The Depression Treatment Cascade: Disparities by Alcohol Use, Drug Use, and Panic Symptoms Among Patients in Routine HIV Care in the United States

  • Bethany L. DiPrete
  • Brian W. Pence
  • Angela M. Bengtson
  • Richard D. Moore
  • David J. Grelotti
  • Conall O’Cleirigh
  • Riddhi Modi
  • Bradley N. Gaynes
Original Paper


Little is known about disparities in depression prevalence, treatment, and remission by psychiatric comorbidities and substance use among persons living with HIV (PLWH). We conducted a cross-sectional analysis in a large cohort of PLWH in routine care and analyzed conditional probabilities of having an indication for depression treatment, receiving treatment, receiving indicated treatment adjustments, and achieving remission, stratified by alcohol use, illicit drug use, and panic symptoms. Overall, 34.7% (95% CI 33.9–35.5%) of participants had an indication for depression treatment and of these, 55.3% (53.8–56.8%) were receiving antidepressants. Among patients receiving antidepressants, 33.0% (31.1–34.9%) had evidence of remitted depression. In a subsample of sites with antidepressant dosage data, only 8.8% (6.7–11.5%) of patients received an indicated treatment adjustment. Current drug users (45.8%, 95% CI 43.6–48.1%) and patients reporting full symptoms of panic disorder (75.0%, 95% CI 72.9–77.1%) were most likely to have an indication for antidepressant treatment, least likely to receive treatment given an indication (current drug use: 47.6%, 95% CI 44.3–51.0%; full panic symptoms: 50.8%, 95% CI 48.0–53.6%), or have evidence of remitted depression when treated (22.3%, 95% CI 18.5–26.6%; and 7.3%, 95% CI 5.5–9.6%, respectively). In a multivariable model, drug use and panic symptoms were independently associated with poorer outcomes along the depression treatment cascade. Few differences were evident by alcohol use. Current drug users were most likely to have an indication for depression treatment, but were least likely to be receiving treatment or to have remitted depression. These same disparities were even more starkly evident among patients with co-occurring symptoms of panic disorder compared to those without. Achieving improvements in the depression treatment cascade will likely require attention to substance use and psychiatric comorbidities.


HIV infections Depression Drug users Alcohol drinking Anxiety disorders 



BWP, RDM, CMO, RM, DJG, and BNG contributed to the acquisition of data. BLD, BWP, and AMB conceived and designed the analysis. BLD and BWP analyzed the data. BLD drafted the manuscript. BWP, AMB, RDM, DJG, RM, CMO, and BNG assisted with the interpretation of the data and critically revised the manuscript for important intellectual content. All authors take responsibility for and approve the final version of the manuscript. We thank the National Institutes of Mental Health (Grant Number R01MH100970) and the National Institute of Allergy and Infectious Diseases (Grant Numbers R24AI067039 and P30 AI50410) for their support of this work.


This work was supported by the National Institutes of Mental Health (Grant Number R01MH100970 to BWP) and by the National Institute of Allergy and Infectious Disease (Grant Numbers R24AI067039, P30AI50410).

