Chronically Depressed Women with HIV Almost Twice As Likely As Others to Die from AIDS-Related Causes; Those with Mental-Health Services Had Half the Death Rate of Those Without

by John S. James

Summary: New study strongly correlates mental state with HIV disease outcome, and shows the importance of mental-health services.

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A study of 1,716 HIV-positive women who were given blood tests and interviews twice a year for seven years from 1994 through 2001 found that those who met research criteria for chronic depressive symptoms were 2.2 times as likely to die of AIDS-related causes as those who were not depressed.(1) After statistically controlling for CD4 count, viral load, aids-related symptoms, HAART or other antiretroviral use, cocaine or heroin use, income level, age, race, and other factors, those who were chronically depressed still were 1.7 times as likely as those who were not to die of AIDS-related causes. Interestingly, "intermittent" depression symptoms had no effect on death rate in this study. Also, HAART treatment itself was associated with less depression.

Those who used mental-health services at any time during this study (about two thirds of the volunteers) were only half as likely to die as those who did not -- with or without statistical correction for all the other factors.

In addition, this study found that women who died from AIDS-related causes were about twice as likely as HIV-positive women who did not die to report clinically significant depression in their last two 6-month visits.

This study analyzed data from the Women's Interagency HIV Study (WIHS), from volunteers' visits to clinics in Brooklyn, Bronx, Chicago, Los Angeles, San Francisco, and Washington DC.

The authors believe that "antiretroviral therapy alone does not meet best-practice standards of care for this population, and therapy must be augmented by appropriate and sensitive mental health treatment, particularly as HIV disease progresses. Thus, finding ways to reduce depressive symptoms has the potential not only to prolong life but also to enhance its quality among women who have HIV."(1)

Comment

Evidence increasingly suggests that treating "mental" illness or distress can improve survival and reduce progression of HIV (and some other diseases) -- not only in obvious ways like improving adherence and social support, but also through biochemical mechanisms that researchers are only beginning to understand. If confirmed, this emerging information could lead to one or more new classes of HIV treatment. These new treatments would probably target human instead of viral biochemistry, probably greatly reducing the development of viral resistance. Available information suggests that they might have a large effect on disease outcome, not a small or marginal one. And some might already be on pharmacy shelves, approved for other purposes with their value for HIV unrecognized.

The new report(1) is consistent with many studies that have found that depression is associated with worse outcome in HIV and other diseases -- and with growing indications that treatment of "mental" conditions can make a big difference in the progression and outcome of the "physical" illness. AIDS Treatment News reported on one of these studies that was published last December ("'Shy' Study Suggests New Treatment Mechanism," AIDS Treatment News #397, December, 2003). This careful research in 54 HIV-positive men(2) found that the HIV viral load set point was eight times higher in people with a high anxiety level -- who also responded less well to antiretroviral treatment, with only about one-eighth the reduction in viral load of other patients, when both began HAART for the first time. Also see Evans 2002(3): "Our findings provide the first evidence that depression may alter the function of killer lymphocytes in HIV-infected women and suggest that depression may decrease natural killer cell activity and lead to an increase in activated CD8 T lymphocytes and viral load" (quote from the abstract).

For reviews, see Cruess 2003(4) and Leserman 2003(5) on depression and stress in HIV; also see Herbert 1993(6) on stress and immunity in humans. And an excellent newspaper article appeared last December in The Washington Post.(7)

The impact of mental health treatment on disease progression and survival needs more attention from doctors, researchers, policy makers, and activists alike. Activists could help by becoming informed, mobilizing public support for research, and supporting the inclusion of mental-health services in HIV medical care.

Ongoing attention and conversation could lead to research that may provide new treatments to reduce HIV disease progression. AIDS Treatment News will follow this area, and suggest ways that readers can help.

References

1. Cook JA, Grey D, Burke J, and others. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. American Journal of Public Health. July 2004; volume 94, number 7, pages 1133-1140.

2. Cole SW, Kemeny ME, Fahey JL, Zack JA, and Naliboff BD. Psychological risk factors for HIV pathogenesis: Mediation by the autonomic nervous system. Biological Psychiatry. December 15, 2003; volume 54, pages 1444-1456.

3. Evans DL, Ten Have TR, Douglas SD, and others. Association of depression with viral load, CD8 T lymphocytes, and natural killer cells in women with HIV infection. American Journal of Psychiatry. 2002; 159, pages 1752-1759.

4. Cruess DG, Douglas SD, Petitto MD, and others. Association of depression, CD8+ T lymphocytes, and natural killer cell activity: Implications for morbidity and mortality in human immunodeficiency virus disease. Current Psychiatry Reports. 2003; 5, pages 445-450.

5. Leserman J. HIV disease progression: Depression, stress, and possible mechanisms. Biological Psychiatry. August 1, 2003; volume 54, number 3, pages 295-306.

6. Herbert TB and Cohen S. Stress and immunity in humans: A meta-analytic review. Psychosomatic Medicine. 1993; volume 55, issue 4, pages 364-379.

7. "Stress Found to Weaken Resistance to Illness" by Shankar Vedantam, Washington Post, December 22, 2003, page A12.

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