Journal of Behavioral Medicine

, Volume 42, Issue 2, pp 330–341 | Cite as

The association between symptoms of generalized anxiety disorder and appointment adherence, overnight hospitalization, and emergency department/urgent care visits among adults living with HIV enrolled in care

  • Zachary L. MannesEmail author
  • Lauren E. Hearn
  • Zhi Zhou
  • Jennifer W. Janelle
  • Robert L. Cook
  • Nicole Ennis


This study examined the association between generalized anxiety disorder (GAD) symptoms and healthcare utilization (HCU) among 801 people living with HIV (PLWH). Participants recruited from community health centers in Florida completed questionnaires assessing demographics, substance use, symptoms of GAD and depression, and HCU. Adjusted binary and multinomial logistic regressions assessed the association between moderate-severe GAD symptoms and past 6-month missed HIV-care appointments, overnight hospitalization, and emergency department (ED)/urgent care visits. Participants reporting moderate-severe GAD symptoms had a greater odds of missing an HIV-care appointment (AOR 2.03, 95% CI 1.28–3.24, p = 0.003), spending 2 (AOR 4.35, 95% CI 2.18–8.69, p < 0.001) or 3+ (AOR 2.79, 95% CI 1.20–6.45, p = 0.016) nights in the hospital, and visiting an ED/urgent care facility 2 (AOR 2.63, 95% CI 1.39–4.96, p = 0.003) or 3+ (AOR 2.59, 95% CI 1.27–5.26 p = 0.008) times compared to participants reporting none-mild anxiety. Depression was associated with fewer ED/urgent care visits and overnight hospitalizations, while no association was found with missed primary care appointments. The role of anxiety in illness management remains understudied among PLWH. Anxiety identification and the development of interventions for anxiety among PLWH may have important consequences for healthcare cost saving, patient retention in care, and HIV-disease management.


HIV/AIDS Anxiety Appointment adherence Overnight hospitalizations Emergency department visits 



We appreciate the contributions of the research staff and the participants who were involved in the Florida Cohort study. We also appreciate the contributions of the staff within the Florida Department of Health HIV Surveillance unit for helping with data on participant HIV viral load.

Compliance with ethical standards

Conflict of interest

Zachary L. Mannes, Lauren E. Hearn, Zhi Zhou, Jennifer W. Janelle, Robert L. Cook and Nicole Ennis declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures were in accordance with the ethical standards of the institutional research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


