Cognitive Therapy and Research

, Volume 38, Issue 4, pp 458–464 | Cite as

Medication Adherence and HIV Symptom Distress in Relation to Panic Disorder Among HIV-Positive Adults Managing Opioid Dependence

  • Jesse D. Kosiba
  • Adam Gonzalez
  • Conall O’Cleirigh
  • Steven A. Safren
Original Article


Panic disorder (PD) occurs at greater rates among those with HIV compared to those without HIV. Rates of PD may be elevated among those with opioid dependence (persons who inject drugs, PWID). Persons with HIV experience common bodily symptoms as a result of the disease and these symptoms overlap with those of PD which may contribute to a “fear of fear” cycle present in PD. HIV-positive, PWID represent an at-risk population in terms of poor medication adherence. HIV symptoms and HIV medication side-effects commonly overlap with panic symptoms and may affect HIV medication adherence. The aim of this investigation was to examine the impact of PD on HIV-related symptom distress and HIV medication adherence in HIV-positive adults (N = 131) in treatment for opioid use. Those with a diagnosis of PD evidenced greater levels of HIV symptom distress and lower levels of medication adherence than those without current PD. Results highlight the clinical importance of assessing for and treating PD among individuals with HIV that are prescribed antiretroviral therapy. Future work would benefit from examining observed associations longitudinally and identifying potential mechanisms involved.


HIV Panic disorder Adherence Distress Substance use 



Funding for data collection for this Project is from R-01 DA018603 (Safren). Some of the investigator time was supported by Grant K24 MH094214 (Safren). Dr. Safren is supported by Grant K24 MH094214. Dr. Gonzalez is supported by Grants from the National Institute for Occupational Safety and Health (200-2011-42057 and 1U01OH010524-01) and the National Institute for Environmental Health Sciences (1R21ES023583-01).

Conflict of Interest

Jesse D. Kosiba, Adam Gonzalez, Conall O’Cleirigh and Steven A. Safren declare that they have no conflict of interest.

Informed Consent

All study participants provided written informed consent. Enrollment occurred between July of 2005 and October of 2008. All study procedures were approved by the Institutional Review Boards at Massachusetts General Hospital (MGH) in Boston, MA and at Rhode Island Hospital in Providence, RI.

Animal Rights

No animal studies were carried out by the authors for this article.


