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TABLE 2. Studies Comparing Rates of Major Depressive Disorder in Asymptomatic and Symptomatic HIV-Positive





HIV-Positive Subjects in Symptomatic Study Group and Asymptomatic Comparison Group

Major Depressive Disordera

Rate (%)

Odds Ratio

28 symptomatic


17 asymptomatic


97 symptomatic


47 asymptomatic


64 symptomatic


102 asymptomatic


294 symptomatic


304 asymptomatic


85 symptomatic


79 asymptomatic


Atkinson et al. (7)


Chuang et al. (8)


Rosenberger et al.



Maj et al. (11)


Kelly et al. (9)








DSM-III-R criteria et al. (7), which u

used for diagnoses in all stud sed DSM-III criteria.

ies except Atkinson

another way, these 17 studies would need to have an aver- age number of participants equal to or exceeding 259, the average number in the 10 published studies. Thus, at min- imum, there would need to exist some number of unpub- lished studies with 4,403 HIV-positive and HIV-negative participants and an average effect size of zero. Given the labor-intensive nature of this research, it seems unlikely that such a large number of unpublished data exist. Fur- thermore, there is an intense demand for research involv- ing HIV-positive individuals, given the numerous aca- demic journals specifically devoted to this population. In our view, it is unlikely that there exists such a large amount of data that has remained unpublished because of null findings.

The next question was whether there was a relationship between HIV status and the presence of dysthymic disor- der. The vote-counting method found that 4.2% of the HIV-positive participants (N=48 of 1,131) had dysthymic disorder, compared to 2.0% of the HIV-negative partici- pants (N=14 of 691), a significant difference (χ2=6.01, df=1, N=1,822, p<0.05). By using the second meta-analytic method, the weighted effect size was 0.28 with a standard error of 0.28. The resulting 95% confidence interval was

    • 0.27

      to 0.83, a nonsignificant finding. Weighted rates were

    • 2.8

      % among HIV-positive and 1.6% among HIV-negative

participants. The inverse normal method of combining significance levels also fell short of rejecting the null hy- pothesis (p[z1.10]>0.05, N=5). Although the observed rate of dysthymic disorder among the HIV-positive sub- jects was roughly double that of the HIV-negative subjects, statistical analyses of this difference provided mixed re- sults. It is unclear whether there is a meaningful difference in rates of dysthymic disorder between these populations.

tion, we created a dummy variable reflecting whether a study group consisted of exclusively homosexual and/or bisexual men. This variable was not significantly associ- ated with either effect size (z=0.40, df=9, p>0.05) or proba- bility levels (z=0.47, df=9, p>0.05). Thus, across studies, the sexual orientation of participants was not associated with observed effect sizes. When the vote-counting method was applied specifically to studies that recruited only gay and bisexual men for the HIV-positive group, an association between HIV status and major depressive disorder status was found (χ2=6.76, df=1, N=1,148, p<0.01). Comparable to the findings for entire aggregated group, 10.4% of HIV-pos- itive gay and bisexual participants (N=81 of 780) and 5.7% of HIV-negative participants (N=21 of 368) currently met criteria for major depressive disorder. The degree to which HIV is associated with a greater risk for major depressive disorder appears to be the same for gay and bisexual men as it is for the general HIV-positive population.

Course of HIV and Depressive Disorders

We examined the possibility that the stage of HIV infec- tion influenced risk for depression. Because of a scarcity of studies providing separate rates of depression for asymp- tomatic and symptomatic HIV-positive subjects and for subjects with AIDS, data for symptomatic HIV-positive subjects and subjects with AIDS were combined. As Table 2 shows, five studies indicated rates of major depressive disorder in both asymptomatic HIV-positive and symp- tomatic HIV-positive patients. We predicted that HIV-pos- itive individuals with physical manifestations of the dis- ease would have higher rates of major depressive disorder than HIV-positive asymptomatic individuals. Unfortu- nately, we were unable to test whether stage of HIV infec- tion influences rates of dysthymic disorder because only one study provided the necessary information for this analysis.

Contrary to our hypothesis, individuals with advanced HIV disease did not differ in rates of major depressive dis- order from asymptomatic HIV-positive individuals. This conclusion was backed by the vote-counting method (χ2= 1.76, df=1, N=1,117, p>0.05), the effect-size method (95% confidence interval=00.56), and the inverse normal method (p[z1.54]>0.05, N=5). Overall, major depressive disorder was present in 8.6% of asymptomatic HIV-posi- tive subjects (N=47 of 549) and in 10.9% of symptomatic HIV-positive subjects and subjects with AIDS (N=62 of 568). These results suggest that physically symptomatic HIV-positive individuals, as a group, appear no more likely to experience major depressive disorder than asymptom- atic HIV-positive individuals.

Sexual Orientation and Risk for Depressive Disorders


The next question was whether sexual orientation mod- erated the relationship between HIV status and the pres- ence of major depressive disorder. To address this ques-

The present study used meta-analytic techniques to re- analyze existing research findings about the association between HIV infection and the risk for depressive disor-


Am J Psychiatry 158:5, May 2001

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