  1. Aidala, A. A., Wilson, M. G., Shubert, V., Gogolishvili, D., Globerman, J., Rueda, S., et al. (2016). Housing status, medical care, and health outcomes among people living with HIV/AIDS: A systematic review. American Journal of Public Health, 106, e1–e23.Google Scholar
  2. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30, 217–237.Google Scholar
  3. Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 ® ). New York: American Psychiatric Pub.Google Scholar
  4. Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & Van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. New York: American Psychological Association.Google Scholar
  5. Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour Research and Therapy, 35, 49–58.Google Scholar
  6. Berry, S. A., Fleishman, J. A., Moore, R. D., & Gebo, K. A. (2012). Trends in reasons for hospitalization in a multisite United States cohort of persons living with HIV, 2001–2008. Journal of acquired immune deficiency syndromes (1999), 59, 368.Google Scholar
  7. Bozzette, S. A., Berry, S. H., Duan, N., Frankel, M. R., Leibowitz, A. A., Lefkowitz, D., et al. (1998). The care of HIV-infected adults in the United States. New England Journal of Medicine, 339, 1897–1904.Google Scholar
  8. Brandt, C., Zvolensky, M. J., Woods, S. P., Gonzalez, A., Safren, S. A., & O’Cleirigh, C. M. (2017). Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature. Clinical Psychology Review, 51, 164–184.Google Scholar
  9. Bulsara, S. M., Wainberg, M. L., & Newton-John, T. R. O. (2018). Predictors of adult retention in HIV care: A systematic review. AIDS and Behavior, 22, 753–764.Google Scholar
  10. Campos, L. N., Guimarães, M. D. C., & Remien, R. H. (2010). Anxiety and depression symptoms as risk factors for non-adherence to antiretroviral therapy in Brazil. AIDS and Behavior, 14, 289–299.Google Scholar
  11. Chaudhury, S., Bakhla, A., & Saini, R. (2016). Prevalence, impact, and management of depression and anxiety in patients with HIV: A review. Neurobehavioral HIV Medicine, 7, 15–30.Google Scholar
  12. Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A. N. (2016). Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical Care, 54, 140.Google Scholar
  13. Choi, B. Y., DiNitto, D. M., Martia, C. N., & Choi, N. G. (2015). Impact of mental health and substance use disorders on emergency department visit outcomes for HIV patients. West Journal of Emergency Medicine, 17, 152–164.Google Scholar
  14. Derose, K. P., Gresenz, C. R., & Ringel, J. S. (2011). Understanding disparities in health care access—and reducing them—through a focus on public health. Health Affairs, 30, 1844–1851.Google Scholar
  15. Do, A. N., Rosenberg, E. S., Sullivan, P. S., Beer, L., Strine, T. W., Schulden, J. D., et al. (2014). Excess burden of depression among HIV-infected persons receiving medical care in the United States: Data from the medical monitoring project and the behavioral risk factor surveillance system. PLoS ONE, 9, e92842.Google Scholar
  16. Dowson, C. A., Kuijer, R. G., & Mulder, R. T. (2004). Anxiety and self-management behaviour in chronic obstructive pulmonary disease: What has been learned? Chronic Respiratory Disease, 1, 213–220. Scholar
  17. Florida Department of Health (FLDOH). (2017). Florida HIV/AIDS surveillance program. Retrieved from
  18. Gardner, L. I., Marks, G., O’daniels, C., Wilson, T. E., Golin, C., Wright, J., et al. (2008). Implementation and evaluation of a clinic-based behavioral intervention: Positive steps for patients with HIV. AIDS Patient Care and STDs, 22, 627–635.Google Scholar
  19. Garey, L., Bakhshaie, J., Sharp, C., Neighbors, C., Zvolensky, M. J., & Gonzalez, A. (2015). Anxiety, depression, and HIV symptoms among persons living with HIV/AIDS: The role of hazardous drinking. AIDS Care, 27, 80–85.Google Scholar
  20. Gaynes, B. N., O’Donnell, J., Nelson, E. L., Heine, A., Zinski, A., Edwards, M., et al. (2015). Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential. General Hospital Psychiatry, 37, 277–282.Google Scholar
