Journal of General Internal Medicine

, Volume 18, Issue 6, pp 450–460 | Cite as

Underdiagnosis of depression in HIV

Who are we missing?
  • Steven M. Asch
  • Amy M. Kilbourne
  • Allen L. Gifford
  • M. Audrey Burnam
  • Barbara Turner
  • Martin F. Shapiro
  • Samuel A. Bozzette
  • the HCSUS Consortium
Original Articles


OBJECTIVE: To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.

DESIGN: Cross-sectional survey.

PATIENTS/PARTICIPANTS: National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.

MEASUREMENTS AND MAIN RESULTS: We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1,140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P<.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P<.01) and those with ≥3 outpatient visits (P<.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.

CONCLUSIONS: Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.

Key words

depression HIV diagnosis 


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  1. 1.
    Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24:1069–78.PubMedCrossRefGoogle Scholar
  2. 2.
    Barefoot JC, Schroll M. Symptoms of depression, acute myocardial infarction, and total mortality in a community sample. Circulation. 1996;93:1976–80.PubMedGoogle Scholar
  3. 3.
    Masand PS, Kaplan DS, Gupta S, et al. Major depression and irritable bowel syndrome: is there a relationship? J Clin Psychiatry. 1995;56:363–7.PubMedGoogle Scholar
  4. 4.
    Roose SP, Glassman AH, Seidman SN. Relationship between depression and other medical illnesses. JAMA. 2001;286:1687–90.PubMedCrossRefGoogle Scholar
  5. 5.
    Sherbourne CD, Wells KB, Hays RD, Rogers W, Burnam MA, Judd LL. Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients. Am J Psychiatry. 151:1777–84.Google Scholar
  6. 6.
    Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:721–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Kilbourne AM, Justice AC, Rabeneck L, Rodriguez-Barradas M, Weissman S. General medical and psychiatric comorbidity among HIV-infected veterans in the post-HAART era. J Clin Epidemiol. 2001;54(suppl 1):22–8.CrossRefGoogle Scholar
  8. 8.
    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
  9. 9.
    Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158:725–30.PubMedCrossRefGoogle Scholar
  10. 10.
    Dew MA, Becket JT, Sanchez J, et al. Prevalence and predictors of depressive, anxiety and substance use disorders in HIV infected and uninfected men: a longitudinal evaluation. Psychol Med. 1997;27:395–409.PubMedCrossRefGoogle Scholar
  11. 11.
    Kelly B, Raphael B, Judd F, et al. Psychiatric disorders in HIV infection. Aust N Z J Psychiatry. 1998;32:441–53.PubMedGoogle Scholar
  12. 12.
    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
  13. 13.
    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
  14. 14.
    Katon W. The epidemiology of depression in medical care. Int J Psychiatry Med. 1987;17:93–112.PubMedCrossRefGoogle Scholar
  15. 15.
    Wells KB, Norquist G, Benjamin B, Rogers W, Kahn K, Brook R. Quality of antidepressant medications prescribed at discharge to depressed elderly patients in general medical hospitals before and after prospective payment system. Gen Hosp Psychiatry. 1994;16:4–15.PubMedCrossRefGoogle Scholar
  16. 16.
    Schulberg HC, Block MR, Madonia MJ, et al. The usual care of major depression in primary care practice. Arch Fam Med. 1997;6:334–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Perez-Stable E, Miranda J, Munoz R, Ying Y. Depression in medical outpatients: under-recognition and misdiagnosis. Arch Intern Med. 1990;150:1083–88.PubMedCrossRefGoogle Scholar
  18. 18.
    Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life. Consensus statement update. JAMA. 1997;278:1186–90.PubMedCrossRefGoogle Scholar
  19. 19.
    Alexopoulos GS, Vrontou C, Kakuma T, et al. Disability in geriatric depression. Am J Psychiatry. 1996;153:877–85.PubMedGoogle Scholar
  20. 20.
    Koenig HG, George LK, Larson DB, McCullough ME, Branch PS, Kuchibhatla M. Depressive symptoms and nine-year survival of 1,001 male veterans hospitalized with medical illness. Am J Geriatr Psychiatry. 1999;7:124–31.PubMedGoogle Scholar
