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der. We tested the hypothesis that HIV-positive individuals would have higher rates of depressive disorders than de- mographically similar HIV-negative individuals, and we examined whether sexual orientation and stage of HIV in- fection moderate the association between HIV status and depression.

Whereas all 10 previous investigations directly compar- ing HIV-positive to HIV-negative subjects on the fre- quency of depressive disorder failed to find a statistically significant relationship, our meta-analysis indicated that HIV-positive individuals are nearly two times more likely to have had a recent episode of major depressive disorder than HIV-negative individuals. This finding is consistent with the large body of research demonstrating a strong as- sociation between other serious medical illnesses and de- pression (2, 3). On the other hand, only one of three analy- ses provided evidence that HIV status is associated with a greater risk for dysthymic disorder. There was no evidence that risk for major depressive disorder is associated with the sexual orientation of HIV-positive individuals. Finall , no support was found for the hypothesis that physically symptomatic patients are more likely to be depressed than asymptomatic individuals.

The results of this analysis suggest that the rate of major depressive disorder in the general HIV-positive popula- tion is at the very upper end of the 4%9% range suggested in previous reviews of this literature (15, 29, 30). Yet, the pursuit of a single estimate of the percentage of HIV-posi- tive individuals affected by depression ignores the vari- ance in observed rates, which itself may be of particular interest. There are likely differences between these study groups in a number of potentially important factors, such as gender, mode of transmission, access to quality health care, and socioeconomic status. Furthermore, the signifi- cant advances in the treatment of HIV infection may affect rates of depression. Whereas new treatments may increase life expectancy, they are also frequently burdensome. More fine-grained examination of these factors in future research could further our understanding of the associa- tion between HIV status and depression.

It is important to note that although HIV-positive indi- viduals had higher rates of major depressive disorder than HIV-negative subjects, depressive disorders seem to be the exception rather than the rule for this population. Only one in 10 HIV-positive individuals had a current episode of major depressive disorder. The observed rates of depres- sion were higher than those typically seen in general pri- mary care patients, but lower than those often seen in gen- eral medical inpatients (3). Such findings suggest that HIV infection is not directly associated with depressive disor- ders and that other correlates of HIV infection play a more direct role. These factors might involve social stigma and other environmental stressors (31). These findings may also encourage investigators to consider the psychological strengths and assets that are involved in protecting the majority of HIV-positive individuals from developing de-

Am J Psychiatry 158:5, May 2001

JEFFREY A. CIESLA AND JOHN E. ROBERTS

pressive disorders. Future research should explore factors that contribute to resiliency to depression, such as adap- tive coping styles, hardiness, and positive social support.

On the basis of a dichotomy between asymptomatic and symptomatic HIV-positive individuals, our analyses sug- gested that rates of major depressive disorder are stable across the course of HIV disease. Yet, this symptomatic/ asymptomatic dichotomy is not entirely adequate for rep- resenting the physical progression and psychological ex- perience of HIV infection. Perhaps the period immediately after receipt of a positive test result is most critical. We might anticipate that the greatest amount of psychological adjustment would need to take place during this period and consequently that the greatest vulnerability to major depressive disorder also might reside here. Although it has been shown that dysphoria is a common response to re- ceiving a positive test result (32, 33), other work has sug- gested that individuals typically adjust rather quickly and are unlikely to develop clinically significant depression at this time (34, 35). Unfortunately, too few studies were available for us to examine this issue more systematically in our meta-analysis.

The present meta-analytic study provides the strongest evidence we are aware of that HIV-positive individuals are at an elevated risk for developing major depressive disor- der. On the other hand, we did not find compelling evi- dence that these individuals are at heightened risk for dysthymic disorder. The lack of consistent, significant find- ings for dysthymic disorder could have been the result of issues of statistical power, diagnostic reliabilit , or true dif- ferences between major depressive disorder and dysthy- mic disorder. First, the analyses of dysthymic disorder had lower statistical power than those of major depressive dis- order because fewer studies assessed dysthymia and be- cause this condition has a lower prevalence than major de- pressive disorder. Second, relative to major depressive disorder, dysthymia is a less severe condition whose symp- toms may be more difficult to reliably tease apart from symptoms of HIV. Finally, it may be the case that HIV is more strongly associated with acute forms of depression, such as the majority of cases of major depressive disorder, than with chronic conditions, such as dysthymic disorder.

Risk for episodes of major depression was apparent for both symptomatic and asymptomatic HIV-positive indi- viduals, suggesting that these episodes had not been mis- diagnosed as a result of overlapping symptoms between HIV infection and depression (e.g., appetite disturbance, fatigue, and concentration difficulties). Clearly, such symptoms should not automatically be dismissed as mere reflections of HIV disease progression, particularly if they are present during the early stages of illness. Nonetheless, in practice, determining whether such symptoms are bet- ter attributable to depression or to HIV disease requires considerable skill. Although our findings suggest the need for routine screening for mood disorders among HIV-pos- itive patients, it is also clear that such evaluations need to

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