  1. Altice, F. L., Kamarulzaman, A., Soriano, V. V., Schechter, M., & Friedland, G. H. (2010). Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet, 376, 367–387. doi: 10.1016/S0140-6736(10)60829-X.PubMedCrossRefGoogle Scholar
  2. Barlow, D. H. (2002). Anxiety and its disorders (2nd ed.). New York, NY: Guilford.Google Scholar
  3. Barrera, T. L., & Norton, P. J. (2009). Quality of life impairment in generalized anxiety disorder, social phobia, and panic disorder. Journal of Anxiety Disorders, 23, 1086–1090. doi: 10.1016/j.janxdis.2009.07.011.PubMedCentralPubMedCrossRefGoogle Scholar
  4. Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A., Sherbourne, C. D., London, A. S., et al. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58, 721–728.PubMedCrossRefGoogle Scholar
  5. Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., et al. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 365, 493–505. doi: 10.1056/NEJMoa1105243.PubMedCentralPubMedCrossRefGoogle Scholar
  6. Del Romero, J., Castilla, J., Hernando, V., Rodriguez, C., & Garcia, S. (2010). Combined antiretroviral treatment and heterosexual transmission of HIV-1: Cross sectional and prospective cohort study. BMJ, 340, c2205. doi: 10.1136/bmj.c2205.PubMedCentralPubMedCrossRefGoogle Scholar
  7. Donnell, D., Baeten, J. M., Kiarie, J., Thomas, K. K., Stevens, W., Cohen, C. R., et al. (2010). Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: A prospective cohort analysis. Lancet, 375, 2092–2098. doi: 10.1016/S0140-6736(10)60705-2.Google Scholar
  8. Ehlers, A. (1995). A 1-year prospective study of panic attacks: Clinical course and factors associated with maintenance. Journal of Abnormal Psychology, 104, 164–172.PubMedCrossRefGoogle Scholar
  9. Emamzadeh-Fard, S., Fard, S. E., SeyedAlinaghi, S., & Paydary, K. (2012). Adherence to anti-retroviral therapy and its determinants in HIV/AIDS patients: A review. Infectious Disorders: Drug Targets, 12, 346–356.CrossRefGoogle Scholar
  10. Fisher, J. D., Smith, L. R., & Lenz, E. M. (2010). Secondary prevention of HIV in the United States: Past, current, and future perspectives. Journal of Acquired Immune Deficiency Syndromes, 55(Suppl 2), S106–S115. doi: 10.1097/QAI.0b013e3181fbca2f.PubMedCentralPubMedCrossRefGoogle Scholar
  11. Gadermann, A. M., Alonso, J., Vilagut, G., Zaslavsky, A. M., & Kessler, R. C. (2012). Comorbidity and disease burden in the National Comorbidity Survey Replication (NCS-R). Depression and Anxiety, 29, 797–806. doi: 10.1002/da.21924.PubMedCentralPubMedCrossRefGoogle Scholar
  12. Garcia de Olalla, P., Knobel, H., Carmona, A., Guelar, A., Lopez-Colomes, J. L., & Cayla, J. A. (2002). Impact of adherence and highly active antiretroviral therapy on survival in HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes, 30, 105–110.PubMedCrossRefGoogle Scholar
  13. Gardner, E. M., Sharma, S., Peng, G., Hullsiek, K. H., Burman, W. J., Macarthur, R. D., et al. (2008). Differential adherence to combination antiretroviral therapy is associated with virological failure with resistance. AIDS, 22, 75–82. doi: 10.1097/QAD.0b013e3282f366ff.PubMedCentralPubMedCrossRefGoogle Scholar
  14. Gay, C., Portillo, C. J., Kelly, R., Coggins, T., Davis, H., Aouizerat, B. E., et al. (2011). Self-reported medication adherence and symptom experience in adults with HIV. Journal of the Association of Nurses in AIDS Care, 22, 257–268. doi: 10.1016/j.jana.2010.11.004.PubMedCentralPubMedCrossRefGoogle Scholar
  15. Gonzalez, A., Barinas, J., & O’Cleirigh, C. (2011a). Substance use: Impact on adherence and HIV medical treatment. Current HIV/AIDS Reports, 8, 223–234. doi: 10.1007/s11904-011-0093-5.PubMedCrossRefGoogle Scholar
  16. Gonzalez, J. S., Batchelder, A. W., Psaros, C., & Safren, S. A. (2011b). Depression and HIV/AIDS treatment nonadherence: A review and meta-analysis. Journal of Acquired Immune Deficiency Syndromes, 58, 181–187. doi: 10.1097/QAI.0b013e31822d490a.PubMedGoogle Scholar
