Journal of General Internal Medicine

, Volume 17, Issue 7, pp 512–520 | Cite as

Clinical importance of HIV and depressive symptoms among veterans with HIV infection

  • Amy M. Kilbourne
  • Amy C. Justice
  • Bruce L. Rollman
  • Kathleen A. McGinnis
  • Linda Rabeneck
  • Sharon Weissman
  • Susan Smola
  • Richard Schultz
  • Jeff Whittle
  • Maria Rodriguez-Barradas
Original Articles


OBJECTIVE: To compare the clinical importance (association with illness severity and survival) of depressive and HIV symptoms among veterans with HIV infection.

DESIGN: Cross-sectional study; survival analysis.

SETTING: Infectious Disease Clinics at 3 VA Medical Centers.

PARTICIPANTS: HIV-infected patients (N=881) and their health care providers from June 1999 through July 2000.

MEASUREMENTS AND MAIN RESULTS: Depressive symptoms were assessed using the 10-item Centers for Epidemiologic Studies Depression Scale (CES-D). Patient baseline survey included an HIV Symptom Index measuring the frequency and bother of 20 common symptoms. Providers were surveyed on patients’ illness severity, and survival data were obtained from VA death records. Of 881 patients, 46% had significant depressive symptoms (CES-D ≥10). Increasing depression symptom severity was associated with increasing HIV symptom frequency (P<.001) and bother (P<.001). Multiple regression results revealed that having moderate or severe depressive symptoms was not associated with provider-reported illness severity or survival. However, HIV symptoms were significantly associated with provider-reported illness severity (P<.01) and survival (P=.05), after adjusting for moderate and severe depressive symptoms, CD4 cell count/mm3, viral load, age, race, and antiretroviral use.

CONCLUSIONS: Depression, while common in this sample, was not associated with illness severity or mortality after adjusting for HIV symptoms. HIV symptoms are associated with severity of illness and survival regardless of patients’ severity of depressive symptoms. This suggests that equal medical consideration should be given to HIV symptoms presented by HIV-infected patients regardless of their depression status, rather than automatically attributing medical complaints to depression.

