Bradley N Gaynes

Perinatal depression: a systematic review of prevalence and incidence.

OBJECTIVE: We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at nonchildbearing times. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. TABULATION, INTEGRATION, AND RESULTS: Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at nonchildbearing times. CONCLUSION: To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.

Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors.

BACKGROUND The primary aim of this study is to examine prospectively the association of stressful life events, social support, depressive symptoms, anger, serum cortisol and lymphocyte subsets with changes in multiple measures of human immunodeficiency virus (HIV) disease progression. METHODS Ninety-six HIV-infected gay men without symptoms or anti-retroviral medication use at baseline were studied every 6 months for up to 9 years. Disease progression was defined in three ways using the Centers for Disease Control (CDC) classifications (e.g. AIDS, clinical AIDS condition and mortality). Cox regression models with time-dependent covariates were used, adjusting for control variables (e.g. race, age, baseline, CD4 T cells and viral load, number of anti-retroviral medications). RESULTS Higher cumulative average stressful life events and lower cumulative average social support predicted faster progression to both the CDC AIDS classification and a clinical AIDS condition. Higher anger scores and CD8 T cells were associated with faster progression to AIDS, and depressive symptoms were associated with faster development of an AIDS clinical condition. Higher levels of serum cortisol predicted all three measures of disease progression. CONCLUSIONS These results suggest that stressful life events, dysphoric mood and limited social support are associated with more rapid clinical progression in HIV infection, with serum cortisol also exerting an independent effect on disease progression.

Deployment and the use of mental health services among U.S. Army wives

BACKGROUND Military operations in Iraq and Afghanistan have involved the frequent and extended deployment of military personnel, many of whom are married. The effect of deployment on mental health in military spouses is largely unstudied. METHODS We examined electronic medical-record data for outpatient care received between 2003 and 2006 by 250,626 wives of active-duty U.S. Army soldiers. After adjustment for the sociodemographic characteristics and the mental health history of the wives, as well as the number of deployments of the personnel, we compared mental health diagnoses according to the number of months of deployment in Operation Iraqi Freedom in the Iraq-Kuwait region and Operation Enduring Freedom in Afghanistan during the same period. RESULTS The deployment of spouses and the length of deployment were associated with mental health diagnoses. In adjusted analyses, as compared with wives of personnel who were not deployed, women whose husbands were deployed for 1 to 11 months received more diagnoses of depressive disorders (27.4 excess cases per 1000 women; 95% confidence interval [CI], 22.4 to 32.3), sleep disorders (11.6 excess cases per 1000; 95% CI, 8.3 to 14.8), anxiety (15.7 excess cases per 1000; 95% CI, 11.8 to 19.6), and acute stress reaction and adjustment disorders (12.0 excess cases per 1000; 95% CI, 8.6 to 15.4). Deployment for more than 11 months was associated with 39.3 excess cases of depressive disorders (95% CI, 33.2 to 45.4), 23.5 excess cases of sleep disorders (95% CI, 19.4 to 27.6), 18.7 excess cases of anxiety (95% CI, 13.9 to 23.5), and 16.4 excess cases of acute stress reaction and adjustment disorders (95% CI, 12.2 to 20.6). CONCLUSIONS Prolonged deployment was associated with more mental health diagnoses among U.S. Army wives, and these findings may have relevance for prevention and treatment efforts.

Screening for Depression in Adult Patients in Primary Care Settings: A Systematic Evidence Review