  21. Jones, D., Cook, R., Rodriguez, A., & Waldrop-Valverde, D. (2013). Personal HIV knowledge, appointment adherence and HIV outcomes. AIDS and Behavior, 17, 242–249.Google Scholar
  22. Joyce, G. F., Chan, K. S., Orlando, M., & Burnam, M. A. (2005). Mental health status and use of general medical services for persons with human immunodeficiency virus. Medical Care, 43, 834–839.Google Scholar
  23. Khan, Y., Glazier, R. H., Moineddin, R., & Schull, M. J. (2011). A population-based study of the association between socioeconomic status and emergency department utilization in Ontario, Canada. Academic Emergency Medicine, 18, 836–843.Google Scholar
  24. Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection anxiety disorders in primary care. Annals of Internal Medicine, 146, 317–325.Google Scholar
  25. Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114, 163–173.Google Scholar
  26. Lazar, R., Kersanske, L., Xia, Q., Daskalakis, D., & Braunstein, S. L. (2017). Hospitalization rates among people with HIV/AIDS in New York City, 2013. Clinical Infectious Diseases, 65, 469–476.Google Scholar
  27. MacDonald, E. M., Pawluk, E. J., Koerner, N., & Goodwill, A. M. (2015). An examination of distress intolerance in undergraduate students high in symptoms of generalized anxiety disorder. Cognitive Behaviour Thearapy, 44, 74–84.Google Scholar
  28. McCusker, J., Roberge, D., Lévesque, J.-F., Ciampi, A., Vadeboncoeur, A., Larouche, D., et al. (2010). Emergency department visits and primary care among adults with chronic conditions. Medical Care, 48, 972–980.Google Scholar
  29. Mohareb, A., Rothman, R., & Hsieh, Y. H. (2013). Emergency department (ED) utilization by HIV-infected ED patients in the United States in 2009 and 2010—A national estimation. HIV Medicine, 14, 605–613.Google Scholar
  30. Mugavero, M. J., Lin, H.-Y., Allison, J. J., Giordano, T. P., Willig, J. H., Raper, J. L., et al. (2009a). Racial disparities in HIV virologic failure: Do missed visits matter? Journal of Acquired Immune Deficiency Syndromes (1999), 50, 100.Google Scholar
  31. Mugavero, M. J., Lin, H.-Y., Willig, J. H., Westfall, A. O., Ulett, K. B., Routman, J. S., et al. (2009b). Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clinical Infectious Diseases, 48, 248–256.Google Scholar
  32. Nel, A., & Ashraf, K. (2011). Common mental health problems and anitretroviral therapy adherence. AIDS Care, 23, 1360–1465.Google Scholar
  33. Ng, R., Kendall, C. E., Burchell, A. N., Bayoumi, A. M., Loutfy, M. R., Raboud, J., et al. (2016). Emergency department use by people with HIV in Ontario: A population-based cohort study. CMAJ Open, 4, E240.Google Scholar
  34. O’Cleirigh, C., Skeer, M., Mayer, K. H., & Safren, S. A. (2009). Functional impairment and health care utilization among HIV-infected men who have sex with men: The relationship with depression and post-traumatic stress. Journal of Behavioral Medicine, 32, 466–477.Google Scholar
  35. Park, W., Choe, P., Kim, S. H., Jo, J., Bang, J., Kim, H., et al. (2007). One-year adherence to clinic visits after highly active antiretroviral therapy: A predictor of clinical progress in HIV patients. Journal of Internal Medicine, 261, 268–275.Google Scholar
  36. Perno, C. F., Ceccherini-Silberstein, F., De Luca, A., Cozzi-Lepri, A., Gori, C., Cingolani, A., et al. (2002). Virologic correlates of adherence to antiretroviral medications and therapeutic failure. Journal of Acquired Immune Deficiency Syndromes, 31, S118–S122.Google Scholar
  37. Ruiz, M. A., Zamorano, E., García-Campayo, J., Pardo, A., Freire, O., & Rejas, J. (2011). Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. Journal of Affective Disorders, 128, 277–286.Google Scholar
  38. Shacham, E., Morgan, J. C., Önen, N. F., Taniguchi, T., & Overton, E. T. (2012). Screening anxiety in the HIV clinic. AIDS and Behavior, 16, 2407–2413.Google Scholar
  39. Sheehan, D. M., Fennie, K. P., Mauck, D. E., Maddox, L. M., Lieb, S., & Trepka, M. J. (2017). Retention in HIV care and viral suppression: Individual-and neighborhood-level predictors of racial/ethnic differences, Florida, 2015. AIDS Patient Care and STDs, 31, 167–175.Google Scholar