Key words

HIV/AIDS symptoms depression 


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  1. 1.
    Kalichman SC, Rompa D, Cage M. Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis. 2000;188:662–70.PubMedCrossRefGoogle Scholar
  2. 2.
    Lyketsos CG, Hoover DR, Guccione M, et al. Depressive symptoms over the course of HIV infection before AIDS. Soc Psychiatry Psychiatr Epidemiol. 1996;31:212–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Lyketsos CG, Hoover DR, Guccione M, et al. Changes in depressive symptoms as AIDS develops. The Multicenter AIDS Cohort Study. Am J Psychiatry. 1996;153:1430–7.PubMedGoogle Scholar
  4. 4.
    Griffin KW, Rabkin JG, Remien RH, Williams JB. Disease severity, physical limitations and depression in HIV-infected men. J Psychosom Res. 1998;44:219–27.PubMedCrossRefGoogle Scholar
  5. 5.
    Hoover DR, Saah AJ, Bacellar H, et al. Signs and symptoms of “asymptomatic” HIV-1 infection in homosexual men. Multicenter AIDS Cohort Study. J Acquir Immune Defic Syndr. 1993;6:66–71.PubMedGoogle Scholar
  6. 6.
    Justice AC, Rabeneck L, Hays RD, Wu AW, Bozzette SA. Sensitivity, specificity, reliability, and clinical validity of provider-reported symptoms: a comparison with self-reported symptoms. Outcomes Committee of the AIDS Clinical Trials Group. J Acquir Immune Defic Syndr. 1999;21:126–33.PubMedGoogle Scholar
  7. 7.
    Justice AC, Chang CH, Rabeneck L, Zackin R. Clinical importance of provider-reported HIV symptoms compared with patient-report. Med Care. 2001;39:397–408.PubMedCrossRefGoogle Scholar
  8. 8.
    Lorenz KA, Shapiro MF, Asch SM, Bozzette SA, Hays RD. Associations of symptoms and health-related quality of life: findings from a national study of persons with HIV infection. Ann Intern Med. 2001;134:854–60.PubMedGoogle Scholar
  9. 9.
    Cunningham WE, Shapiro MF, Hays RD, et al. Constitutional symptoms and health-related quality of life in patients with symptomatic HIV disease. Am J Med. 1998;104:129–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Wilson IB, Cleary PD. Clinical predictors of declines in physical functioning in persons with AIDS: results of a longitudinal Study. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;16:343–9.PubMedGoogle Scholar
  11. 11.
    Wilson IB, Roubenoff R, Knox TA, Spiegelman D, Gorbach SL. Relation of lean body mass to health-related quality of life in persons with HIV. J Acquir Immune Defic Syndr. 2000;24:137–46.PubMedGoogle Scholar
  12. 12.
    Wheeler DA, Gilbert CL, Launer CA, et al. Weight loss as a predictor of survival and disease progression in HIV infection. Terry Beirn community programs for clinical research on AIDS. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:80–5.PubMedGoogle Scholar
  13. 13.
    Ickovics JR, Hamburger ME, Vlahov D, et al. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA. 2001;285:1466–74.PubMedCrossRefGoogle Scholar
  14. 14.
    Lyketsos CG, Hoover DR, Guccione M, et al. Depressive symptoms as predictors of medical outcomes in HIV infection. Multicenter AIDS Cohort Study. JAMA. 1993;270:2563–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Lyketsos CG, Federman EB. Psychiatric disorders and HIV infection: impact on one another. Epidemiol Rev. 1995;17:152–64.PubMedGoogle Scholar
  16. 16.
    Rabkin JG, Goetz RR, Remien RH, Williams JB, Todak G, Gorman JM. Stability of mood despite HIV illness progression in a group of homosexual men. Am J Psychiatry. 1997;154:231–8.PubMedGoogle Scholar
  17. 17.
    Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA. 1993;270:2568–73.PubMedCrossRefGoogle Scholar
  18. 18.
    Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: the effects of stress, depressive symptoms, and social support. Psychosom Med. 1999;61:397–406.PubMedGoogle Scholar
  19. 19.
    Graber MA, Bergus G, Dawson JD, Wood GB, Levy BT, Levin I. Effect of a patient’s psychiatric history on physicians’ estimation of probability of disease. J Gen Intern Med. 2000;15:204–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Smola S, Justice AC, Wagner J, Rabeneck L, Weissman S, Rodriguez-Barradas M. Veterans aging cohort three-site study (VACS 3): overview and description. J Clin Epidemiol. 2001;54(suppl 1):61–76.CrossRefGoogle Scholar
  21. 21.
    Andresen EM, Carter WB, Malmgren JA, Patrick DK. Screening for depression in well older adults: evaluation of a short form of the CES-D. Am J Prev Med. 1994;10:77–84.PubMedGoogle Scholar
  22. 22.
    Low-Beer S, Chan K, Yip B, et al. Depressive symptoms decline among persons on HIV protease inhibitors. J Acquir Immune Defic Syndr. 2000;23:295–301.PubMedGoogle Scholar
  23. 23.
    Mulrow CD, Williams JW Jr, Gerety MB, Ramirez G, Montiel OM, Kerber C. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913–21.PubMedGoogle Scholar
  24. 24.
    Zich JM, Attkisson CC, Greenfield TK. Screening for depression in primary care clinics: the CESD and the BDI. Int J Psychiatry Med. 1990;20:259–77.PubMedCrossRefGoogle Scholar
  25. 25.
    Symptom Index HIV. AIDS Clinical Trials Group (ACTG) of the National Institute of Allergy and Infectious Disease. Available at: Accessed May 8, 2002.Google Scholar
  26. 26.
    Justice AC, Holmes W, Gifford AL, et al. Development and validation of a self-completed HIV symptom index. J Clin Epidemiol. 2001;54(suppl 1):77–90.CrossRefGoogle Scholar
  27. 27.
    Charlson ME, Sax FL, MacKenzie R, Fields SD, Braham RL, Douglas RG. Assessing illness severity: does clinical judgment work? J Chronic Dis. 1986;39:439–52.PubMedCrossRefGoogle Scholar
  28. 28.
    Knaus WA, Harrell FE, Lynn J, et al. The SUPPORT prognostic model: objective assessments of survival for seriously ill hospitalized adults. Ann Intern Med. 1995;122:191–203.PubMedGoogle Scholar
  29. 29.
    McKlish DK, Powell SH. How well can physicians estimate mortality in a medical intensive care unit? Med Decis Making. 1989;9:125–32.CrossRefGoogle Scholar
  30. 30.
    Fisher SG, Weber L, Goldberg J, et al. Mortality ascertainment in the veteran population: alternatives to the National Death Index. Am J Epidemiol. 1995;141:242–50.PubMedGoogle Scholar
  31. 31.
    Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA. Regression modeling strategies for improved prognostic prediction. Stat Med. 1984;3:143–52.PubMedCrossRefGoogle Scholar
  32. 32.
    Office of Quality and Performance, Veterans Health Administration and the Health Quality Assessment Project, Center for Health Quality, Outcomes and Economic Research. Health Status and Outcomes of Veterans: Physical and Mental Component Summary Scores: Veterans SF-36 1999 Large Health Survey of Veteran Enrollees Executive Report. Washington, DC: Department of Veterans Affairs; 2000.Google Scholar
  33. 33.
    Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated service system. Psychiatr Serv. 2000;51:890–2.PubMedCrossRefGoogle Scholar
  34. 34.
    Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917–25.PubMedGoogle Scholar
  36. 36.
    Lyketsos CG, Hutton H, Fishman M, Schwartz J, Treisman GJ. Psychiatric morbidity on entry to an HIV primary care clinic. AIDS. 1996;10:1033–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Sherbourne CD, Hays RD, Fleishman J, et al. Impact of psychiatric condition on health-related quality of life in persons with HIV infection. Am J Psychiatry. 2000;157:248–54.PubMedCrossRefGoogle Scholar
  38. 38.
    Gerber PD, Barrett JE, Barrett JA, et al. The relationship of presenting physical complaints to depressive symptoms in primary care patients. J Gen Intern Med. 1992;7:170–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Mechanic D. Effects of psychological distress on perceptions of physical health and use of medical and psychiatric facilities. J Human Stress. 1978;4:26–32.PubMedGoogle Scholar
  40. 40.
    Suh T, Gallo JJ. Symptom profiles of depression among general medical service users compared with specialty mental health service users. Psychol Med. 1997;27:1051–63.PubMedCrossRefGoogle Scholar
  41. 41.
    Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11:1–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Bangsberg DR, Moss A. When should we delay highly active antiretroviral therapy? J Gen Intern Med. 1999;14:446–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Centers for Disease Control and Prevention. Update: trends in AIDS incidence, deaths, and prevalence-United States, 1996. Morb Mortal Wkly Rep. 1997;46:165–73.Google Scholar

