AIDS and Behavior

, Volume 23, Issue 3, pp 592–601 | Cite as

The Depression Treatment Cascade: Disparities by Alcohol Use, Drug Use, and Panic Symptoms Among Patients in Routine HIV Care in the United States

  • Bethany L. DiPreteEmail author
  • Brian W. Pence
  • Angela M. Bengtson
  • Richard D. Moore
  • David J. Grelotti
  • Conall O’Cleirigh
  • Riddhi Modi
  • Bradley N. Gaynes
Original Paper


Little is known about disparities in depression prevalence, treatment, and remission by psychiatric comorbidities and substance use among persons living with HIV (PLWH). We conducted a cross-sectional analysis in a large cohort of PLWH in routine care and analyzed conditional probabilities of having an indication for depression treatment, receiving treatment, receiving indicated treatment adjustments, and achieving remission, stratified by alcohol use, illicit drug use, and panic symptoms. Overall, 34.7% (95% CI 33.9–35.5%) of participants had an indication for depression treatment and of these, 55.3% (53.8–56.8%) were receiving antidepressants. Among patients receiving antidepressants, 33.0% (31.1–34.9%) had evidence of remitted depression. In a subsample of sites with antidepressant dosage data, only 8.8% (6.7–11.5%) of patients received an indicated treatment adjustment. Current drug users (45.8%, 95% CI 43.6–48.1%) and patients reporting full symptoms of panic disorder (75.0%, 95% CI 72.9–77.1%) were most likely to have an indication for antidepressant treatment, least likely to receive treatment given an indication (current drug use: 47.6%, 95% CI 44.3–51.0%; full panic symptoms: 50.8%, 95% CI 48.0–53.6%), or have evidence of remitted depression when treated (22.3%, 95% CI 18.5–26.6%; and 7.3%, 95% CI 5.5–9.6%, respectively). In a multivariable model, drug use and panic symptoms were independently associated with poorer outcomes along the depression treatment cascade. Few differences were evident by alcohol use. Current drug users were most likely to have an indication for depression treatment, but were least likely to be receiving treatment or to have remitted depression. These same disparities were even more starkly evident among patients with co-occurring symptoms of panic disorder compared to those without. Achieving improvements in the depression treatment cascade will likely require attention to substance use and psychiatric comorbidities.


HIV infections Depression Drug users Alcohol drinking Anxiety disorders 



BWP, RDM, CMO, RM, DJG, and BNG contributed to the acquisition of data. BLD, BWP, and AMB conceived and designed the analysis. BLD and BWP analyzed the data. BLD drafted the manuscript. BWP, AMB, RDM, DJG, RM, CMO, and BNG assisted with the interpretation of the data and critically revised the manuscript for important intellectual content. All authors take responsibility for and approve the final version of the manuscript. We thank the National Institutes of Mental Health (Grant Number R01MH100970) and the National Institute of Allergy and Infectious Diseases (Grant Numbers R24AI067039 and P30 AI50410) for their support of this work.


This work was supported by the National Institutes of Mental Health (Grant Number R01MH100970 to BWP) and by the National Institute of Allergy and Infectious Disease (Grant Numbers R24AI067039, P30AI50410).

Compliance with Ethical Standards

Conflict of interest

BWP has received a speaking honorarium from MSD. No other conflicts of interest are declared.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Bethany L. DiPrete
    • 1
    Email author
  • Brian W. Pence
    • 1
  • Angela M. Bengtson
    • 1
  • Richard D. Moore
    • 2
  • David J. Grelotti
    • 3
  • Conall O’Cleirigh
    • 4
    • 5
  • Riddhi Modi
    • 6
  • Bradley N. Gaynes
    • 7
  1. 1.Department of Epidemiology, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Department of Medicine, School of MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of PsychiatryUniversity of California, San DiegoSan DiegoUSA
  4. 4.The Fenway InstituteFenway HealthBostonUSA
  5. 5.Department of PsychiatryHarvard Medical School/Massachusetts General HospitalBostonUSA
  6. 6.Department of Medicine, Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamUSA
  7. 7.Department of Psychiatry, School of MedicineUniversity of North Carolina at Chapel HillChapel HillUSA

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