Major depressive disorder (MDD) is common, with an estimated lifetime prevalence of 13.2%. In primary care settings, prevalence estimates of MDD range from 5% to 13% in all adults (1, 2), with lower estimates in those older than 55 years (6% to 9%) (3, 4). Primary care practitioners manage approximately one third to one half of nonelderly adults (5, 6) and almost two thirds of older adults (7) who received treatment for MDD. The severity of depressive symptoms in patients who receive treatment in primary care is equivalent to that of patients treated in psychiatric settings (8). For example, approximately 43% of such primary care patients report some degree of suicidal ideation within the previous week (8, 9). In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems to ensure accurate diagnosis, effective treatment, and follow-up. Subsequent reviewers have concluded that screening does not improve health outcomes (10), but care management systems for depressed patients improve depression remission rates (11). Commentators on these divergent reviews have been divided (12, 13). We conducted this systematic review to aid the USPSTF in updating its 2002 recommendation for adult depression screening in primary care. We sought to 1) identify evidence published since the previous review on the benefits of screening for depression in primary care and integrate it with the previously identified evidence and 2) review the evidence in several areas in which evidence was insufficient at the time of the previous review or not was examined by the previous review (14). This includes the benefits of depression treatment in older adults, the harms of depression screening, and the harms of depression treatment with antidepressant medications. Methods Scope of the Review We developed an analytic framework (Appendix Figure 1) and 5 key questions that focused on the evidence that the USPSTF required to update its recommendation by using the USPSTFs methods (15). Appendix Figure 1. Analytic framework and key questions. SSRI = selective serotonin reuptake inhibitor. 1. Is there direct evidence that screening for depression among adults and elderly patients in primary care reduces morbidity and/or mortality? 1a. What is the effect of clinician feedback of screening test results (with or without additional care management support) on depression response and remission in screening-detected depressed patients receiving usual care? 2. What are the adverse effects of screening for depressive disorders in adults and elderly patients in primary care? 3. Is antidepressant and/or psychotherapy treatment of elderly depressed patients effective in improving health outcomes? 4. What are the adverse effects of antidepressant treatment (particularly selective serotonin reuptake inhibitors [SSRIs] and other second-generation drugs) for depression in adults and elderly patients? This article discusses methods and results for key questions 1, 1a, and 4. Detailed methods and results for the remaining key questions are in the full report (16). Data Sources and Searches We used the Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, and PsycINFO to search for relevant systematic reviews, meta-analyses, and primary studies published in English from January 1998 to December 2007. The full report provides the search strategies (16). Study Selection Two investigators reviewed 4088 abstracts published in English and 412 full-text articles (Appendix Figure 2) against key questionspecific inclusion and exclusion criteria (Appendix Table 1). Articles for key questions 1 and 1a were limited to randomized and controlled clinical trials that were conducted in primary care or similar settings. Key question 1 trials compared outcomes in screened and unscreened patients. Trials for key question 1a were required to have used the screening results for care decisions for intervention recipients and not for the control participants. Outcomes for these 2 questions were focused on depression response and remission. Appendix Figure 2. Search results and article flow, by key question. KQ = key question. * Numbers differ slightly from the full report (16) because only articles relevant to the more limited body of literature discussed in this publication are included in this figure. Appendix Table 1. Inclusion and Exclusion Criteria for KQs Discussed We focused our review of harms of treatment (key question 4) on already-synthesized evidence, supplemented by large observational studies. Methods for incorporating systematic reviews and meta-analyses are detailed elsewhere (Appendix Table 2). We examined serious adverse effects associated with antidepressant treatment, including suicide-related events (completed suicide, serious self-harm or attempted suicide, suicidal ideation, or suicidal behavior [usually defined to include suicide attempts, preparatory acts, or nonfatal serious self-harm]), and serious psychiatric events, including hospitalization. For older adults, we also considered evidence of serious medical events (for example, upper gastrointestinal bleeding) that were associated with SSRI and other second-generation antidepressant use. We examined rates of early discontinuation as a proxy for less serious adverse effects, particularly discontinuation due to adverse effects as a measure of tolerability. We focused on second-generation antidepressants (SSRIs in particular) because of their preponderance of use in the United States (17, 18). Appendix Table 2. Use of Existing Systematic Reviews Updated Searching and Study Examination Because of the delay between completion of the systematic review and publication, we repeated our search strategy through February 2009. We reviewed 800 abstracts against inclusion and exclusion criteria, and 21 seemed to meet criteria for this systematic review. After examining results of each of these new studies (as described in the abstracts), we determined that they would be unlikely to change our conclusions. Appendix Table 3 lists these studies. Appendix Table 3. Studies Found in Bridge Search With Possible Inclusion or Exclusion Criteria Data Extraction and Quality Assessment Two investigators rated articles for quality by using design-specific quality criteria on the basis of the USPSTF methods (15). The National Institute for Health and Clinical Excellence (19) criteria (for all study designs) and the Oxman criteria (20) (for systematic reviews) supplemented these methods. One investigator abstracted data from included studies into evidence tables and another verified it. The full review shows complete quality criteria (16). Regulatory reviews provided unique challenges and could not be evaluated by using typical quality criteria. For example, their search approach was different because they can mandate that manufacturers supply requested data. Because of the large number of trials (often in the hundreds) and proprietary information involved, however, they did not provide detailed information about individual trials. Data Synthesis and Analysis Data synthesis was primarily qualitative because of clinical heterogeneity. For cohort studies included for key question 4, we calculated absolute event rates and CIs for suicide-related events on the basis of reported data if this information was not provided. The 95% CIs were calculated on the basis of a Poisson distribution by using the GENMOD procedure (SAS software, version 8.2, SAS Institute, Cary, North Carolina) with the RISK option. Similarly, for the meta-analyses of antidepressant trials included for key question 4, we calculated missing CIs by using the FREQ procedure. Role of Funding Source The Agency for Healthcare Research and Quality funded this work, provided project oversight, and assisted in external review of the draft report but had no role in the design, conduct, or reporting of the review. The authors worked with 4 USPSTF members at key points throughout the review process to develop the analytic framework and key questions and resolve issues about scope and approach. The draft systematic review was reviewed by 6 experts and was revised on the basis of their feedback. Results Key Question 1 Is there direct evidence that screening for depression among adults and elderly patients in primary care reduces morbidity and/or mortality? One fair-quality randomized, controlled trial (RCT) of primary care patients reported mixed results when screened participants were compared with an unscreened usual care group (21) (Table). Concerns about the follow-up sample, however, limit our confidence in the results. At 3-month follow-up, the proportion of people who met criteria for depression, according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, was similar in the screened (37%) and usual care groups (46%) (P= 0.19), although power to detect a population-level effect was inadequate (n= 218). After the investigators controlled for baseline severity of depression (which differed between the screened and usual care groups in the full randomized sample), the mean reduction in symptom counts derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, was similar for the 2 groups (1.6 in screened patients vs. 1.5 in unscreened patients; P= 0.21). However, among the subset of patients who were depressed at baseline, screened patients were more likely than unscreened patients to be in complete remission at follow-up (1 symptom of depression in 48% of those screened vs. 27% of those not screened; P< 0.05). Only patients from 1 of the 2 study sites were included in the follow-up sample. At this site, only those with a diagnosis of depression at baseline and a random sample of the remaining participants (oversampling those with depressive sympt

Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder

Context The relative benefits and harms of newer, second-generation antidepressants are sometimes confusing. Contribution In this review of 46 head-to-head randomized trials, the authors generally found no major differences in the numbers of adults with major depression who responded to second-generation antidepressants, such as selective serotonin reuptake inhibitors, bupropion, duloxetine, mirtazapine, and venlafaxine. The overall incidence of adverse events appeared similar across drugs, although types of adverse events varied. Cautions Trials were funded by industry and had variable quality and follow-up duration. Implications Second-generation antidepressants generally have similar benefits but different possible harms for adults with major depression. The Editors Major depressive disorder is a serious disabling illness that affects more than 16% of adults in the United States at some point in their lifetime (1). In 2000, the economic burden of depressive disorders in the United States was estimated to be

Prevalence of DSM-IV-defined mood, anxiety, and substance use disorders in an HIV clinic in the southeastern United States

83.1 billion (2). Current practice guidelines for the treatment of major depressive disorder recommend pharmacotherapy, psychotherapy, psychotherapy plus pharmacotherapy, or electroconvulsive therapy. In most cases, pharmacotherapy is first-line treatment for major depressive disorder. Moreover, it is a practical tool for primary care physicians, who prescribe the majority of antidepressants in the United States (3). Pharmacologic treatment for major depressive disorder includes first-generation antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and second-generation antidepressants. Second-generation medications include selective serotonin reuptake inhibitors (SSRIs); selective norepinephrine reuptake inhibitors; and other drugs that selectively affect the activity of neurotransmitters, such as serotonin, norepinephrine, and dopamine. In general, the efficacy of first- and second-generation antidepressant medications is similar (4-6). However, first-generation antidepressants often cause multiple side effects that many patients find intolerable (7-9), and the risk for harm when taken in overdose or in combination with certain medications is high. Because of their relatively favorable side effect profile, the second-generation antidepressants play a prominent role in the management of patients with major depressive disorder. Reviews have compared the efficacy and tolerability of newer second-generation antidepressants with those of placebo or older treatments (6, 10, 11) but did not evaluate comparative evidence for second-generation antidepressants. We therefore sought to systematically evaluate comparative data on the efficacy, effectiveness, and tolerability of commonly prescribed second-generation antidepressants. Specifically, we conducted a systematic review and meta-analysis of comparative evidence for 6 SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline) and 4 other second-generation antidepressants (bupropion, duloxetine, mirtazapine, and venlafaxine). From here on, we refer to these agents collectively as antidepressants. We examine the role of these agents in the initial treatment of ambulatory adult patients with major depressive disorder. Methods Key Questions Key questions designed to address the comparative efficacy, effectiveness, safety, and tolerability of antidepressants guided our research. A consortium of 12 state Medicaid programs, the Canadian Coordinating Office for Health Technology Assessment, the California HealthCare Foundation, and key experts formulated the questions and provided funding for this research. Literature Search To identify articles relevant to each key question, we searched MEDLINE, EMBASE, and PsychLit; the Cochrane Library; and the International Pharmaceutical Abstracts. To capture articles relevant to the scope of our topic, our searches covered 1980 through 28 February 2005. We manually searched reference lists of relevant review articles and letters to the editor. Pharmaceutical manufacturers were invited to submit dossiers, including citations, as outlined by the Drug Effectiveness Review Project (12). We requested unpublished studies from the U.S. Food and Drug Administration, but this agency did not release unpublished data. Study Selection Two persons independently reviewed titles and abstracts. If both reviewers agreed that a trial did not meet preestablished eligibility criteria (Appendix Table), we excluded it. To assess efficacy and effectiveness, we included head-to-head trials comparing one antidepressant with another. We defined effectiveness trials as those that were conducted in primary care settings, had an adequate duration of follow-up (3 months), had minimal inclusion and exclusion criteria (so that participants represented the general population), assessed health outcomes rather than intermediate outcomes, and