated with poor HIV-medication adherence, which may result in treatment failure or poorer health outcomes.

* This study found a high prevalence of symptoms of mental health (60%) and substance abuse (32%) comorbidities in a population of HIV-positive patients receiving care in the Southeast.

* Such comorbidities should be addressed to improve HIV treatment outcomes.

Kathryn Whetten, PHD, Susan S. Reif, PHD, Sonia Napravnik, PHD, Marvin S. Swartz, MD, Nathan M. Thielman, MD, Joseph J. Eron, Jr, MD, Kristin Lowe, BS, and Tomas Soto, PHD

From the Department of Public Policy, the Department of Community and Family Medicine, and the Health Inequalities Program, Duke University, Durham, NC; the Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; the Department of Psychiatry and Behavioral Sciences, the Division of Infectious Diseases and International Health, and the Department of Medicine, Duke University Medical Center, Durham, NC; and the Department of Research, The CORE Center/Cook County Hospital, Chicago, IL.

Supported by Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS), grant 93-230, and its Center for Substance Abuse Treatment (CSAT); the HIV/AIDS Bureau (HAB), Health Resources and Services Administration; the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA); the University of North Carolina (UNC) Center for AIDS Research, grant #P30-AI50410.

Institutional Review Board approval was received from each site.

The content of this publication does not necessarily reflect the views or policies of SAMHSA, HRSA, NIH or the US Department of Health and Human Services. The authors have no commercial or proprietary interest in the screening instrument or in anything mentioned in the article.

Reprint requests to Dr. Kristin Lowe, Center for Health Policy, Law, and Management, Duke University, Box 90253, Durham, NC 27708. Email: [e-mail]