  17. Gonzalez, A., Mimiaga, M. J., Israel, J., Bedoya, A., & Safren, S. A. (2013). Substance use predictors of poor medication adherence: The role of substance use coping among HIV-infected patients in opioid dependence treatment. AIDS and Behavior, 17, 168–173. doi: 10.1007/s10461-012-0319-6.PubMedCentralPubMedCrossRefGoogle Scholar
  18. Gonzalez, A., Zvolensky, M. J., Parent, J., Grover, K. W., & Hickey, M. (2012). HIV symptom distress and anxiety sensitivity in relation to panic, social anxiety, and depression symptoms among HIV-positive adults. AIDS Patient Care and STDS, 26, 156–164. doi: 10.1089/apc.2011.0309.PubMedCrossRefGoogle Scholar
  19. Goodwin, R. D., & Eaton, W. W. (2003). Asthma and the risk of panic attacks among adults in the community. Psychological Medicine, 33, 879–885.PubMedCrossRefGoogle Scholar
  20. Grant, B. F., Hasin, D. S., Chou, S. P., Stinson, F. S., & Dawson, D. A. (2004). Nicotine dependence and psychiatric disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61, 1107–1115. doi: 10.1001/archpsyc.61.11.1107.PubMedCrossRefGoogle Scholar
  21. Gros, D. F., Milanak, M. E., Brady, K. T., & Back, S. E. (2013). Frequency and severity of comorbid mood and anxiety disorders in prescription opioid dependence. American Journal on Addictions, 22, 261–265. doi: 10.1111/j.1521-0391.2012.12008.x.PubMedCrossRefGoogle Scholar
  22. Hinkin, C. H., Hardy, D. J., Mason, K. I., Castellon, S. A., Durvasula, R. S., Lam, M. N., et al. (2004). Medication adherence in HIV-infected adults: Effect of patient age, cognitive status, and substance abuse. AIDS, 18(Suppl 1), S19–S25.PubMedCentralPubMedCrossRefGoogle Scholar
  23. Ickovics, J. R., Hamburger, M. E., Vlahov, D., Schoenbaum, E. E., Schuman, P., Boland, R. J., et al. (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV Epidemiology Research Study. JAMA, 285, 1466–1474.PubMedCrossRefGoogle Scholar
  24. Justice, A. C., Chang, C. H., Rabeneck, L., & Zackin, R. (2001). Clinical importance of provider-reported HIV symptoms compared with patient-report. Medical Care, 39, 397–408.PubMedCrossRefGoogle Scholar
  25. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005a). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. doi: 10.1001/archpsyc.62.6.593.PubMedCrossRefGoogle Scholar
  26. Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005b). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627. doi: 10.1001/archpsyc.62.6.617.PubMedCentralPubMedCrossRefGoogle Scholar
  27. Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63, 415–424. doi: 10.1001/archpsyc.63.4.415.PubMedCentralPubMedCrossRefGoogle Scholar
  28. Kuritzkes, D. R. (2004). Preventing and managing antiretroviral drug resistance. AIDS Patient Care and STDS, 18, 259–273. doi: 10.1089/108729104323076007.PubMedCrossRefGoogle Scholar
  29. Lejuez, C. W., Paulson, A., Daughters, S. B., Bornovalova, M. A., & Zvolensky, M. J. (2006). The association between heroin use and anxiety sensitivity among inner-city individuals in residential drug use treatment. Behaviour Research Therapy, 44, 667–677. doi: 10.1016/j.brat.2005.04.006.Google Scholar
  30. Leserman, J. (2008). Role of depression, stress, and trauma in HIV disease progression. Psychosomatic Medicine, 70, 539–545. doi: 10.1097/PSY.0b013e3181777a5f.PubMedCrossRefGoogle Scholar
  31. Liu, H., Miller, L. G., Hays, R. D., Wagner, G., Golin, C. E., Hu, W., et al. (2006). A practical method to calibrate self-reported adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 43(Suppl 1), S104–S112. doi: 10.1097/01.qai.0000245888.97003.a3.PubMedCrossRefGoogle Scholar
  32. Low-Beer, S., Yip, B., O’Shaughnessy, M. V., Hogg, R. S., & Montaner, J. S. (2000). Adherence to triple therapy and viral load response. Journal of Acquired Immune Deficiency Syndromes, 23, 360–361.PubMedCrossRefGoogle Scholar