had an adequate sample size to determine a minimally important difference (from a patients perspective) on a health-related quality of life instrument (13). To assess safety and tolerability, we included head-to-head trials, placebo-controlled trials, and observational studies with large samples (>100 patients) lasting at least 1 year. We required a larger sample size for observational studies because we wanted primarily to detect adverse events that were not frequent enough to be apparent in smaller trials. Data Abstraction and Quality Assessment Trained reviewers abstracted data from each study, and a senior reviewer read each abstracted article and evaluated completeness of data extraction. We recorded intention-to-treat results if they were available. We assessed the internal validity (quality) of trials by using predefined criteria from the U.S. Preventive Services Task Force (ratings of good, fair, or poor) (14) and the National Health Service Centre for Reviews and Dissemination (15). Elements of internal validity assessment included randomization, allocation concealment, similarity of compared groups at baseline, use of intention-to-treat analysis, and overall and differential loss to follow-up. We defined loss to follow-up as the number of persons who underwent randomization but did not complete the study (16), independent of the reason and whether intention-to-treat analysis was used. We rated studies as poor if they had more than 40% overall loss to follow-up or more than 15 percentage points of differential loss to follow-up between study groups. Data Synthesis We first qualitatively summarized the studies. When more than 3 head-to-head trials compared the same treatments, we did quantitative analyses. In these, the primary outcome measure was treatment response, defined as 50% or greater improvement on the Hamilton Rating Scale for Depression (HAM-D) or the MontgomeryAsberg Depression Rating Scale from baseline to study end. The relative benefit reflects the ratio of benefits or risks in one treatment group compared with another. When treatment effects differed between studies, we explored potential reasons for these differences. For each meta-analysis, we tested for heterogeneity of treatment effects by using I2 statistics. If no heterogeneity was detected, we applied both a random-effects and a fixed-effects model. We report the results of the more conservative random-effects models (17) because the validity of tests of heterogeneity can be limited with a small number of component studies. To estimate possible publication bias caused by the tendency of published studies to be positive, we used funnel plots, the Begg adjusted rank correlation test (18), and the Egger regression approach (19). However, because these tests have low statistical power when the number of trials is small (20), undetected bias may still be present. All statistical analyses were conducted by using StatsDirect Statistical Software, version 2.3.8 (StatsDirect, Ltd., Sale, United Kingdom). We calculated the mean incidence and 95% CIs for specific adverse events reported in included trials. Because assessment and reporting of adverse events varied greatly among trials, this evidence should be interpreted with caution. Role of the Funding Sources The funding sources contributed to the development of the key questions but had no role in the conduct or reporting of the study or in the decision to submit the manuscript for publication. Results We found 820 unduplicated citations. Manual review of the reference lists of pertinent review articles produced another 74 articles. Although 6 pharmaceutical companies submitted dossiers, no included studies stemmed from the dossiers. Therefore, 894 citations were included in our database (Appendix Figure). Forty-six randomized, controlled trials compared the effectiveness or efficacy of one SSRI or other antidepressant with that of another in the treatment of major depressive disorder (Tables 1 and 2). (Complete evidence tables are available at www.ohsu.edu/drugeffectiveness/reports/final.cfm or from the authors.) Most studies were efficacy trials and received a rating of fair for internal validity; some trials rated fair may have fulfilled all quality criteria but did not report methods to an extent that answered all of our questions. We considered 2 trials from Europe (21, 22) and 1 trial from the United States (23) conducted in primary care settings to be effectiveness trials. Sixty percent of included trials were less than 12 weeks in duration. The samples consisted mostly of persons younger than 60 years of age; samples consisted of persons 60 years of age or older in 6 trials (13%) and children or adolescents younger than 18 years of age in 3 trials (7%). Although sponsorship did not influence our quality rating, it may have influenced reporting. About 85% of trials in our review were sponsored by a pharmaceutical company, and an additional 11% had at least 1 author affiliated with a pharmaceutical company. The remaining 4% of included studies