  21. 21.
    Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002;40:52–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Goldman LS, Nielsen NH, Champion HC. Awareness, diagnosis, and treatment of depression. J Gen Intern Med. 1999;14:569–80.PubMedCrossRefGoogle Scholar
  23. 23.
    Singh N, Squier C, Sivek C, et al. Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance. AIDS Care. 1996;8:261–9.PubMedCrossRefGoogle Scholar
  24. 24.
    DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Hays RD, Kravitz RL, Mazel RM, et al. The impact of patient adherence on health outcomes for patients with chronic disease in the Medical Outcomes Study. J Behav Med. 1994;17:347–60.PubMedCrossRefGoogle Scholar
  26. 26.
    Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160:3278–85.PubMedCrossRefGoogle Scholar
  27. 27.
    Carney RM, Freedland KE, Eisen SA, Rich MW, Jaffe AS. Major depression and medication adherence in elderly patients with coronary disease. Health Psychol. 1995;14:88–90.PubMedCrossRefGoogle Scholar
  28. 28.
    Bosley CM, Fosbury JA, Cochrane GM. The psychological factors associated with poor compliance with treatment in asthma. Eur Respir J. 1995;8:899–904.PubMedGoogle Scholar
  29. 29.
    Wenger N, Gifford A, Lui H, et al. Patient characteristics and attitudes associated with antiretroviral adherence. In: Program and Abstracts of the 6th Conference on Retroviruses and Opportunistic Infections. Chicago, Ill: January 31–February 4, 1999; Abstract ’98.Google Scholar
  30. 30.
    Cook RL, Hunt S, Woodward C, et al. Problem drinking and adherence to HIV therapy. J Gen Intern Med. 1999;14(suppl 2):93.Google Scholar
  31. 31.
    Frankel MR, Shapiro MF, Duan N, et al. National probability samples in studies of low-prevalence diseases, Part II: designing and implementing the HIV Cost and Services Utilization Study Sample. Health Serv Res. 1999;34:969–92.PubMedGoogle Scholar
  32. 32.
    Shapiro MF, Berk ML, Berry SH, et al. National probability samples in studies of low-prevalence diseases, Part 1: perspectives and lessons learned from the HIV Cost and Services Utilization Study. Health Serv Res. 1999;34:951–68.PubMedGoogle Scholar
  33. 33.
    Kessler RC, Andrews G, Mroczek D, Ustun B, Wittchen H. The World Health Organization Composite International Diagnostic Interview Short Form (CIDI-SF). Int J Methods Psychiatr Res. 1998;7:171–85.CrossRefGoogle Scholar
  34. 34.
    Orlando M, Burnam MA, London AS, et al. Brief screening of psychiatric disorders among a national sample of HIV-positive adults: concordance between the Composite International Diagnostic Interview (CIDI) and the CIDI short form (CIDI-SF). Int J Methods Psychiatr Res. 2001;10:97–107.CrossRefGoogle Scholar
  35. 35.
    Robins LN, Wing J, Wittchen HU, et al. The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry. 1988;45:1069–77.PubMedGoogle Scholar
  36. 36.
    Kilbourne AM, Andersen RM, Asch S, et al. Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus. Med Care Res Rev. 2002;59:36–58.PubMedGoogle Scholar
  37. 37.
    Andersen R, Bozzette S, Shapiro M, et al. Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HIV Cost and Services Utilization Study. Health Serv Res. 2000;35:389–416.PubMedGoogle Scholar
  38. 38.
    Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed? JAMA. 2002;287:1160–70.PubMedCrossRefGoogle Scholar
  39. 39.
    Coyne JC, Fechner-Bates S, Schwenk TL. Prevalence, nature, and comorbidity of depressive disorders in primary care. Gen Hosp Psychiatry. 1994;16:267–76.PubMedCrossRefGoogle Scholar
  40. 40.
    Whyte EM, Mulsant BH. Post stroke depression: epidemiology, pathophysiology, and biological treatment. Biol Psychiatry. 2002;52:253–64.PubMedCrossRefGoogle Scholar
  41. 41.
    Burg MM, Abrams D. Depression in chronic medical illness: the case of coronary heart disease. J Clin Psychol. 2001;57:1323–37.PubMedCrossRefGoogle Scholar
  42. 42.
    Leopold KA, Ahles TA, Walch S, et al. Prevalence of mood disorders and utility of the PRIME-MD in patients undergoing radiation therapy. Int J Radiat Oncol Biol Phys. 1998;42:1105–12.PubMedCrossRefGoogle Scholar
