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HIV AND DEPRESSION

45 HIV-positive gay men

11.11

33 HIV-negative men

3.03

124 HIV-positive gay men

4.03

84 HIV-negative gay men

3.57

144 HIV-positive men and women

6.90

29 HIV-negative men and women

6.94

166 HIV-positive gay men

10.24

31 HIV-negative gay men

6.45

124 HIV-positive intravenous drug users

22.58

99 HIV-negative intravenous drug users

17.17

602 HIV-positive men and women

7.14

353 HIV-negative men and women

1.98

98 HIV-positive gay men

8.16

71 HIV-negative gay men

2.82

50 HIV-positive men and women

0.00

47 HIV-negative men and women

0.00

183 HIV-positive gay men

7.65

84 HIV-negative gay men

8.33

164 HIV-positive gay men

18.29

65 HIV-negative gay men

9.23

Fukunishi et al. (4)

1997

Rabkin et al. (6)b

1997

Kelly et al. (9)b

1998

Lipsitz et al. (10)

1994

Maj et al. (11)

1994

Perkins et al. (12)b

1994

1.00

Chuang et al. (8)

1992

Rosenberger et al. (13)b

1993

Williams et al. (14)b

1991

1.07

0.88

2.08

2.60

TABLE 1. Studies Comparing Rates of Depressive Disorders in Groups of

HIV-Positive and HIV-Negative

1.27

3.59

0.86

1.65

Study Atkinson et al. (7)b

Year 1988

Subjects in HIV-Positive Study Group and HIV-Negative Comparison Group

Major Depressive Disordera

Rate (%)

Odds Ratio

2.35

Subjects

Dysthymic Disordera Rate (%) Odds Ratio

2.42 0.00 11.29 5.05 0.66 0.85 0.00 2.82 13.11 4.76

4.87

2.25

1.09

0.14

2.75

a DSM-III-R criteria used for diagnoses in all studies except Atkinson et al. (7), which u IV criteria. b All HIV-positive subjects were gay or bisexual.

sed DSM-III criteria, and Rabkin et a

l. (6), which used DSM-

analyzed separately, without aggregation. Thus far, the available studies are able to rule out only very large differ- ences in rates of depression. It therefore remains possible that HIV infection is associated with higher rates of de- pression, although this difference may be modest and un- detectable in these studies because of poor statistical power.

It also is possible that the effects of HIV infection are moderated by other characteristics of infected individuals. In other words, high risk for depression might be present only among certain HIV-positive individuals. For example, risk for depressive disorders might vary over the course of HIV infection. Some evidence from questionnaire studies has suggested that rates of depressive symptoms increase as HIV disease progresses (9, 18). Likewise, sexual orienta- tion, disease stage, gender, or intravenous drug use may influence the degree to which HIV status is associated with risk for depressive disorders. In this regard, it is important for investigations that contrast an HIV-positive group and an HIV-negative comparison group to match participants on these potentially important characteristics. Popula- tions at particular risk for contracting HIV (e.g., gay men, intravenous drug users) may concurrently be at risk for depression, independent of HIV status. Failure to select appropriate comparison groups could lead to biased re- sults. It is fortunate that all of the studies in this meta- analysis attempted to match their comparison and HIV- positive study groups on at least one of these demographic factors.

The present study is a quantitative review of risk for de- pressive disorders in the context of HIV infection. Meta- analytic techniques were used to aggregate and reanalyze the data provided in 10 previous studies that compared the relative risk for depressive disorders among HIV-nega-

tive and HIV-positive subjects. Three main questions were addressed. First, we tested whether HIV status was associ- ated with either major depressive disorder or dysthymic disorder. Second, we tested whether risk for depressive disorders was moderated by the sexual orientation of the HIV-positive subjects. Finally, we investigated the degree to which HIV-related symptoms affected rates of depres- sion in groups of HIV-positive subjects.

Method

Selection of Studies

To identify studies for inclusion in this review, we conducted a thorough literature search using the standard electronic data- bases PsychInfo, MEDLINE, and AIDSLINE. In addition, we re- viewed the introduction and reference sections of relevant stud- ies. Studies were eligible for inclusion if 1) both an HIV-positive group and an HIV-negative comparison group were evaluated, 2) diagnostic interviews were conducted, 3) current (1- to 6-month) rates of major depressive disorder and/or dysthymic disorder were reported, 4) data were provided from the earliest assessment if the study was longitudinal, and 5) the study subjects were not recruited specifically through the mental health system.

Criterion 1 was adopted to limit the influence of factors that vary across studies such as recruitment strategy, diagnostic sys- tem or interview, and demographic characteristics. This type of control is particularly important because of the large differences in mood disorder rates observed between studies (and even within studies [10]). If a study adopted strategies leading to con- servative or liberal estimates of psychopathology, presumably these same strategies were applied to both the HIV-positive and HIV-negative study groups. Criterion 2 was adopted to avoid the difficulties associated with diagnosis of depression on the basis of self-report inventories (19). Self-report inventories are particu- larly problematic for use with this population. Many of the physi- cal symptoms of HIV disease overlap with symptoms of depres- sion (20–23). In an interview, the clinician can investigate such overlapping symptoms and decide whether the symptom in

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Am J Psychiatry 158:5, May 2001

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