STAR*D: revising conventional wisdom.

Background: Mood and anxiety disorders, particularly depression, and substance abuse (SA) commonly co-occur with HIV infection. Appropriate policy and program planning require accurate prevalence estimates. Yet most estimates are based on screening instruments, which are likely to overstate true prevalence. Setting: Large academic medical center in Southeast. Participants: A total of 1,125 patients, representing 80% of HIV-positive patients seen over a 2.5-year period, completed the Substance Abuse-Mental Illness Symptoms Screener, a brief screening instrument for probable mood, anxiety, and SA disorders. Separately, 148 participants in a validation study completed the Substance Abuse-Mental Illness Symptoms Screener and a reference standard diagnostic tool, the Structured Clinical Interview for DSM-IV. Methods: Using the validation study sample, we developed logistic regression models to predict any Structured Clinical Interview for DSM-IV mood/anxiety disorder, any SA, and certain specific diagnoses. Explanatory variables included sociodemographic and clinical information and responses to Substance Abuse-Mental Illness Symptoms Screener questions. We applied coefficients from these models to the full clinic sample to obtain 12-month clinic-wide diagnosis prevalence estimates. Results: We estimate that in the preceding year, 39% of clinic patients had a mood/anxiety diagnosis and 21% had an SA diagnosis, including 8% with both. Of patients with a mood/anxiety diagnosis, 76% had clinically relevant depression and 11% had posttraumatic stress disorder. Conclusions: The burden of psychiatric disorders in this mixed urban and rural clinic population in the southeastern United States is comparable to that reported from other HIV-positive populations and significantly exceeds general population estimates. Because psychiatric disorders have important implications for clinical management of HIV/AIDS, these results suggest the potential benefit of routine integration of mental health identification and treatment into HIV service sites.

Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy.

The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study used a series of sequenced, randomized treatment trials following a first and, if needed, subsequent treatment steps to define the tolerability and effectiveness of various options in both acute and longer term treatment. Adult outpatients (n = 4041) with nonpsychotic major depressive disorder, substantial chronic and recurrent depression, and co-morbid psychiatric and general medical conditions were enrolled in 41 representative primary and specialty care settings. About one-third of participants remitted in first step treatment with citalopram, 50% of these within 6 weeks. Poorer outcomes were associated with minority status, socioeconomic disadvantage, more axis I and III co-morbid disorders, lower function and quality of life, and anxious and melancholic features. In step 2 medication switch, there were no significant differences in remission among within-class, out-of-class or dual-action agents: sertraline (27%), bupropion-sustained release (26%) and venlafaxine-extended release (25%). In step 2 medication augmentation of citalopram, there was no significant difference in remission between bupropion-sustained release (39%) and buspirone (33%), although participants using bupropion-sustained release had greater symptom reduction and better tolerability. There were no significant differences in remission in step 2 between cognitive therapy and medication treatment in either the switch (31% vs 27%) or augmentation (31% vs 33%) strategies, although participants in cognitive therapy augmentation had a longer time to remission than those in medication augmentation (55 vs 40 days). In step 3, there were no differences in remission between a switch to mirtazapine (8%) or nortriptyline (12%), or between augmentation with lithium (13%) or T3 (triiodothyronine, liothyronine) [25%], although more participants discontinued lithium due to adverse effects than discontinued T3. In the fourth step, there was no difference in remission between tranylcypromine (14%) or venlafaxine-extended release plus mirtazapine (16%), although the combination treatment had fewer adverse effects and had the advantages of not requiring a washout period or diet restrictions. Participants requiring more than two well delivered treatments may be characterized as treatment resistant given the substantially lower remission rates after that point. Treatment resistance was associated with more concurrent axis I or III co-morbid conditions, socioeconomic disadvantage, chronicity and melancholic or anxious features. However, if participants remained in treatment for up to four steps, about 67% reached remission. Times to remission were not substantially longer for later treatment steps. The importance of reaching remission is highlighted by the lower relapse rates in naturalistic follow-up for participants entering in remission compared with those entering with response but not remission (step 1: 34% vs 59%; step 2: 47% vs 68%; step 3: 42% vs 76%; step 4: 50% vs 83%). Clinical decision making based on the itemized measurement of symptoms and adverse effects at each treatment visit was feasible in STAR*D’s real world settings and resulted in adequate dosages and durations of treatment that generally exceeded those typically found in practice settings. Although switch and augmentation strategies could not be directly compared due to the equipoise stratified randomized design, the higher remission rates at step 2 with medication augmentation are intriguing and merit further study.