  33. Marc, L. G., Wang, M. M., & Testa, M. A. (2012). Psychometric evaluation of the HIV symptom distress scale. AIDS Care, 24, 1432–1441. doi: 10.1080/09540121.2012.656567.PubMedCentralPubMedCrossRefGoogle Scholar
  34. Martins, S. S., Keyes, K. M., Storr, C. L., Zhu, H., & Chilcoat, H. D. (2009). Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence, 103, 16–24. doi: 10.1016/j.drugalcdep.2009.01.019.PubMedCentralPubMedCrossRefGoogle Scholar
  35. Paterson, D. L., Swindells, S., Mohr, J., Brester, M., Vergis, E. N., Squier, C., et al. (2000). Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 133, 21–30.PubMedCrossRefGoogle Scholar
  36. Puskas, C. M., Forrest, J. I., Parashar, S., Salters, K. A., Cescon, A. M., Kaida, A., et al. (2011). Women and vulnerability to HAART non-adherence: A literature review of treatment adherence by gender from 2000 to 2011. Current HIV/AIDS Reports, 8, 277–287. doi: 10.1007/s11904-011-0098-0.PubMedCrossRefGoogle Scholar
  37. Safren, S. A., O’Cleirigh, C. M., Bullis, J. R., Otto, M. W., Stein, M. D., & Pollack, M. H. (2012). Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 80, 404–415. doi: 10.1037/a0028208.PubMedCentralPubMedCrossRefGoogle Scholar
  38. Safren, S. A., O’Cleirigh, C., Tan, J. Y., Raminani, S. R., Reilly, L. C., Otto, M. W., et al. (2009). A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychology, 28, 1–10. doi: 10.1037/a0012715.PubMedCentralPubMedCrossRefGoogle Scholar
  39. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33. (quiz 34–57).PubMedGoogle Scholar
  40. Smitherman, T. A., Kolivas, E. D., & Bailey, J. R. (2013). Panic disorder and migraine: Comorbidity, mechanisms, and clinical implications. Headache, 53, 23–45. doi: 10.1111/head.12004.PubMedCrossRefGoogle Scholar
  41. Stirratt, M. J., Remien, R. H., Smith, A., Copeland, O. Q., Dolezal, C., Krieger, D., et al. (2006). The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS and Behavior, 10, 483–493. doi: 10.1007/s10461-006-9106-6.PubMedCrossRefGoogle Scholar
  42. Tsao, J. C., Dobalian, A., & Naliboff, B. D. (2004). Panic disorder and pain in a national sample of persons living with HIV. Pain, 109, 172–180. doi: 10.1016/j.pain.2004.02.001.PubMedCrossRefGoogle Scholar
  43. Tucker, J. S., Burnam, M. A., Sherbourne, C. D., Kung, F. Y., & Gifford, A. L. (2003). Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection. American Journal of Medicine, 114, 573–580.PubMedCrossRefGoogle Scholar
  44. Turner, B. J., Laine, C., Cosler, L., & Hauck, W. W. (2003). Relationship of gender, depression, and health care delivery with antiretroviral adherence in HIV-infected drug users. Journal of General Internal Medicine, 18, 248–257.PubMedCentralPubMedCrossRefGoogle Scholar
  45. Von Korff, M., Crane, P., Lane, M., Miglioretti, D. L., Simon, G., Saunders, K., et al. (2005). Chronic spinal pain and physical–mental comorbidity in the United States: Results from the national comorbidity survey replication. Pain, 113, 331–339. doi: 10.1016/j.pain.2004.11.010.CrossRefGoogle Scholar
  46. Willgoss, T. G., & Yohannes, A. M. (2013). Anxiety disorders in patients with COPD: A systematic review. Respiratory Care, 58, 858–866. doi: 10.4187/respcare.01862.PubMedGoogle Scholar
  47. Zogg, J. B., Woods, S. P., Sauceda, J. A., Wiebe, J. S., & Simoni, J. M. (2012). The role of prospective memory in medication adherence: A review of an emerging literature. Journal of Behavioral Medicine, 35, 47–62. doi: 10.1007/s10865-011-9341-9.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Jesse D. Kosiba
    • 1
  • Adam Gonzalez
    • 2
  • Conall O’Cleirigh
    • 1
    • 3
    • 4
  • Steven A. Safren
    • 1
    • 3
    • 4
  1. 1.Department of PsychiatryMassachusetts General HospitalBostonUSA
  2. 2.Department of Psychiatry and Behavioral ScienceState University of New York at Stony BrookStony BrookUSA
  3. 3.Department of PsychiatryHarvard Medical SchoolCambridgeUSA
  4. 4.The Fenway InstituteBostonUSA

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