  40. Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097.Google Scholar
  41. Staton-Tindall, M., Harp, K. L. H., Minieri, A. L., Oser, C., Webster, J. M., Havens, J., et al. (2015). An exploratory study of mental health and HIV risk behavior among drug-using rural women in jail. Psychiatric Rehabilitation Journal, 38, 45–54.Google Scholar
  42. Tashima, K. T., Hogan, J. W., Gardner, L. I., Korkontzelou, C., Schoenbaum, E. E., Schuman, P., et al. (2001). A longitudinal analysis of hospitalization and emergency department use among human immunodeficiency virus—Infected women reporting protease inhibitor use. Clinical Infectious Diseases, 33, 2055–2060.Google Scholar
  43. The Antiretroviral Therapy Cohort Collaboration. (2010). Causes of death in HIV-1—Infected patients treated with antiretroviral therapy, 1996–2006: Collaborative analysis of 13 HIV cohort studies. Clinical Infectious Diseases, 50, 1387–1396.Google Scholar
  44. Traeger, L., O’cleirigh, C., Skeer, M. R., Mayer, K. H., & Safren, S. A. (2012). Risk factors for missed HIV primary care visits among men who have sex with men. Journal of Behavioral Medicine, 35, 548–553.Google Scholar
  45. US Preventive Services Task Force. (2004). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: Recommendation statement. Annals of Internal Medicine, 140, 554.Google Scholar
  46. Uthman, O. A., Magidson, J. F., Safren, S. A., & Nachega, J. B. (2014). Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: A systematic review and meta-analysis. Current HIV/AIDS Reports, 11, 291–307.Google Scholar
  47. Vagenas, P., Azar, M. M., Copenhaver, M. M., Springer, S. A., Molina, P. E., & Altice, F. L. (2015). The impact of alcohol use and related disorders on the HIV Continuum of care: A systematic review. Current HIV/AIDS Reports, 12, 421–436.Google Scholar
  48. Venkat, A., Shippert, B., Hanneman, D., Nesbit, C., Piontkowsky, D. M., Bhat, S., et al. (2008). Emergency department utilization by HIV-positive adults in the HAART era. International Journal of Emergency Medicine, 1, 287–296.Google Scholar
  49. Waldrop-Valverde, D., Guo, Y., Ownby, R. L., Rodriguez, A., & Jones, D. L. (2014). Risk and protective factors for retention in HIV care. AIDS and Behavior, 18, 1483–1491.Google Scholar
  50. Weaver, K. E., Llabre, M. M., Duran, R. E., Antoni, M. H., Ironson, G., Penedo, F. J., et al. (2005). A stress and coping model of medication adherencea nd viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART). Health Psychology, 24, 385–392.Google Scholar
  51. Willie, T. C., Overstreet, N. M., Sullivan, T. P., Sikkema, K. J., & Hansen, N. B. (2016). Barriers to HIV medication adherence: Examining distinct anxiety and depression symptoms among women living with HIV who experienced childhood sexual abuse. Behavioral Medicine, 42, 120–127.Google Scholar
  52. Yehia, B. R., Stewart, L., Momplaisir, F., Mody, A., Holtzman, C. W., Jacobs, L. M., et al. (2015). Barriers and facilitators to patient retention in HIV care. BMC Infectious Diseases, 15, 246.Google Scholar
  53. Zullig, L. L., Whitson, H. E., Hastings, S. N., Beadles, C., Kravchenko, J., Akushevich, I., et al. (2016). A systematic review of conceptual frameworks of medical complexity and new model development. Journal of General Internal Medicine, 31, 329–337.Google Scholar
  54. Zuniga, J. A., Yoo-Jeong, D. T., Guo, Y., & Waldrop-Valverde, D. (2016). The role of depression in retention in care for persons living with HIV. AIDS Patient Care STDS, 30, 34–38.Google Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Department of Clinical and Health Psychology, College of Public Health and Health ProfessionsUniversity of FloridaGainesvilleUSA
  2. 2.Mental Health and Behavioral Sciences ServiceJames A. Haley Veterans’ HospitalLakelandUSA
  3. 3.Department of Epidemiology, College of Public Health and Health Professions and College of MedicineUniversity of FloridaGainesvilleUSA
  4. 4.Department of Infectious Diseases and Global Medicine, College of MedicineUniversity of FloridaGainesvilleUSA

Personalised recommendations