  43. 43.
    Goldney RD, Fisher LJ, Wilson DH. Mental health literacy: an impediment to the optimum treatment of major depression in the community. J Affect Disord. 2001;64:277–84.PubMedCrossRefGoogle Scholar
  44. 44.
    Lin E, Parikh SV. Sociodemographic, clinical, and attitudinal characteristics of the untreated depressed in Ontario. J Affect Disord. 1999;53:153–62.PubMedCrossRefGoogle Scholar
  45. 45.
    Goldman DP, Smith JP. Can patient self-management help explain the SES health gradient? Proc Natl Acad Sci USA. 2002;99:10929–34.PubMedCrossRefGoogle Scholar
  46. 46.
    Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–73.PubMedCrossRefGoogle Scholar
  47. 47.
    Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3:333–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Conwell Y, Suicide in the elderly. In: Schneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ, eds. Diagnosis and Treatment of Depression in Late Life. Results of the NIMH Consensus Development Conference. Washington, DC: American Psychiatric Press; 1994;397–418.Google Scholar
  49. 49.
    Katz MH, Douglas JM Jr, Bolan GA, et al. Depression and use of mental health services among HIV-infected men. AIDS Care. 1996;8:433–42.PubMedCrossRefGoogle Scholar
  50. 50.
    Fleishman JA, Hsia DC, Hellinger FJ. Correlates of medical service utilization among people with HIV infection. Health Serv Res. 1994;29:527–48.PubMedGoogle Scholar
  51. 51.
    Burnam MA, Bing EG, Morton SC, et al. Use of mental health and substance abuse treatment services among adults with HIV in the United States. Arch Gen Psychiatry. 2001;58:729–36.PubMedCrossRefGoogle Scholar
  52. 52.
    National Institute of Mental Health. The Unwanted Co-traveler: Depression’s Toll on Other Illnesses. HIV and Depression Fact Sheet. Bethesda, Md: National Institute of Mental Health; 2000.Google Scholar
  53. 53.
    Redelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 1998;338:1516–20.PubMedCrossRefGoogle Scholar
  54. 54.
    Piscitelli SC, Burstein AH, Chaitt D, Alfaro RM, Falloon J. Indinavir concentrations and St John’s Wort. Lancet. 2000;355:547–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.PubMedGoogle Scholar
  56. 56.
    Rabkin JG, Wagner GJ, Rabkin R. Fluoxetine treatment for depression in patients with HIV and AIDS: a randomized, placebo-controlled trial. Am J Psychiatry. 1999;156:101–7.PubMedGoogle Scholar
  57. 57.
    Markowitz JC, Klerman GL, Clougherty KF, et al. Individual psychotherapies for depressed HIV-positive patients. Am J Psychiatry. 1995;152:1504–9.PubMedGoogle Scholar
  58. 58.
    Gill D, Hatcher S. A systematic review of the treatment of depression with antidepressant drugs in patients who also have a physical illness. In: The COCHRANE Database. London, UK: Department of Liaison Psychiatry, Whipps Cross Hospital; 1999.Google Scholar
  59. 59.
    Ferrando SJ, Goldman JD, Charness WE. Selective serotonin reuptake inhibitor treatment of depression in symptomatic HIV infection and AIDS. Improvements in affective and somatic symptoms. Gen Hosp Psychiatry. 1997;19:89–97.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Steven M. Asch
    • 8
    • 1
    • 2
  • Amy M. Kilbourne
    • 3
    • 4
  • Allen L. Gifford
    • 5
  • M. Audrey Burnam
    • 2
  • Barbara Turner
    • 7
  • Martin F. Shapiro
    • 1
    • 2
  • Samuel A. Bozzette
    • 2
    • 5
    • 6
  • the HCSUS Consortium
  1. 1.UCLA Department of MedicineLos Angeles
  2. 2.RANDSanta Monica
  3. 3.Center for Health Equity Research and Promotion and VA PittsburghUniversity of Pittsburgh School of MedicinePittsburgh
  4. 4.Departments of Medicine and PsychiatryUniversity of Pittsburgh School of MedicinePittsburgh
  5. 5.VA San Diego Healthcare SystemUniversity of California San DiegoSan Diego
  6. 6.Department of MedicineUniversity of California San DiegoSan Diego
  7. 7.Section of General Internal MedicineUniversity of PennsylvaniaPhiladelphia
  8. 8.VA Greater Los Angeles Healthcare SystemLos Angeles

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