March 14, 2013
Myles Helfand: How much reliable data are there on the ways in which mental health and HIV intersect?
Francine Cournos: The studies suggest that the single most common reason people seek mental health treatment is depression. And the rates of depression in HIV populations vary from very low to very high. But probably, if you look at samples of people in treatment, they hover around 30%. So that's a lot.
David Fawcett: That's right. I've seen various meta-analyses that do come in around that 30% mark, as well. That seems to be a fairly consistent number.
Francine Cournos: There's a lot of descriptive data on rates of mental illness among HIV populations, and almost no research that's been done on the treatment of mental disorders in the context of HIV. So, for most treatment decisions, you can't look to data that's been collected in HIV populations. But in terms of prevalence rates, there are a lot of different studies, both in the U.S. and abroad; and they show very different rates, depending on who is in the study.
What I would say is that virtually all of them show rates of many mental disorders that are much higher than in the general population -- especially for depression, anxiety disorders, substance abuse disorders. To give you an example: If you want to look at injection drug users, close to 100% of those people have opioid dependence. That would mean, since substance use disorders are also mental illnesses, that's a population where 100% of people have mental illness. Whereas if you were looking at, let's say, a population of people who were not using substances at all, you'd get a very different rate of mental illness.
Substance use disorders and mental illnesses travel together. If you have one, you have a 50% chance of having the other. So someone with a substance use disorder has a 50% lifetime risk of another mental illness. And someone with a non-substance-use mental illness has a 50% chance of developing a substance use disorder. So you see a lot of that comorbidity.
When you look at people who are sex workers, they have very poor mental health, in studies that have been done -- in large measure because sex workers, especially those who are on the street, are people with very strong childhood histories of trauma and adult histories of trauma. They have a lot of PTSD, a lot of substance use. So that's a population with very poor mental health.
And then, when you look at men who have sex with men: That's a much more varied population, from people who are very healthy, to people who have had a lot of childhood trauma, bullying, rejection by family, and some of the associated mental health problems that come along with discrimination and abuse.
David Fawcett: One thing I would add to that is that a lot of these symptoms are transient. Someone may have a really severe time with, say, depressive symptoms at some point. And then it might clear. They might get their resilience back, a little bit. And then some other thing might kick it off. So it's very hard to track; it's not a consistent kind of thing over time.
Francine Cournos: I totally agree with that. Mental disorders tend to be episodic: You feel bad, then you go into a remission. And then you go along, and you're well for a while.
David Fawcett: Right.
Myles Helfand: Are there any longitudinal studies that have worked out what rates of depression are among people before they become infected with HIV, and to what extent that changes after a person is diagnosed?
Francine Cournos: No one is doing longitudinal studies, not any that I've seen.
Myles Helfand: Why is that?
Francine Cournos: Because if you look at the National Institute of Mental Health: What have they funded in the way of HIV-related studies? The vast majority are behavioral studies for prevention intervention.
David Fawcett: Right.
Francine Cournos: Looking at mental illness and its treatment has only gotten a very teeny piece of the budget. I mean, of course, prevention and behavioral strategies to reduce risk are really important. But the mental illness component is very poorly represented in the agenda of NIH.
Myles Helfand: In the absence of solid research or conclusive data in this area, what can we say about the intersection between HIV and mental health?
Francine Cournos: There are people who think -- and this gets back to the fact that severe depression is probably medical -- that there are certain things going on that are interactions between the things that appear to be mental illnesses and those that are the response of the immune system. Maybe the best example would be treating hepatitis C with interferon, which we know causes very high rates of depression. What you see is that, in the face of getting pegylated interferon, people get an immune response. And part of the immune response, by its very nature, looks a lot like depression. There's incredible fatigue and mood changes, with a very high rate of depression.
My personal feeling is that we're on the wrong track when we think about severe depression as a mental disorder independent of the body. It's really something going on in the body. It may be linked to the immune system. We only have hypotheses. But depressed people die younger. Mentally ill people die younger. And depression and other mental illnesses are very bad for your physical health.
Myles Helfand: We also know that there are some direct cause/effect relationships, such as that of mental health on adherence rates, which also has a direct impact on your overall physical health and your risk of long-term death.
Francine Cournos: Right. Yes. And we know that the two disorders that show up the most in that regard are substance use disorders and depression. Those are the two with the clearest evidence that they interfere with adherence.
Myles Helfand: Dr. Fawcett?
David Fawcett: What I'm hearing a lot -- and, because I'm living with HIV, I'm experiencing a lot, as well -- is this ominous reality of combining aging with long-term survival.
As people are starting to get cardiac problems, and liver problems, and kidney problems, there are concerns about taking all of these heavy-duty medications indefinitely, and putting that with the issues of age; I think there's a little bit of a dark cloud, more so than normal, as we get into the next decade of the epidemic. Those issues of aging and long-term medication use and the virus itself really combine into something that I think people are stressing about a lot. And it's not always verbalized, but it's there, a little bit of a shadow in the background.
Myles Helfand: Are you describing the arc that you've observed in your own therapy practice?
David Fawcett: Yes, in terms of what I see with clients, what I hear people describing, in terms of having more and more complications -- indicative of other problems, not just mood disorders. I had a client who seemed perfectly healthy, started doing exercise and shattered his hip. And there's a whole other podcast we could do about making sure everybody's informed: He was never told about calcium deficiency and vitamin D, and some supplements he might be able to take just because of the impact of the medication.
There are a lot of those kinds of emerging symptoms -- physical, mental and emotional -- that we're seeing that are impacting people right now who have been basically managing and living with the virus for a number of years.