Compliance with Ethical Standards

Conflict of interest

BWP has received a speaking honorarium from MSD. No other conflicts of interest are declared.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Pence BW, Miller WC, Whetten K, Eron JJ, Gaynes BN. Prevalence of DSM-IV-defined mood, anxiety, and substance use disorders in an HIV clinic in the Southeastern United States. JAIDS. 2006;42(3):298–306.PubMedGoogle Scholar
  2. 2.
    Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.CrossRefGoogle Scholar
  3. 3.
    Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. AJP. 2001;158(5):725–30.CrossRefGoogle Scholar
  4. 4.
    Orlando M, Burnam MA, Beckman R, et al. Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV cost and services utilization study. Int J Methods Psychiatr Res. 2002;11(2):75–82.CrossRefGoogle Scholar
  5. 5.
    Schumacher JE, McCullumsmith C, Mugavero MJ, et al. Routine depression screening in an HIV clinic cohort identifies patients with complex psychiatric co-morbidities who show significant response to treatment. AIDS Behav. 2013;17(8):2781–91.CrossRefGoogle Scholar
  6. 6.
    Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDS. 2008;22(3):233–43.CrossRefGoogle Scholar
  7. 7.
    Mugavero M, Ostermann J, Whetten K, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDs. 2006;20(6):418–28.CrossRefGoogle Scholar
  8. 8.
    Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011. Scholar
  9. 9.
    Zuniga JA, Yoo-Jeong M, Dai T, Guo Y, Waldrop-Valverde D. The role of depression in retention in care for persons living with HIV. AIDS Patient Care STDs. 2015;30(1):34–8.CrossRefGoogle Scholar
  10. 10.
    Pence BW, Miller WC, Gaynes BN, Eron JJ. Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. JAIDS. 2007;44(2):159–66.PubMedGoogle Scholar
  11. 11.
    Todd JV, Cole SR, Pence BW, et al. Effects of antiretroviral therapy and depressive symptoms on all-cause mortality among HIV-infected women. Am J Epidemiol. 2017;185(10):869–78.CrossRefGoogle Scholar
  12. 12.
    Mugavero MJ, Pence BW, Whetten K, et al. Predictors of AIDS-related morbidity and mortality in a Southern U.S. Cohort. AIDS Patient Care STDs. 2007;21(9):681–90.CrossRefGoogle Scholar
  13. 13.
    Pence BW, O’Donnell JK, Gaynes BN. Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care. AIDS. 2012;26(5):656–8.CrossRefGoogle Scholar
  14. 14.
    Pence BW, Gaynes BN, Adams JL, et al. The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial. AIDS. 2015;29(15):1975–86.CrossRefGoogle Scholar
  15. 15.
    Himelhoch S, Medoff DR. Efficacy of antidepressant medication among HIV-positive individuals with depression: a systematic review and meta-analysis. AIDS Patient Care STDs. 2005;19(12):813–22.CrossRefGoogle Scholar
  16. 16.
    Himelhoch S, Medoff DR, Oyeniyi G. Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: a systematic review and meta-analysis. AIDS Patient Care STDS. 2007;21(10):732–9.CrossRefGoogle Scholar
  17. 17.
    Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014;47(3):259–69.CrossRefGoogle Scholar
  18. 18.
    Springer SA, Dushaj A, Azar MM. The impact of DSM-IV mental disorders on adherence to combination antiretroviral therapy among adult persons living with HIV/AIDS: a systematic review. AIDS Behav. 2012;16(8):2119–43.CrossRefGoogle Scholar
  19. 19.
    Tsai AC, Karasic DH, Hammer GP, et al. Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial. Am J Public Health. 2013;103(2):308–15.CrossRefGoogle Scholar
  20. 20.
    Pyne JM, Fortney JC, Curran GM, et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med. 2011;171(1):23–31.PubMedGoogle Scholar
  21. 21.
    O’Cleirigh C, Magidson JF, Skeer MR, Mayer KH, Safren SA. Prevalence of psychiatric and substance abuse symptomatology among HIV-infected gay and bisexual men in HIV primary care. Psychosomatics. 2015;56(5):470–8.CrossRefGoogle Scholar
  22. 22.
    Cholera R, Pence BW, Bengtson AM, et al. Mind the gap: gaps in antidepressant treatment, treatment adjustments, and outcomes among patients in routine HIV care in a multisite U.S. Clinical Cohort. PLoS ONE. 2017;12(1):e0166435.CrossRefGoogle Scholar
  23. 23.
    Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.CrossRefGoogle Scholar
  24. 24.
    Kay ES, Batey DS, Mugavero MJ. The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future. AIDS Res Ther. 2016;13:35.CrossRefGoogle Scholar
  25. 25.
    Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis. 2013;57(8):1164–71.CrossRefGoogle Scholar
  26. 26.