Depression and health-related quality of life.

Background:Mental illness (MI) and substance abuse (SA) are common in HIV-positive patients. MI/SA consistently predict poorer antiretroviral adherence, suggesting that affected patients should be at higher risk of poor virologic and immunologic response to highly active antiretroviral therapy (HAART). Participants:198 HAART-naive patients initiated HAART at an academic medical center serving a heterogeneous population. Methods:Participants were assigned a predicted probability from 0 to 1 of having each of the following: (1) any mood, anxiety, or substance use disorder; (2) clinically relevant depression; (3) alcohol abuse/dependence; and (4) drug abuse/dependence. Probabilities were based on responses to questions on an MI/SA screening instrument (Substance Abuse and Mental Illness Symptoms Screener [SAMISS]) and other clinical and sociodemographic characteristics and were derived using predictive logistic regression modeling from a separate validation study of the SAMISS compared with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses. Using survival analysis techniques, we assessed baseline predicted probability of psychiatric illness as a predictor of time from HAART initiation to virologic suppression (first viral load [VL] <400 copies/mL), from HAART initiation to overall virologic failure (first VL ≥400 copies/mL after suppression, time set to 0 for patients never achieving suppression), from virologic suppression to virologic rebound (first VL ≥400 copies/mL), and from HAART initiation to immunologic failure (first CD4 cell count lower than baseline). Results:A higher predicted probability of any psychiatric disorder was associated with a slower rate of virologic suppression (adjusted hazard ratio [aHR] = 0.86 per 25% increment, 95% confidence interval [CI]: 0.75 to 0.98) and a faster rate of overall virologic failure (aHR = 1.22, 95% CI: 1.06 to 1.40). Associations with other outcomes were consistent in direction but not statistically significant. Predicted probability of depression was associated with slower virologic suppression (aHR = 0.79, 95% CI: 0.63 to 0.98), and predicted probabilities of alcohol and drug abuse/dependence was associated with faster overall virologic failure (aHR = 1.37, 95% CI: 1.08 to 1.74 and aHR = 1.18, 95% CI: 1.00 to 1.39, respectively). Conclusions:These results are consistent with an inferior virologic response to first HAART among patients with concurrent mood, anxiety, and substance use disorders, suggesting a clinical benefit to identification and treatment of psychiatric illness among patients initiating antiretroviral therapy.

Minor depression in family practice: functional morbidity, co-morbidity, service utilization and outcomes

Chronic medical conditions drastically affect the lives of those afflicted, leading to pain, disability, and disruption. Comorbid depression can exacerbate the effects of medical illness and may be an independent source of suffering and disability. Data from the Epidemiological Follow-Up Study (NHEFS) of the first National Health and Nutrition Examination Survey (NHANES I) are used to examine the manner in which depression and comorbid medical conditions interact to affect health-related quality of life (HRQOL). The findings suggest a) that the effects of depression are comparable with those of arthritis, diabetes, and hypertension; and b) that depression and chronic medical illnesses interact to amplify the effects of the medical illness. The data also support the merit of adopting a multidimensional approach to HRQOL rather than treating it unidimensionally.