Copyright information

© Society of General Internal Medicine 2002

Authors and Affiliations

  • Amy M. Kilbourne
    • 1
    • 2
  • Amy C. Justice
    • 1
    • 2
  • Bruce L. Rollman
    • 2
  • Kathleen A. McGinnis
    • 1
  • Linda Rabeneck
    • 4
  • Sharon Weissman
    • 7
  • Susan Smola
    • 1
  • Richard Schultz
    • 3
  • Jeff Whittle
    • 8
  • Maria Rodriguez-Barradas
    • 5
    • 6
  1. 1.the VA Pittsburgh Center for Health Equity Research and PromotionPittsburgh
  2. 2.School of Medicine, Division of General Internal Medicinethe University of Pittsburgh Center for Research on Health CarePittsburgh
  3. 3.the University of Pittsburgh Center for Social and Urban ResearchPittsburgh
  4. 4.Division of Gastroenterology, Department of MedicineUniversity of TorontoTorontoCanada
  5. 5.the Department of MedicineBaylor College of MedicineHouston
  6. 6.the VA Medical CenterHouston
  7. 7.the Hospital of Saint RaphaelNew Haven
  8. 8.the Department of Internal Medicine, Geriatric and General MedicineKansas University Medical Center, and Kansas City VA Medical CenterKansas City

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