    Brandt C, Zvolensky MJ, Woods SP, Gonzalez A, Safren SA, O’Cleirigh CM. Anxiety symptoms and disorders among adults living with HIV and AIDS: a critical review and integrative synthesis of the empirical literature. Clin Psychol Rev. 2017;51:164–84.CrossRefGoogle Scholar
  27. 27.
    Chander G, Lau B, Moore RD. Hazardous alcohol use: a risk factor for non-adherence and lack of suppression in HIV infection. J Acquir Immune Defic Syndr. 2006;43(4):411–7.CrossRefGoogle Scholar
  28. 28.
    Gaynes BN, Pence BW, Eron JJ, Miller WC. Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population. Psychosom Med. 2008;70(4):505–11.CrossRefGoogle Scholar
  29. 29.
    Lucas GM, Gebo KA, Chaisson RE, Moore RD. Longitudinal assessment of the effects of drug and alcohol abuse on HIV-1 treatment outcomes in an urban clinic. AIDS. 2002;16(5):767–74.CrossRefGoogle Scholar
  30. 30.
    Hahn JA, Samet JH. Alcohol and HIV disease progression: weighing the evidence. Curr HIV/AIDS Rep. 2010;7(4):226–33.CrossRefGoogle Scholar
  31. 31.
    Nolan S, Walley AY, Heeren TC, et al. HIV-infected individuals who use alcohol and other drugs, and virologic suppression. AIDS Care. 2017;29(9):1129–36.CrossRefGoogle Scholar
  32. 32.
    Gaynes BN, O’Donnell J, Nelson E, et al. Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential. Gen Hosp Psychiatry. 2015;37(4):277–82.CrossRefGoogle Scholar
  33. 33.
    Israelski DM, Prentiss DE, Lubega S, et al. Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS. AIDS Care. 2007;19(2):220–5.CrossRefGoogle Scholar
  34. 34.
    Sowa NA, Bengtson A, Gaynes BN, Pence BW. Predictors of depression recovery in HIV-infected individuals managed through measurement-based care in infectious disease clinics. J Affect Disord. 2016;192:153–61.CrossRefGoogle Scholar
  35. 35.
    Kitahata MM, Rodriguez B, Haubrich R, et al. Cohort profile: the Centers for AIDS Research Network of Integrated Clinical Systems. Int J Epidemiol. 2008;37(5):948–55.CrossRefGoogle Scholar
  36. 36.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.CrossRefGoogle Scholar
  37. 37.
    Crane PK, Gibbons LE, Willig JH, et al. Measuring depression levels in HIV-infected patients as part of routine clinical care using the 9-item patient health questionnaire (PHQ-9). AIDS Care. 2010;22(7):874–85.CrossRefGoogle Scholar
  38. 38.
    Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann. 2002;32(9):509–15.CrossRefGoogle Scholar
  39. 39.
    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88(6):791–804.CrossRefGoogle Scholar
  40. 40.
    Humeniuk R, Ali R, Babor TF, et al. Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. 2008;103(6):1039–47.CrossRefGoogle Scholar
  41. 41.
    WHO Assist Working Group. The Alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183–94.CrossRefGoogle Scholar
  42. 42.
    Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737–44.CrossRefGoogle Scholar
  43. 43.
    Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med. 2003;18(6):450–60.CrossRefGoogle Scholar
  44. 44.
    Bengtson AM, Pence BW, Crane HM, et al. Disparities in depressive symptoms and antidepressant treatment by gender and race/ethnicity among people living with HIV in the United States. PLoS ONE. 2016;11(8):e0160738.CrossRefGoogle Scholar
  45. 45.
    Bakker A, van Balkom AJ, Spinhoven P. SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis. Acta Psychiatr Scand. 2002;106(3):163–7.CrossRefGoogle Scholar
  46. 46.
    Grelotti DJ, Hammer GP, Dilley JW, et al. Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial. AIDS Care. 2017;29(3):273–9.CrossRefGoogle Scholar
  47. 47.
    DiPrete BL, Pence BW, Grelotti DJ, Gaynes BN. Measurement of depression treatment among patients receiving HIV primary care: whither the truth? J Affect Disord. 2018. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Bethany L. DiPrete
    • 1
  • Brian W. Pence
    • 1
  • Angela M. Bengtson
    • 1
  • Richard D. Moore
    • 2
  • David J. Grelotti
    • 3
  • Conall O’Cleirigh
    • 4
    • 5
  • Riddhi Modi
    • 6
  • Bradley N. Gaynes
    • 7
  1. 1.Department of Epidemiology, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Department of Medicine, School of MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of PsychiatryUniversity of California, San DiegoSan DiegoUSA
  4. 4.The Fenway InstituteFenway HealthBostonUSA
  5. 5.Department of PsychiatryHarvard Medical School/Massachusetts General HospitalBostonUSA
  6. 6.Department of Medicine, Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamUSA
  7. 7.Department of Psychiatry, School of MedicineUniversity of North Carolina at Chapel HillChapel HillUSA

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